Critic of the Application of Frederick Herzberg’s Two-Factor theory in Assessing and understanding employee motivation at work: a Ghanaian Perspective Essay

Critic of the Application of Frederick Herzberg’s Two-Factor theory in Assessing and understanding employee motivation at work: a Ghanaian Perspective. Patrick Ashiadey The Frederick Herzberg Two Factor Theory has had a considerable amount of practical and as well as theoretical influences. In fact, from a practical perspective, the influence of Herzberg’s motivation theory can be seen at every organizational level as well as within every department. From a theoretical perspective, Herzberg’s motivation theory can be perceived as having similarities to Maslow’s Theory of Need with the exception that for Herzberg’s theory, the needs aren’t placed in a progressive continuum, rather they are divided into two independent factors. Herzberg’s motivation theory emerged from a collection of data gathered by the interview of 203 accountants and engineers within the Pittsburgh area. The interview process consisted of asking the respondents to describe a work situation where they felt very happy as well as very unhappy. These descriptions were to include as many details as possible, including their feelings, the interpretation of the situation as well as the events that are suggestive of a change. The analysis of the responses confirmed the proposed hypothesis, where some factors where contributors to job satisfaction, while others were not. In addition, some factors were noted to be a source of dissatisfaction when absent. These were categorized as â€Å"Motivators† and â€Å"Hygiene† factors, the latter also being referred to as Maintenance Factors. (Wikipedia, 2013). Employee motivation in Ghana however takes on a different turn due to many factors that flaw the two factor Theory. This white paper seeks to discuss but a few of these factors. Firstly the difference in cultures and upbringing of the typical Africa especially the Ghanaian worker right from infancy to the work age differs from those used in the interview process as they are from entirely different geographical areas. Th e average Ghanaian lives on or below the poverty line and as such will be happy just having a job with his basic salary regardless of the existence of motivators or hygiene factors. The mentality of the average Ghanaian worker makes him fear joblessness as other forms of employment are hard to come by and that alone will motivate him or her to stay in the job in the absence of motivators or  hygiene factors. That is the theory does not take into account individual personality traits that could provide a different response to a motivator or hygiene factor. The Theory also lacks in the understanding of the inter-relations between some of the motivators which I totally agree with as can be seen from http://www.leadership-central.com/two-factor-theory.html#ixzz2g2Bs3nao in comparison to the dual structure theory. Example, one might receive adequate job recognition nut he or she may not be satisfied with the level of responsibilities therefore one would question the internal motivational value of job recognition for the individual. Lack of highly skilled personnel in the Ghanaian job market, makes the average Ghanaian worker dependent upon his or her professional level which would be more or less sensitive to one or the other of the factors. Frederick Herzberg’s sample space for his research included 203 accountants and engineers, a huge disparity from the large population of Ghanaian workers in the public sector who were only recently introduced to the single spine structure. Responses to the same questions posed to the accountants and engineers that led to the development of the theory would have produced different results as what mattered to a worker in the US would not necessarily have mattered to a worker in Ghana like recreational facilities. This leads us to the point where hygiene factors and motivators vary depending on the types of individuals involved and the nature of work examined. There is also the case where there exists no prove that highly satisfied people are also high performers per a research done on the internet. Example is the average Ghanaian worker in the public sector enjoying the new single spine salary structure still requiring some form of extra cash for him or her to carry out his or her civil duties. All said and done, it is a well-known fact that the Application of the Two Factor Theory is definitely well established within organizational settings. In fact, every leader has the responsibility to ensure that their employee’s hygiene factors are attended to and that proper motivators are implemented to increase job satisfaction. The most common mistake committed by leaders is to attend to the hygiene factor while expecting employee motivation. One application for Herzberg’s theory of motivation that isn’t well known is its importance in managing quality. A great paper by Heinz Weihrich shows the link between the Two Factor Theory  of motivation and quality. He equates the reliability or â€Å"R† factor of a product as being the hygiene factor and therefore customers have grown to expect products they purchase to be reliable. The â€Å"S† factor, the motivator, refers to the product features.

Homosexuality: Disorder or Innate

Is homosexuality an innate, normal sexual orientation or something one becomes through life’s trials? Leonardo da Vinci, Michelangelo, Francis Bacon, Herman Melville and Fredrick the Great all had one thing common, other than their famous personas. Every one of these men were homosexuals. In today’s society, homosexuality has grown to be labeled as a â€Å"sin† and/or something that one chooses to be rather born with.From religious leaders to medical doctors, homosexuality is thought to be a â€Å"disease† in society. Many even believe that homosexuality is a sexual orientation caused by how one was raised. I, on the other hand, believe otherwise. I believe that sexual orientation, or more specifically homosexuality, is something one is born with and not a disorder or choice. Charles Socarides, M. D. founder of NARTH (National Association for Research & Therapy of homosexuality wrote: By declaring a condition [homosexuality] a ‘non-condition,' a group of practitioners had removed it from our list of serious psychosexual disorders. The action was all the more remarkable when one considers that it involved the out-of-hand and peremptory disregard and dismissal not only of hundreds of psychiatric and psychoanalytic research papers and reports, but also of a number of other serious studies by groups of psychiatrists, psychologists, and educators over the past seventy years†¦In essence, this movement within the American Psychiatric Association has accomplished what every other society, with rare exceptions, would have trembled to tamper with–a revision of a basic code and concept of life and biology; that men and women normally mate with the opposite sex and not with each other. (Socradies) More generally, Dr. Socarides believes that for the medical world to remove homosexuality from the list of mental disorders is astounding. He believes that there is something mentally wrong with humans that prefer same sex partner s.I, on the other hand, believe sexual orientation is something one is born with, or is innate. The APA, American Psychological Association, agrees that homosexuality is not a mental disorder and has made revisions in their way of thought and practices. The APA states on its website â€Å"Psychologists, psychiatrists and other mental health professionals agree that homosexuality is not an illness, mental disorder or an emotional problem. Over 35 years of objective, well-designed scientific research has shown that homosexuality, in and [of] itself, is not associated with mental disorders or emotional or social problems.When researchers examined data about these people who were not in therapy, the idea that homosexuality was a mental illness was quickly found to be untrue† (American Psychiatric Association). Ruling out the belief, that homosexuality is not a disorder can help by not having to seek â€Å"treatment† because it is curable. However, this leads some to think that if it homosexuality isn’t due to a disorder it must be the parents who raise them that way. The opposing viewpoint generally believes that children raised by lesbian co-parents should and do seem to grow up more open to homoerotic relationships.This may be partly due to genetic and family socialization processes. Judith Stacey, Ph. D. agrees with this notion. In a 2001 article Stacey stated, â€Å"The sexual orientation of parents appears to have a unique (although not large) effect on children in the politically sensitive domain of sexuality. The evidence, while scanty and under analyzed, hints that parental sexual orientation is positively associated with the possibility that children will be more likely to attain a similar orientation-and theory and common sense also support such a view† (Stacey PhD). I disagree with Ms. Stacey.The gender identity of preadolescent children raised by lesbian mothers has been found consistently to be in line with their biological gender. None of more than 500 children studied have shown evidence of gender-identity confusion, wished to be the other gender, or consistently engaged in cross-gender behavior. No differences have been found in the toy, game, activity, dress, or friendship preferences of boys or girls who had lesbian mothers, compared with those who had heterosexual mothers. James G. Pawelski, M. D. supports my viewpoint. Using data from a national sample of adolescents, Dr.Pawelski finds â€Å"no difference on the basis of whether the parents were the same or different genders in the proportion of adolescents who reported having had sexual intercourse, nor was a difference found in the number who reported having a ‘romantic relationship' within the past 18 months† [ (Pawelski MD) ]. Agreeing with this view and observation may bring less scrutiny about same-sex couples adopting and/or raising a child. Unfortunately, it doesn’t help with the people who believe homosexuality is a result of same-sex sexual abuse. There is no universal definition of child sexual abuse. However, a central haracteristic of any abuse is the dominant position of an adult that allows him or her to force or coerce a child into sexual activity. Child sexual abuse is not solely restricted to physical contact; such abuse could include non-contact abuse, such as exposure, voyeurism, and child pornography. Timothy J. Dailey, Ph. D. , wrote that â€Å"[M]en who sexually molest boys all too often lead their victims into homosexuality and pedophilia. The evidence indicates that a high percentage of homosexuals and pedophiles were themselves sexually abused as children† [ (Dailey PhD) ]. This situation has been occurring in the Catholic Church lately.Many male priests are molesting young children, most of them being male themselves. To hold Dr. Dailey’s theory/assumption to be truth may add more controversy to this already intense situation. It also may cause people to further assume that just being raised by a male can â€Å"turn† someone gay. However, I do not agree with Dr. Dailey’s assumption and neither does the American Psychiatric Association who stated in a May 2000 website fact sheet that â€Å"[N]o specific psychosocial or family dynamic cause for homosexuality has been identified, including histories of childhood sexual abuse.Sexual abuse does not appear to be more prevalent in children who grow up to identify as gay, lesbian, or bisexual, than in children who identify as heterosexual† [ (American Psychiatric Association) ]. Just because some adults who were molested as children are gay, does not mean that the molestation was the cause of the sexual orientation. As, the American Psychiatric Association found, there are no more cases of children being gay after being molested by the same-sex then the cases of children who are heterosexual. It is incorrect to assume that homosexuality is something that life situations make o ccur.This brings us to the last major â€Å"excuse† for being homosexual which arises from various religious beliefs. Buddhism, Hinduism, Islam and Judaism are all religions that have negative views on homosexuality, but the one that speaks the loudest against it is Christianity, or more specifically the Catholic Church. Many Christians believe that homosexual activity is inherently sinful, irrespective of the relationship between the two persons. Many biblical passages condemn all forms of homosexual behaviors, using inclusive terms such as â€Å"sodomite† or â€Å"homosexual. â€Å". Same-sex practices are uniquely offensive to God.After all, God destroyed Sodom and its inhabitants because of their homosexual activity. All the men in the town wanted to have homosexual sex with the visiting angels. Homosexual behavior is one of a small group of behaviors that will prevent a person from attaining salvation and going to heaven. 1 Corinthians 6:9-10 says that â€Å"â € ¦ neither†¦ effeminate, nor abusers of themselves with mankind†¦ shall inherit the kingdom of God. † Other English translators substitute the term â€Å"homosexuals† here. Christians believe and were taught to believe that homosexuality is something that is chosen; an act against God and his law.Where the Bible mentions homosexual behavior at all, it clearly condemns it. I freely grant that. The issue is precisely whether that Biblical judgment is correct. The Bible sanctioned slavery as well and nowhere attacked it as unjust. Are we prepared to argue today that slavery is biblically justified? If you are a heterosexual†¦ can you explain why you are attracted to the opposite sex? Being a heterosexual, I can say that the first thing that comes to mind when asked that question is that it is just a feeling. It is hard to explain but I just have a drive towards males.However, what if the social norm was different? What if the social norm was to be homosex ual and people were scolding you for â€Å"choosing† to be heterosexual? Do you think being heterosexual is something you just â€Å"decided† to be one day? Most, if not all, heterosexuals would answer â€Å"No, I was born straight†. Well, then why is it so hard to grasp that homosexuals are born with the drive to be homosexual innately? If we can be heterosexual at birth, why can they not be homosexual at birth? Society and Religion has branded our minds to think that homosexuality is a chosen path†¦ I disagree.I did not â€Å"choose† to be â€Å"straight†; therefore, I do not and cannot believe that homosexuals â€Å"choose† to be gay. To join my belief means that one agrees that they themselves were born with their own drive for the opposite or same sex. Homosexuality is not a â€Å"disorder†. Homosexuality is not the affect of a prior incident in life. Homosexuality is not a preference that one day someone woke up and said, à ¢â‚¬Å"Hey I feel like being different so I am going to be gay. † As funny as that sounds, it is how many heterosexuals think about homosexuality; that it was something one just chose to be one day to â€Å"rebel†, like getting a tattoo or a piercing.Society and Religion have made their own assumptions about homosexuality because it is not a norm. Today’s world is afraid of anything different. People hate change and fear it. Thus, many come up with wild stories and assumptions to explain things that are different and normally they are not good ones. Being â€Å"gay† or â€Å"lesbian† is different from what society tells us to be, but why does that mean that it is something we chose to be or just become? I was born with an attraction to the opposite-sex. Many, if not all, heterosexuals can and would claim the same thing.So why is it so hard to believe that statement if the word â€Å"homosexual† replaced â€Å"heterosexual†? Does it not make sense? Do not be afraid of difference. Do not be ignorant. Be open and accepting that some people’s sexual orientation is homosexual just as you may be open to the belief that there are people that are heterosexual.

Vision and Mission of Japan Airline Group Essay

Vision and Mission of Japan Airline Group - Essay Example It embraces complying with environmental laws and regulations, promoting efficient use of energy and resources, waste reduction and recycling, selecting environment-friendly products, and social contributions. The Japan Airlines Group Code of Conduct clearly articulates the values that the company pursues with regard to different aspects of its business activities. On the other hand, the group’s vision statement, although stating how the company sees its development and emphasizing global expansion, specifics of the supporting industry, and focus on differentiation, would benefit from more precise and quantifiable approach to what the Japan Airlines want to become. For instance, their vision statement may be â€Å"to become the world leading company in terms of safety† or â€Å"#1 Airline in the flights within Asian region†. The mission statement of the JAL Group is as follows: â€Å"Proud to be the largest domestic network in the industry, we bring peoples, their cultures and their hearts closer together, contributing to peace and prosperity in Japan and beyond. All this is predicated on a relentless commitment to flight safety. We strive to become a world-class air transportation group, one that is consistently chosen by our customers, and maximizes corporate value in pursuit of our fundamental policy of sharing the value we create with all our stakeholders. The JAL Group now is spreading new wings of trust, preparing for a renewed push forward† (Annual Report 2005, retrieved April 12, 2006). Overall, the mission statement of the Japan Airline Group can be assessed very positively. It reflects the company’s philosophy and its self-concept, clearly indicates what products and markets the company offers, how it sees its role in the society and what are the factors contributing to its success and growth.

Should the drinking age be lowered to 18 Essay Example | Topics and Well Written Essays - 1250 words

Should the drinking age be lowered to 18 - Essay Example state public policies being properly enforced or having their intended effect: neighboring states may have differing policies, alcohol companies may lobby against strict enforcement, and the ubiquity of alcohol in contemporary society makes the acquisition of the substance almost too easy for underage drinkers. For much time, the solution to the rising occurrences of tragedies regarding alcohol-related deaths in younger adults has been to raise the MLDA to decrease both supply and demand to those most susceptible to alcohol’s deadly effects. However, as will be contended here, this is the wrong approach to take in trying to solve this grave problem. The solution lies not in changing actions, but in changing thoughts. Conceptually, all actions are the physical result of some mental process; actions are merely the effects where mental processes are the causes. By changing the mental processes that correspond to the physical actions, we can stop the problem at its roots. Moreover, unlike enforcing an artificially high standard of maturity in the form of an MLDA, changing perceptions and attitudes is something that can be controlled with time. In what follows, it shall be seen that the MLDA is not too high or too low, but is irrelevant to the present considerations. What must be changed is how youth treat alcohol, see its effects, and use it in a social setting. Concerning the prevalence of underage drinking in the United States, it is reported that almost 11% of all alcohol consumed is done so by youth, and a vast majority of these drinks are consumed in a â€Å"binge† fashion (Drinking in America: Myths, Realities, and Prevention Policy, 2005). Annually, this results in almost 150,000 emergency room visits by youths related to injuries and health problems related to alcohol use (Drug Abuse Warning Network, 2005: National Estimates of Drug-Related Emergency Department Visits). A 2007 survey found such figures as 45% of youth drank â€Å"some amount of alcohol†,

Questions week 10 Essay Example | Topics and Well Written Essays - 250 words

Questions week 10 - Essay Example This would mean that cars that could not move could not be stolen. Thus, this solves the crime of stolen cars. Other crimes such as murder cannot necessarily be solved since people are free to make their own decisions and decisions are often unpredictable. However, positive role models and morals can influence better decisions. Society in general, has a responsibility when it comes to crime in society. Geographical locations, race and gender determine how society acts towards others. These actions can leave society responsible for crime. It is also important to determine influences that society has. Society can influence crime and should take responsibility for its influences whether positive or negative. Our current policies are not enough since the increase of crime is happening everywhere. A change needs to take place that enforces better policies that work. If I could personally do something differently I would choose to help change society which in return can help to change crime. A better and more responsible society with adequate morals can contribute to a lessened crime rate and better actions throughout society. Most of this positive change should come from role models, mentors and any parental

The Positivist Lens Essay Example | Topics and Well Written Essays - 500 words

The Positivist Lens - Essay Example Multiple studies have shown that Corporate Social Responsibility can no longer be seen by organizations as discretionary, rather it is now a pertinent strategic issue. However, there still is a gap in the empirical evidence on the actual link between CSR and actual business performance. The study will investigate the extent to which CSR has impacted business performance and by extension its benefits to society as a whole. Creswell, (2008) document that quantitative research questions are designed to inquire about the relationships among variables that the investigator is seeking to know. The quantitative research question for this investigation is; The purpose of the key purpose of the study will be to establish whether there is a correlation, positive or negative, between corporate social responsibility and actual business performance. The study also seeks to establish and define any existing trends for measuring business performance in relation to existing strategy. The paper also purposes to establish the impact of CSR on business performance focusing on key performance indicators which include market value, revenue and shareholder value. The study will also have the purpose of establishing the approaches for effectively measuring the impact of CSR on business performance. The topic will be analyzed through the positivist lens which proposes that perceptual data derived from sensory experience and logically and mathematically treated is the source of all knowledge. The approach has been shown to provide better measurements in all areas be they classifications or levels; besides it allows for the monitoring of trends over time, (Creswell, 2008). Since it provides for statistical manipulation, the researcher can find statistical correlations hence have a clearer picture on how the key variables; CSR and actual business performance relate. Besides,

Personal statement Example | Topics and Well Written Essays - 500 words - 7

Personal Statement Example This made me feel completely at par with how I thought life should be for my own self. I have also played solo at the college level in a number of events. Even though I always want to perform at the very best, I get nervous when so many people are watching and their eyes are glued on to you. In essence, this makes a person feel good as well because he wants to give his utmost so that the audience could get enthralled with the music that is being played. The only riposte that I could muster was to play it well and give my best shot so that I could be satisfied with my music and the manner in which I made the people enjoy. The skills that I have learned through have been in the form of my preparation, organizing things and prioritizing other aspects of my daily routine. An example of this is my earnest desire to do something big within the gaining of mastery of guzheng. Since I worked my way through things, I found this to be a pattern which was unique to my personality and hence my skills and abilities adopted the same easily. This brings a sense of pride within my personality because I want to give my best and feel the glory that is coming within my own domains. I would always like to be at the very best because it is something that I am a part of and which I can do at the best of my skills and abilities. I have seen that I have changed a lot during the time that I have performed music for the people. It has made me feel that I am responsible for bringing a sense of excitement and enjoyment within their respective lives. The experience of performing in front of so many people is something that comes very naturally to me even though it gets to me sometimes with tiresome avenues opening up all the same. However, I appreciate how I take up the fields of excitement that people feel within their folds when I am playing music for them. I have seen that my life has changed quite a

Climate Assignment Example | Topics and Well Written Essays - 500 words

Climate - Assignment Example The main theme of this article is to offer detailed information regarding the harassment of the weather scientists by various sections of society, especially the fossil fuel industry. Since the scientific community has identified exploitation of fossil fuel as the main reason for global warming, this section of society has been prosecuting them on various levels, in spite of mounting evidence. Climate change can be broadly defined as the long-term time period shift in weather statistics including the average climate (NOAA, 2007). One of main concerns in environmental study is global warming with the continuous increase in temperature all over the world. It is also one of the topics that are hotly debated between various sections of the modern society (US National Academy of Sciences & the Royal Society, 2008). Mann begins by saying that weather scientists who are working in this area are gathering mounting evidences regarding the increase of surface warming all over the world. One such source is the thermometers that are monitoring the changes in hundreds and thousands of locations all over the world and recording those changes at a permanent location. The scientists are also getting indirect estimates from such sources as the ice cores as well as tree rings; for calculation of change in temperature during past years (US National Academy of Sciences & the Royal Society, 2008). Since last few decades, there are many theories that seek to explain the reason of the global warming such as the cycle of sun spots and changes in Earth climate, natural variability of the climate or changes due to human activity. Mann states that as per some climatologists, the main source of global warming is the sun spots and the 11 year Sun–cycle. The energy output of the Sun varies considerably depending on the abundance of some isotopes of beryllium or carbon atoms and number of sunspots. But, as per the evidence that

International Business Strategy Essay Example | Topics and Well Written Essays - 3500 words - 3

International Business Strategy - Essay Example also factors related to consumer viewpoint in their willingness to sample new products with untrusted or unknown new competitive players, based also on their traditional cultural values. These factors need to be considered prior to entering Spain as a viable profit opportunity. However, evidence provides that the growth rates in Spain associated with consumer willingness to purchase mobile products makes this a quality opportunity if new methods to undercut these values can be accomplished through marketing or other innovative communications methods. Spain represents a tremendous new market opportunity that is marked with sustained growth, despite problems that exist in labour shortages and the presence of a highly regulated labour market. It is recommended to pursue this strategy of expansion into the Spanish marketplace and improve long-term manufacturing and R&D capabilities in the process. Conducting business in the Middle Eastern markets is considerably different than that of Spain, both at the business and economic levels as well as cultural. These factors must be taken into consideration in order to develop a business model that can bring higher profitability and growth to the company entering this new market. The company described is a mobile communications manufacturer, specialising in the development of new consumer mobile technology products. Spain is marked with an uncertain labour market as well as a radically different cultural tendency that is present at the employee level as well as in relation to how managers conduct routine organisational processes. This report identifies the factors that will impede or enhance new market entry, via Greenfield entry, by reporting on issues which will directly impact success in this new market entry strategy. The consumer electronics market in Spain has experienced a steady growth rate of 10.8 percent between 2004 and 2008 (forbes.com 2010). This represents a consumer market that is adopting new technologies,

Gaddafi Essay Example for Free

Gaddafi Essay The person that I chose to represent Machiavellis ideas is Muammar Gaddafi. He is the longest serving head of state in the world next to Queen Elizabeth II. He is known for his controversial political strategy and his very unusual personality. Gaddafi is easily spotted in animal skins and colorful clothing. His name regularly pops up on lists of the worst dressed world leaders. Ronald Regan named him the Mad Dog of the Middle East. Muammar Gaddafis reputation ranges from a popular revolutionary to an international reject. Gaddafi graduated from the University of Libya then continued to pursue a British military education. While in Great Britain he began to devise a plan to overthrow the Libyan monarchy. In 1969, Libyan King Idris was overthrown by a small group of Gaddafis Junior military leaders. A year later, being inspired by Egyptian President Gamal Nasser, he decided to close US and British military bases and expel all Italians and Jews. While trying to enforce Islamic socialism, he banned alcoholic beverages and gambling and failed at trying to unite Libya with other countries. By the mid-1980s, he was widely regarded in the West as the principal financier of international terrorism. He was also accused by the United States of being responsible for direct control of the 1986 Berlin discotheque that killed three people and wounded more than 200, of whom a substantial number were U. S. servicemen. Gaddafis adopted daughter was killed in a bombing of Libya that was retaliation for the U. S. After that two Libyans were accused of placing a bomb on Pan Am Flight 103, which exploded and killed 270 people, Gaddafi refused to give up the suspects to America or Britain. Gaddafi finally admitted responsibility for the attack in 2003 and paid more than $2. 7 billion to the families of the victims, initiating the end of Libyas international isolation. Now in Machiavellis The Qualities ofa Prince the very first paragraph talks about how everything dealing with the government is viewed through a military lens. Machiavelli doesnt believe that the prince is a man who is skilled in many disciplines, but he believes that the prince should own a responsibility to make sure that whatever he governs is stable. Gaddafi took responsibility for Libya by creating his own form of government called Jamahiriya, in which the nation is governed by the masses or local councils and he defended his government by saying, There is no state with a democracy except Libya n the whole planet. Machiavelli also raises the question whether it is better to be loved than to be feared. In the twelfth paragraph he states l say that every prince must desire to be considered merciful and not cruel; nevertheless, he must take care not to misuse this mercy. It is said that Gaddafis examples and thoughts inspire the struggling troubled masses and haunts the ones doin g the trouble. This is why he is loved by people of the world, but feared by the ruling cliques who know that his words and actions expose them for what they are.

Human Resource Management (HRM) in Different Organisations

Human Resource Management (HRM) in Different Organisations Human Resource Management (HRM) is the function within an organization that focuses on recruitment of, management of, and providing direction for the people who work in the organization. Human Resource Management can also be performed by line managers. (http://humanresources.about.com/od/glossaryh/f/hr_management.htm) Storey defines HRM as a distinctive approach to employment management which seeks to achieve competitive advantage through the strategic development of a highly committed and capable workforce, using an arryay of cultural, structural and personnel techniques. (Human Resource Management by Julie Beardwell Tim Claydon 5th edition) Thus, HRM includes so many activities like planning, recruitment, selection, training, motivation, remuneration, etc. HRM aims at mounting people through work. In addition to this concern for the individual, HRM is also about developing the environment within the company for developing good qualities. There must be good professional relationship between boss and the employees. The HR manager has to look at all these aspects of the company with long term view to the company. One way of presentating this is that it might have been said of the personnel manager that they were involved mainly in recruitment, payment and keeping account. They therefore concerned themselves with a fairly slight view of the people in the organization. (http://www.encompassculture.com/readinggroups/teachingmanagement/humanresourcemanagement/) The main activities of HRM: The one that we would list are as follows: Recruitment and selection Examples: HRM at nokia:Nokia Connecting People this motto is known all over the world. Nokia employs thousands of people from the world each and every year. Their method of recruitment is really very accurate and selective, and they recruit the people who fulfill their all requirements for the job. ( http://www.oppapers.com/essays/Nokia-Analysis/131739) Training and development Example: HRM at hospitality industry: Nowadays, in each and every industry, training is necessary. An introductory guide is fully updated with recent informations, news and datas.the hospitality industry mainly give attention to following avtivity of human resource management. Selection, appointment and induction Training and management development Labor turnover Employee relations and employment law (http://www.flipkart.com/human-resource-management-hospitality-industry/0750666366-s5w3f9hgko) HRM at B S healthcare London: It is the place where I am working. After interview they had a training for all new comers. It is basically a pharmacy industry which makes the medicines on daily order bases. When I was selected in the interview, I was told to complete 10 specific tasks related to my job of making the medicines, specially suspensions. And after identifying the skills they train the new employees nicely. (Personal experience) Example: Disneys Polynesian Resort: It has developed a training program, to facilitate employee understanding and commitment to the business and its values called Magic of Polynesia. At Edward Jones, new brokers attend 17 weeks of training at costs ranging between $50,000 and $70,000 per person. Conversely, many organizations provide minimal initial training, little on-going development programs, and poorly implemented on-the-job training (http://www.allbusiness.com/human-resources/1100302-1.html) Human resource planning Provision of contracts Provision of fair treatment Provision of equal opportunities Assessing performance of employees Employee counseling Example: HRM at health centers: Health centre employees must have some nice degree but it is also important that they behave very nicely to the patients. So continuous viewing of the staff in health centers must be monitored by the manager. Generally, in health centers HRM is being observed in following ways: A study of nurse staffing, organization and quality of care A study of staffing level, mix and outcome indicators An examination of nurse staffing, patient mortality rates.( http://www.human-resources-health.com/content/2/1/6#IDAQXWED) Employee welfare Example: HRM at Starbucks: Starbucks believes that one of their most expensive resources are their workers. Here the personnel are provided very good environment to work and they are very well treated by the boss also. Managers believe that they are playing the major role in their benefits. All workers are called partners of the starbucks, no matter what job they are doing in the coffee shop. Each partner is eligible to receive health care, participate in the Bean Stock program, and get a free pound of coffee each week. (http://www.academicmind.com/unpublishedpapers/business/marketing/2002-04-000aag-catching-the-starbucks-fever.html) Example: HRM at Hotels: Here, management staff is getting more benefits than non management receives. If the staff work more than 40 hours then they are paid per hour on regular basis and thay may get extra pay for doing over-time. They also have very good pension scheme and they can join in from day 1. (Human Resource management in hotel industry: strategy and innovation by Kim Hoque) Health and safety Example: HRM at airlines industry: Airlines have adopted a short-permits, cost-rational move toward to HRM and health and safety, evidenced by a range of plannings, in order to increase competitive advantage. But, here profit was considered more important than the health and safety of the workers. But nowadays, the management has been improved and the workers get more benefits from the company. (http://www.emeraldinsight.com/Insight/viewContentItem.do?contentType=ArticlehdAction=lnkpdfcontentId=879290) Disciplining individual Dealing with grievances Dismissal Negotiation Encouraging involvement (Introducing human resource management by Margaret Foot 2nd edition) Major characteristics of HRM: The major characteristics of HRM have been identified as follows: The importance of adopting a strategic approach is emphasized. Line managers play a very important role. They achieve the competitive advantage by the efforts of the workers. This can variously be interpreted into actions known as soft HRM. A unitary rather than a pluralist approach prevail in the relationship between managers and employees. (Introducing human resource management by Margaret Foot 2nd edition) Strategic human resource management: Strategic human resource management can be defined as the linking of human resources with strategic goals and objectives in order to progress business performance and develop organizational culture that foster innovation, flexibility and competitive advantage. In an organisation SHRM means accepting and involving the HR function as a strategic colleague in the formulation and execution of the companys strategies through HR behavior such as recruiting, selecting, training and rewarding personnel. (http://ezinearticles.com/?What-is-Strategic-Human-Resource-Management?id=549585) (http://www.indianmba.com/Faculty_Column/FC722/fc722.html) Since the early 1980s when human resource management arrived on the managerial agenda, there has been considerable debate concerning its nature and its nature and its value to organizations. Indeed, the now large literature rarely differentiates between HRM and SHRM. Some have focused HRM as a means of gaining commitment and linked this to outcomes of enhanced organizational performance and business effectiveness through best practice models or high performance work practices. (Human Resource Management by Julie Bardwell Tim Claydon, 5th edition) Features of SHRM: The key features of SHRM are: There is a strong relation between HR policy and practices and final organizational strategic aims and the organizational environment. There is some organizing diagram linking HR intervention so that they are equally helpful Much of the responsibility for the management of human resources is developed losing the line.   Ã‚  Ã‚  Ã‚  Example: HRM at Cisco System: Charles Schwab was the manager at Cisco system. They think that for providing outstanding customer services, it is necessary to treat their own employees very well. This translates into Schwab employees with five years of service being eligible for four-week paid sabbaticals that can be combined with vacation time. The practices at these sharp contrast to the well-known restaurants that pay minimum weges. ( http://www.allbusiness.com/human-resources/1100302-1.html) How SHRM differs from HRM: In the last two decades there has been an increasing awareness that HR functions were like an island unto itself with softer people-centred values far away from the hard world of real business. In order to justify its own existence HR functions had to be seen as more intimately connected with the strategy and day to day running of the business side of the enterprise. Strategic human resource management focuses on human resource programs with long-term objectives. Instead of focusing on internal human resource issues, the focus is on addressing and solving problems that effect people management programs in the long run and often globally. ((http://ezinearticles.com/?What-is-Strategic-Human-Resource-Management?id=549585) (http://www.indianmba.com/Faculty_Column/FC722/fc722.html) What are strategic goals and objectives?: Strategic goals are statements of what you wish to get over the period of planned plan, for examples next month, next year, ten years. They reflect the detailed analysis you do that starts with creating a idea, a role statement and a work statement, and then your analysis of your environment, strengths, opportunities and threats. In other way, drafting five or six major strategic or business goals may seem relatively simple. The actual writing may be but connecting the goals to the break of the strategic planning process requires a high degree of analytic and reasonable skill. Example: HRM in boots: boots is a company which produces different kind of products. It is very difficult to make a major change in the organizational staff, ans also it is too difficult for multitask business to single task operations. During the year 2002-03 boots engaged in a programme of focus group meeting for all of their retail employees with the aim of informing and engaging everyone in the business; this involved more than 51000 people staff. The key objective of the meeting was that all staff develop understanding of Boots markets, customers and competitors. (http://www.bized.co.uk/compfact/boots/boots_old/boots_old_15.htm) Organizational innovation and HRM: Innovations can be defined as deliberate and radical changes in existing products or services, processes or the organisation in order to reach competitive advantage compared with competitors . Crucial aspects in this definition are: Innovation means the introduction of something new, at least for the standing organization, in terms of new products or services, new technology or new forms of organization; Innovation takes place with the intention to gain some advantage; Innovations develop through radical jumps although many authors also speak of incremental innovation; Innovations can be managed; this means that there are activities/stages such as goal formulation, design and organization, implementation and monitoring. But they can also present an opportunity: answering them gives the organization the option to expand or to develop into a new direction. In our conceptual framework we distinguish four types of developments: Economic developments, like changes in markets and industries, changes in demands for products and/or services, etc. Technological developments, like the development and application of new technology. Social/cultural developments, like demographical changes, changes in individual preferences, such as individualization, emancipation of specific groups, etc. Political developments, like changes in government policies (towards innovations), general trends like liberalization of trade, supra-national co-operation, etc. (http://www.allbusiness.com/professional-scientific/management-consulting/1024364-1.html) Example of HRM-innovation: The delegation of the responsibility for the development and introduction of new work methods to a team (devolution). Example of HRM-innovation: The introduction of a reward system that is related to innovation outcomes, like the number of new products, the successful implementation of a new technology, etc. Example of HRM-innovation: The HR leadership award which was a part of global excellence awards presented at the congress, is in recognition of Mr. Joshis leadership and contribution to the field of HR. as a tradability. Example of HRM-innovations: The introduction of a more flexible staffing approach e.g. by giving people contracts for the duration of their projects instead of permanent contracts. (http://www.zyduscadila.com/press/Asia%20Pacfic%20HRM%20Congress%20Award%20.pdf) HRM and FLEXIBILITY: The human resource management practices that may affect labor flexibility, that is, the adaptability of a firms workforce. A random sample of managers in the largest manufacturers in Taiwan completed a structured questionnaire containing a measure of employee participation as an indicator of a firms labor flexibility. Important terms related to flexibility of an organization are listed below: Labor market flexibility, where it is said that regulation and resulting inflexibility of the job market act against growth and should be minimized. Flexible firm: a model of organization developed by the former Institute of Manpower Studies in the UK during the 1980s. Argues for a workforce composed of core and peripheral workforces. They take care of the organizations key functions. Peripheral workers are split into three categories: Regular employees engaged in relatively low-skill, routine work. Fairly low pay and insecure the next wave of technology can remove the need for these people. Contingent employees working on high-skill tasks, perhaps on short-term contracts or projects. High pay, no job security but this is compensated for by the freedom to pick and choose projects. Low-skill, low pay contract workers often provided by an agency for cleaning, routine security, catering, etc. Within the model there are some key explanatory concepts:numerical,functionalandpayflexibility and also distancing. The model has its critics and there is little evidence that organizations have made much use of it as a strategic concept. However, individual components such as sub-contracting are commonplace. Flexible specialization. An argument that fordism or mass production is declining in favor of smaller niche market manufacturing. Consumers are more demanding, it seems, wanting more individual products. Questionable. Example: HRM at McDonalds: McDonalds places emphasis on the training and development of its workers. They provide career opportunities for people to achieve their potential. Specially, the firm offers both part-time and full-time career opportunities, which helps staff to combine work with family or educational commitments. Job progression is used to encourage employees who got their 1st job in the firm to progress to manage positions. Over half of the companys middle and senior managers have moved up from restaurant-based positions. ( http://www.bized.co.uk/compfact/mcdonalds/mc16.htm) Managing organizations strategically: A processual view of strategy sees it as the pattern emerging over the time in an organization as actions of both planned and unplanned nature are carried out to enable the organization as a whole to carry on into the future. It follows from this view that strategic choices or managerial decisions are those that have: A corporate dimension: relate to the whole organization as opposed simply to a part of it; A long term implication: whether this be a matter of just surviving in the sense of staying viable or a matter of aiming to operate at higher level of performance. (The strategic management of human resources-Jhon Leopold 2nd edition) SHRM and culture: Over the past decade, the management of a firms entire supply chain has become the process for building improved and stronger upstream and downstream business linkage. Over the past decade, the management of a firms total supply chain has become the process for building better and stronger upstream and downstream business linkages. He concept organizational culture refers to the character of a firm, i.e., what makes the organization unique in the eyes of insiders and outsiders. While there are many definitions of culture, the common theme is the presence of shared values, beliefs, assumptions, and patterns of behavior. Two critical cultural elements are inherent in this definition. The first element of culture is the shared nature of job or role expectations. Over time, supply chain members also develop a common awareness about what is expected of them and what they can anticipate in return. In this sense, there are two aspects of shared expectations: The internal culture that characterizes employee expectations and The external culture that designates channel member expectations. (The strategic management of human resources-Jhon Leopold 2nd edition) Conclusion: I, definitely, think that the linking of HRM with strategic goals and objectives by any organization will help to improve business performance and develop organizational culture s that foster and flexibility. Research on diversity of national cultures and their influence on employees behavior inspire much optimism about emerging perspectives on culture and SHRM practices. There is a growing amount of research that illuminates differences in the way organizations around the globe make decisions, allocate resources, negotiate, manage and motivate employees and train them. Also, from above examples, it can be said that human resource management plays most important role in development of any organization. Strategic HRM is really important for creating innovative culture of an organization. REFERENCES: What Is Human Resource Management?-http://humanresources.about.com/od/glossaryh/f/hr_management.htm HRM INTRODUCTION-http://tutor2u.net/business/people/hrm_introduction.htm hrm- http://www.businessdictionary.com/definition/human-resource-management-HRM.html Strategic human resource management-http://www.cipd.co.uk/subjects/corpstrtgy/general/strathrm.htm HUMAN RESOURCE MANAGEMENT http://www.encompassculture.com/readinggroups/teachingmanagement/humanresourcemanagement/ Influence of Culture on Strategic Human Resourcehttp://www.strathmore.edu/research/strategic-human-resource-mgt.pdf Challenges of hrm-http://www.zeromillion.com/business/hrm.html What is hrm?-http://ezinearticles.com/?What-is-Strategic-Human-Resource-Management?id=549585 Can you give me an example of human resource management at the company?-http://www.bized.co.uk/compfact/mcdonalds/mc16.htm Nokia analysis-http://www.oppapers.com/essays/Nokia-Analysis/131739 Office of Personnel Management- http://www.opm.gov/studies/alignnet.pdf Can you give me an example of HRM at the company?-http://www.bized.co.uk/compfact/boots/boots_old/boots_old_15.htm HRM in the airline industry: strategies an outcomeshttp://www.emeraldinsight.com/Insight/viewContentItem.do?contentType=ArticlehdAction=lnkpdfcontentId=879290 Hrm at The Hospitality Industry http://www.flipkart.com/human-resource-management-hospitality-industry/0750666366-s5w3f9hgko The effects of culture and human resource management- http://www.allbusiness.com/human-resources/1100302-1.html Hand book on hrm- http://books.google.co.uk/books?id=D78K7QIdR3UCpg=PA142dq=hrm%2Bgoalssource=gbs_selected_pagescad=3#v=onepageq=hrm%2Bgoalsf=false Innovating Organisations and HRM:-http://www.allbusiness.com/professional-scientific/management-consulting/1024364-1.html What Are The Characteristics of Good Strategic Goals and Objectives Within Strategic Planning?http://work911.com/planningmaster/faq/goalsgood.htm http://www.human-resources-health.com/content/2/1/6#IDAQXWED JOURNAL of diversity management- Third Quarter 2007 Human Resource Management by Julie Beardwell Tim Claydon, 5th edition Organizational Behaviour by David Buchanan, 5th edition Introducing human resource management by Margaret Foot 2nd edition The strategic management of human resources-Jhon Leopold 2nd edition Human resource management practiceBy Michael Armstrong page 144 Human Resource management in hotel industry: strategy and innovation by Kim Hoque Strategic Human Resource Management by Susan Jacson BIBLIOGRAPHY: JOURNAL of diversity management- Third Quarter 2007 Human Resource Management by Julie Beardwell Tim Claydon, 5th edition Organizational Behaviour by David Buchanan, 5th edition Introducing human resource management by Margaret Foot 2nd edition The strategic management of human resources-Jhon Leopold 2nd edition Human resource management practiceBy Michael Armstrong page 144 Human Resource management in hotel industry: strategy and innovation by Kim Hoque Strategic Human Resource Management by Susan Jacson

Abraham Lincoln :: essays research papers

Abraham Lincoln On the stormy morning of Sunday, February 12, Nancy Hanks Lincoln, wife of Thomas, gave birth to a boy. He was born on a bed of poles covered with corn husks. The baby was named Abraham after his grandfather. In 1811 the Lincolns moved to a farm on Knob Creek which was also near Hodgenville. In 1811 or 1812, Abraham's younger brother, Thomas, died in infancy. Abraham spent a short amount of time in a log schoolhouse. He began to learn his ABC's from a teacher named Zachariah Riney. He attended school with his sister, Sarah. Late in 1816 the Lincoln family moved to southern Indiana and settled near present day Gentryville. A cabin was constructed near Little Pigeon Creek. It measured 16 X 18 feet, and it had one window. Abraham's mother, Nancy, passed away on October 5th, 1818, she died of milk sickness. In 1819, Abraham would barrow books from his neighbors to read. In 1821 Abraham attended school taught by James Swaney for about 4 months. Also in 1824 Abraham attended school taught by Azel Dorsey. In 1827 Abraham's sister, Sarah died giving birth to her son. In 1831, Lincoln decided to leave his family and go off on his own. In July he moved to New Salem, Illinois, where he boarded at Rutledge's tavern and became acquainted with the owner's daughter, Ann. New Salem was a frontier village consisting of one long street on a bluff over the Sangamon River. On August 6th, 1832 Lincoln was defeated while running for the Illinois State Legislature. Lincoln began to operate a general store in New Salem along with William F. Berry. Again, In 1834, Lincoln ran for the Illinois State Legislature, but this time he was elected. During the summer, John T. Stuart advised Lincoln to study law. On December 1 he took his seat in state government in Vandalia. In 1837 Lincoln, 28, was admitted to the Illinois Bar on March 1, and he moved to Springfield on April 15. He became a law partner of John Stuart and lived with Joshua Speed. Lincoln now had income from a law practice as well as a state legislator. November 4,1842 Lincoln married Mary Todd. The first son of the Lincolns, Robert Todd, was born August 1, 1843 at the Globe Tavern. In 1844 Abraham and Mary purchased a home from Dr. Dresser in Springfield for $1500. It was located at the corner of Eighth and Jackson. The family moved in on May 2nd. In 1849 Lincoln failed in his attempt to be appointed commissioner of the General Land Office, and he returned to a full time law practice in Springfield as his

Steps to Implement Organizational Changes Essay -- leadership, transfo

Explain fully what you believe are the most important features in the successful implantation of organisational change. In an organisation, there are many variables. These include leadership, those who are involved such as employees, motivations for example financial gain and current economic climate along with many others, for organisational change to be successful there are many features and criteria’s that must be fulfilled before it can lead to success. Organisational change is when a â€Å"Company or organization going through a transformation. Organization change occurs when business strategies or major sections of an organization are altered.†[1] This means that areas of an organisation progress from one position of action to another in the attempt to improve an areas efficiency or ability. The motivation for change can greatly impact on the support of those involved, this could be due to extrinsic factors such as financial gain or intrinsic factors such as ethical practise, this motive however must be strong enough and required with a realistic view for success will promote support from those in the organisation who care for the causation of the change. Those it does not affect will often be ambivalent to the effort required to make the change. To decide on the action needed to be taken before implementing any change requires great amounts of thought and consideration as each change made is a potential risk for an organisation and some changes may mean interference or conflict between departments of the organisation thus creating an inharmonious mechanism which in turn can seriously affect the performance of an organisation. It is a common analogy that an organisation or business is like a clock, with varying cogs and mechani... ...ement Model - Change Management Training from MindTools.com. n.d.. MindTools.com. [ONLINE] Available at:http://www.mindtools.com/pages/article/newPPM_94.htm . [Accessed 20 January 2014]. Forces for and resistance to organisational change- 2010. Fred C.Lunenberg. [ONLINE] Available at:http://www.nationalforum.com/Electronic%20Journal%20Volumes/Lunenburg,%20Fred%20C.%20Forces%20For%20and%20Resistance%20to%20Change%20NFEASJ%20V27%20N4%202010.pdf. [Accessed 20 January 2014]. What is organization change? definition and meaning. n.d. Business dictionary [ONLINE] Available at:http://www.businessdictionary.com/definition/organization-change.html. [Accessed 20 January 2014]. Top-down organisational change initiatives n.d. Emerald insight . [ONLINE] Available at:http://www.emeraldinsight.com/learning/management_thinking/articles/pdf/top_down.pdf. [Accessed 20 January 2014].

English Prose Study Essay :: English Literature

English Prose Study Essay Miss Havisham is first introduced to the reader when Mr Pumblechook (Pips Uncle) announces that Miss Havisham Requests Pips presence to play at her house. Miss Havisham fits into the main plot because she trains Estella to â€Å" break their hearts.† When Pip sees Estella for the fist time, he instantly falls in love with her. Miss Havisham sees this and she encourages Pip to do so. Miss Havisham was also, in Pips eyes, the cause of his ‘Great expectations’ Miss Havisham may also have been placed in the novel by Dickens, To explore how the effects of bad experiences on people. In this case it would be Miss Havisham being jilted on her wedding day In the first description of Satis house you get the image of a dilapidated house that has been abandoned even though there is someone there still living there. When pip goes to miss Havishams house she asks him to touch her heart. This according to her is ‘Broken.’ When Miss Havisham says ‘I sometimes have sick fancies’ this shows that Miss Havisham is mentally disturbed in the head. Satis house is an old decaying house, which was turned this way by Miss Havishams neglect. When Pip returns to miss Havishams she takes him into her wedding breakfast room. There is a rotting cake in the middle of the table. This sums up Miss Havishams life perfectly. Forgotten and Mouldy. Another thing that is made out to be strange is that al the clocks have been stopped at twenty to nine. This makes it sound like her life has been frozen in time, as she also wore one shoe, half her veil was arranged and she still wore a decaying wedding dress. This makes the readers believe that she has frozen time at that exact point. Miss Havisham plays an important part in the Novel as she leads pip into believing that she was his benefactor because he believed that she was rearing him for Estella when in fact it was the convict (Magwitch). Miss Havishams character at the beginning of the novel is made out to be cruel and heartless, however later on in the novel she turns over a new leaf and begs for Pip’s forgiveness just before she is burnt to death. Charles Dickens explores the theme of sin and forgiveness in the novel. Throughout the novel some of the people who have sinned tried to redeem themselves the other people who have sinned haven’t. In addition, Dickens explores the theme of what is a gentle man. Compyson Who jilted Miss Havisham and manipulated Magwitch into doing his dirty

A critical analysis of a magazine article Essay

Gail Porter is a popular British female celebrity. She has recently made it public knowledge that she has been diagnosed with alopecia. Alopecia is a condition that affects men and women, resulting in drastic hair loss. The magazine the article was taken from is called â€Å"Closer†. This magazine has a wide target audience of British women of many ages. The article is presented as a personal description of her condition and its effects by Porter herself. The writer has appealed to the target audience in a good way, because the article is aimed at different audiences. It could firstly be aimed at women who have an interest in Gail Porter, due to the fact that she is a famous TV presenter, secondly it could be aimed at readers who have suffered from alopecia themselves, or know someone who has suffered from the condition. Thirdly the article could be aimed at young women, who are interested in celebrity gossip. The purpose of the text is that the writer is trying to inform readers about Porter’s condition, and also to entertain the audience, because the article could be known as celebrity gossip. There is a good use of pragmatics throughout the text. See more: how to write a good critical analysis essay Pragmatics is the social context of communication. Some readers may think the article is subtle, while others may disagree and think it has a hidden agenda. For example Gail has suffered from a terrible condition, if she were to inform readers about her trauma, she would not say, â€Å"Before I went out – to the launch of my new programme, Dead Famous Live†, this implies the article does have a hidden agenda because she is secretly trying to promote her new programme. The article is in first person; therefore the audience is influenced into reading it straight away, because they feel they are reading the words of Gail herself. Pronouns have been used, which is very effective because this technique draws the reader into the article further. Emotive language has also been used, making the reader feel pity for her. This terminology draws readers into the text further, because they want to know more about how Gail is coping, therefore they will also take in the facts that Gail has launched an launched a new programme, has been to America, has recently had a baby, gone through a divorce and also has a new boyfriend. All of these facts appeal to different audiences, which is what, makes the article so effective. The structure of the text appeals to the target audience very well. In bold writing and quotations, it reads, â€Å"I was scared I’d be judged†. This appeals to the audiences emotions drawing them into the article. It also reads on the top of the page â€Å"Up close and personal†; this involves women because they feel they are actually getting up close and personal with Porter. The side story also appeals to the target audience because Carly Morrell is 22 years of age, therefore the side story appeals to a younger audience. I think overall the article is very appealing; women who read this article can be influenced into feeling pity for the TV presenter. This is easily done as the article comes across as subtle, however if readers were to read in between the lines they will realize the article in fact has a hidden agenda. If I were to read this article generally, therefore not analyzing it, I think I would also have been influenced by it and what it says.

Why a Safe but Challenging Environment Is Important

Medical Decision Making http://mdm. sagepub. com/ Do Patient Decision Aids Meet Effectiveness Criteria of the International Patient Decision Aid Standards Collaboration? A Systematic Review and Meta-analysis Annette M. O'Connor, Carol Bennett, Dawn Stacey, Michael J. Barry, Nananda F. Col, Karen B. Eden, Vikki Entwistle, Valerie Fiset, Margaret Holmes-Rovner, Sara Khangura, Hilary Llewellyn-Thomas and David Rovner Med Decis Making published online 14 September 2007 DOI: 10. 1177/0272989X07307319.   A more recent version of this article was published on – Oct 5, 2007 Published by: http://www. sagepublications. com On behalf of: Society for Medical Decision Making Additional services and information for Medical Decision Making can be found at: Email Alerts: http://mdm. sagepub. com/cgi/alerts Subscriptions: http://mdm. sagepub. com/subscriptions Reprints: http://www. sagepub. com/journalsReprints. nav Permissions: http://www. sagepub. com/journalsPermissions. nav Version of Re cord – Oct 5, 2007 ;; OnlineFirst Version of Record – Sep 14, 2007 What is This? Downloaded from mdm. sagepub. com by guest on July 22, 2012 Med Decis Making OnlineFirst, published on September 14, 2007 as doi:10. 1177/0272989X07307319 Do Patient Decision Aids Meet Effectiveness Criteria of the International Patient Decision Aid Standards Collaboration? A Systematic Review and Meta-analysis Annette M. O’Connor, RN, PhD, Carol Bennett, MSc, Dawn Stacey, RN, PhD, Michael J. Barry, MD, Nananda F. Col, MD, MPH, MPP, Karen B. Eden, PhD, Vikki Entwistle, PhD, Valerie Fiset, MScN, Margaret Holmes-Rovner, PhD, Sara Khangura, Hilary Llewellyn-Thomas, PhD, David Rovner, MD Objective. Related article: Explain the Post 16 Options 2017 To describe the extent to which patient decision aids (PtDAs) meet effectiveness standards of the International Patient Decision Aids Collaboration (IPDAS). Data sources. Five electronic databases (to July 2006) and personal contacts (to December 2006). Results. Among 55 randomized controlled trials, 38 (69%) used at least 1 measure that mapped onto an IPDAS effectiveness criterion. Measures of decision quality were knowledge scores (27 trials), accurate risk perceptions (12 trials), and value congruence with the chosen option (3 trials). PtDAs improved knowledge scores relative to usual care (weighted mean difference [WMD] = 15. %, 95% confidence interval [CI] = 11. 7 to 18. 7); detailed PtDAs were somewhat more effective than simpler PtDAs (WMD = 4. 6%, 95% CI = 3. 0 to 6. 2). PtDAs with probabilities improved accurate risk perceptions relative to those without probabilities (relative risk = 1. 6, 95% CI = 1. 4 to 1. 9). Relative to simpler PtDAs, detailed PtDAs improved value cong ruence with the chosen option. Only 2 of 6 IPDAS decision process criteria were measured: feeling informed (15 trials) and feeling clear about values (13 trials). PtDAs improved these process measures relative to usual care (feeling uninformed WMD = –8. , 95% CI = –11. 9 to –4. 8; unclear values WMD = –6. 3, 95% CI = –10. 0 to –2. 7). There was no difference in process measures when detailed and simple PtDAs were compared. Conclusions. PtDAs improve decision quality and the decision process’s measures of feeling informed and clear about values; however, the size of the effect varies across studies. Several IPDAS decision process measures have not been used. Future trials need to use a minimum data set of IPDAS evaluation measures. The degree of detail PtDAs require for positive effects on IPDAS criteria should be explored. Key words: decision support techniques; patient education; patient participation; randomized controlled trials. (Med Decis Making 2007;XX:xx–xx) Received 23 July 2007 from the Ottawa Health Research Institute, Canada (AMO, SK, CB); University of Ottawa, Canada (AMO, DS); Massachusetts General Hospital, Boston (MJB); Maine Medical Center, Portland, Maine (NFC); Oregon Health and Science University, Portland (KBE); Social Dimensions of Health Institute, Dundee, UK (VE); Algonquin College, Ottawa, Canada (VF); Michigan State University, East Lansing (MH-R, DR); and Dartmouth Medical School, Hanover, New Hampshire (HL-T). Financial support for this study was provided by a group grant of the Canadian Institutes of Health Research. The funding agreement ensured the authors’ independence in designing the study, interpreting the data, and writing and publishing the report. Address correspondence to Annette M. O’Connor, RN, PhD, University of Ottawa, Ottawa Health Research Institute, 1053 Carling Avenue, ASB, Ottawa, Ontario, Canada K1Y 4E9; e-mail: [email  protected] ca. DOI: 10. 1177/0272989X07307319 P atient decision aids (PtDAs) are adjuncts to counseling that explain options, clarify personal values for the benefits versus harms, and guide patients in deliberation and communication. With the rapid proliferation of these tools, the International Patient Decision Aids Collaboration (IPDAS) has reached agreement on criteria for judging the quality of PtDAs. 1 IPDAS is a network of more than 100 researchers, practitioners, patients, and policy makers from 14 countries. These collaborators developed a checklist of criteria that payers, patients, practitioners, developers, and researchers can use to assess PtDAs they encounter. The criteria address 3 domains of quality: clinical content, the development process, and effectiveness. 554 †¢ MEDICAL DECISION MAKING/MON–MON 2007 Downloaded from mdm. sagepub. com by guest on July 22, 2012 Copyright 2007 by Society for Medical Decision Making.DECISION AIDS â€Å"EFFECTIVENESS CRITERIA OF DECISION AIDS†This article addresses the 3rd domain, the evaluation of PtDAs’ effectiveness in fostering a high-quality decision process and a high-quality choice. Over the past decade, there has been considerable debate about the definition of a good decision when there is no single best therapeutic action and choices depend on how patients value benefits versus harms. 2–6 To select criteria for decision quality, IPDAS participants were asked to identify â€Å"the things that you would nee d to observe in order to say that after using a patient decision aid, the way the decision was made was good and the choice that was made was good. IPDAS endorsed the following criteria for establishing that a decision aid is effective: †¢ Decision quality: The PtDA improves the match between the chosen option and the features that matter most to the informed patient. †¢ Decision processes leading to decision quality: The PtDA helps patients to recognize that a decision needs to be made, know options and their features, understand that values affect the decision, be clear about the option features that matter most, discuss values with their practitioner, and become involved in preferred ways. Our study objectives were 1) to describe the number and types of measures used in randomized controlled trials (RCTs) that correspond to IPDAS criteria for effectiveness and 2) to determine the extent to which RCTs of PtDAs meet these new IPDAS criteria for effectiveness. METHODS We have been updating the Cochrane Review of decision aids since the late 1990s. 7–9 This review differed from previous reviews by focusing on the new IPDAS criteria. Moreover, we used a new systematic review software, TrialStat SRS, to manage the search and data extraction; therefore, our search, screen, and data extraction were redone completely. Data sources included 1) electronic databases to July 2006 (MEDLINE, PsycINFO, CINAHL, and EMBASE), 2) Cochrane Controlled Trials Register (2006, issue 2), and 3) contact with known developers and evaluators to December 2006. The search strategy is described in the appendix. The search was not restricted on the basis of language. PtDAs were defined as interventions designed to help people make specific, deliberated choices among options (including the status quo) by providing information about the options and outcomes (e. . , benefits, DECISION AIDS: PAST, PRESENT, AND FUTURE harms) in sufficient detail that an individual could judge their value implicitly. Patient decision aids may also include information about the clinical condition, outcome probabilities tailored to personal risk factors, an explicit values clarification exercise (e. g. , a relevance chart, utility assessments of probable outcome states, a weigh scale), descriptions of others’ experiences, and guidance in the steps of decision making and communicating with others. This definition excludes interventions focused solely on lifestyle changes, hypothetical situations, clinical trial entry, or general advanced directives; education programs not geared to a specific decision; and interventions designed to promote adherence to a recommended option or to elicit passive informed consent. In the current review, we also excluded studies whose PtDAs were not available for inspection to catalogue their elements according to the new IPDAS domains. As a consequence, a few studies reported in the previous reviews were not included. We included published RCTs comparing 1) PtDAs to usual-care controls or 2) detailed PtDAs to simpler ones (which may not have the level of detail or may not contain all of the IPDAS elements). Participants were deciding about screening or treatment options for themselves, for a child, or for an incapacitated significant other. Two reviewers independently screened each study (CB, SK, DS, AMO, VF), extracted data (CB, SK), and assessed study quality (C. B. , S. K. ) using standardized forms, including the Jadad scale. 0 Inconsistencies were resolved by consensus. Trial results were described individually. Metaanalysis was used for decision quality and for decision process measures because these effects were expected to be independent of the type of decision. Meta-analysis was performed only on those outcomes with similar types of measures. Review Manager 4. 211 was used to estimate a weighted treatment effect (with 95% confidence intervals [CIs]), defined as weighted mean differences ( WMDs) for continuous measures and pooled relative risks (RRs) for dichotomous outcomes. The data used in each meta-analysis can be viewed in the online supplement available at http://mdm. sagepub. com/cgi/ content/full/Volume/Issue/Page#/DC1. All data were analyzed with a DerSimonian and Laird12 random effects model because of the diverse nature of the trials. Forest plots were used to assess and display potential heterogeneity, and funnel plots were used to explore publication bias. Because of statistically significant heterogeneity for most of the outcomes, we performed post hoc subanalyses to explore the potential causes of heterogeneity. Heterogeneity was explored according 555 Downloaded from mdm. sagepub. com by guest on July 22, 2012 O’CONNOR AND OTHERS to the following factors: type of decision (treatment versus screening), type of media of decision aid (video/ computer versus audio booklet/pamphlet), and a possible ceiling effect based on good usual-care scores (removal of studies with lower knowledge and realistic risk perception scores; removal of studies with higher decisional conflict scores for subscales feeling uninformed and unclear values). We analyzed the effects of removing the biggest outlier(s) defined by visual inspection of the forest plots. In addition, a post hoc analysis was performed to examine the effect of 1) excluding trials of low methodological quality and 2) excluding trials that were outliers and contributed to heterogeneity.RESULTSOf the 22,778 unique citations obtained in the review, we identified 1293 as relevant by title and then screened those abstracts (see Figure 1). Of these, 130 citations were retrieved for full-text review. Sixty-four studies were excluded for the following reasons: the study was not focused on making a choice (n = 33), the study was not an RCT (n = 14), the decision support intervention did not meet the definition of a PtDA (n = 8), the study involved a hypothetical situation (n = 6), and no outcome data were provided (n = 3). In all, 55 eligible trials (66 references) were found for duplicate data extraction and analysis. The 55 published RCTs evaluating individual PtDAs13–78 used 51 different PtDAs that focused on 23 different screening or treatment topics (see Table 1). Among the 51 different PtDAs, the elements most frequently included were information about the options and outcomes in sufficient detail to judge their value implicitly (100% by definition), information about the clinical condition (98%), outcome probabilities (84%), examples of others’ experiences (59%), explicit values clarification exercises (55%), and guidance in the steps of decision making (47%). Quality ratings in the trials ranged from 0/5 to 3/5. All studies lost 2 points because patients or practitioners could not be blinded to the intervention. As shown in Table 2, 38 of the 55 trials (69%) reported at least 1 outcome that could be mapped onto an IPDAS criterion for effectiveness; 33 (60%) measured some aspect of decision quality, and 15 (27%) measured a decision process leading to decision quality. Decision Quality As noted above, the definition of decision quality has 2 elements: the extent to which decisions are 556 †¢ MEDICAL DECISION MAKING/MON–MON 2007 informed and based on personal values. Trials used 3 measures corresponding to this definition: knowledge test results, accuracy of risk perceptions, and value congruence with chosen option. Knowledge. Twenty-seven of the 55 studies examined the effects of PtDAs on knowledge; 18 of these compared PtDAs to usual care, and 9 compared PtDAs with more or less detail. The studies’ knowledge tests were based on information contained in the PtDA, thereby establishing content validity. The proportion of accurate responses was transformed to a percentage scale ranging from 0% (no correct responses) to 100% (perfectly accurate responses). In the comparison of PtDAs to usual care15,16,18,26,28,29, 31,36,39,41,43,48,50,64,65,69,73,78 (Figure 2), PtDAs had higher average knowledge scores (WMD = 15. 2%, 95% CI = 11. 7, 18. 7). The 9 studies comparing detailed with simpler PtDAs22,24,30,35,54,60,61,63,66 (Figure 3) showed a smaller effect (WMD = 4. 6%, 95% CI = 3. 0, 6. 2). Accurate risk perceptions. Eleven of 55 studies examined the effects of including probabilities of PtDAs on the accuracy of patients’ perceived probabilities of outcomes. 4,28,41,43–45,54,63,73,74,77 Eight studies measured perceived probabilities as percentages,24,28,43–45,54,73,74 and 3 gauged probabilities in words. 41,63. 77 Perceived outcome probabilities were classified as accurate according to the percentage of individuals whose judgments corresponded to the scientific evidence about the chances of an outcome for similar people. In 4 of 5 studies that elicited perceived probabilities for multiple outcomes,24,44,54,60 the propo rtion of realistic expectations was averaged; in the remaining study,43 the most conservative result was chosen for meta-analysis. People who received a detailed PtDA with descriptions of outcomes and probabilities were more likely to have accurate risk perceptions than those who did not receive this information; the pooled RR of having accurate risk perceptions was 1. 6 (95% CI = 1. 4, 1. 9; Figure 4). The pooled relative risk for probabilities described in words was 1. 3 (95% CI = 1. 1, 1. 5). The pooled relative risk for probabilities described as numbers was 1. 8 (95% CI = 1. 4, 2. 3). Value congruence with chosen option. Four of 55 studies measured value congruence with the chosen option; however, Lerman and others41 did not calculate differences between interventions. The 3 trials comparing interventions were similar in that they 1) focused on the decision to take menopausal hormone replacement therapy (HRT) and 2) compared 2 active interventions. However, these trials used different measures of value (text continued on p 565) Downloaded from mdm. sagepub. com by guest on July 22, 2012 DECISION AIDS â€Å"EFFECTIVENESS CRITERIA OF DECISION AIDS† 2,778 unique citations identified for initial screening (screening based on review of the title) 1,293 potentially relevant citations identified and screened (based on review of the abastract) for retrieval 130 citations retrieved for full-text review 64 excluded: study not focused on making a choice (n = 33); study was not RCT (n = 14); decision support intervention did not meet the definition of a PtDA (n = 8); study involved a hypothetical situatio n (n = 6); no outcome data provided (n = 2); protocol only (n = 1) 5 eligible trials (66 references) for duplicate data extraction Data entry & RCT meta- analysis Figure 1 Flowchart of the procedural steps in the systematic review. RCT = randomized controlled trial; PtDA = patient decision aid. DECISION AIDS: PAST, PRESENT, AND FUTURE Downloaded from mdm. sagepub. com by guest on July 22, 2012 557 Table 1 Elements in DAs Characteristics of 55 Trials Included in the Systematic Review of Patient Decision Aids 558 Number of Enrollees in Intervention + Comparison: Options Considered Quality Rating (Jadad) Others’ Experiences Comparison of Most and Least Intensive Intervention Options and Clinical Outcomes Problem Explicit Outcome Values Probability Clarification Guidance in Steps of DM Source, Year, Location Auvinen and others13,14 2004, Finland 3/5 1/5 2/5 3/5 2/5 2/5 — X — X X X — — X X X — — X — X X — — X X — — X — X — — — X — — X X X — X — — — X — — — — — X — — — X — — — X — — — — — — — — X — — Barry and others15 1997, United States Bekker and others,16,17 2004, United Kingdom Bernstein and others18 1998, United States Pamphlet PtDA Standard care by clinical guideline Interactive videodisc PtDA Usual care Decision analysis plus consultation Usual care Video PtDA Usual care Clancy and others19 1988, United States 30 + 30 men: prostate cancer treatment 67 + 61 women: HRT 1/5 — X X X X X X X X X — X X X X X 103 + 100 men: prostate cancer treatment 104 + 123 men: benign prostate hypertrophy treatment 59 + 58 women: prenatal diagnostic screening for Down syndrome 65 + 53 patients: ischemic heart disease treatment 753 + 263 physicians: hepatitis B vaccine Davison and Degner20 1997, Canada Deschamps and others21 2004, Canada 3/5 — X X X — X — X — X — — — X — X — X — X — X — — — X — — — X — X Downloaded from mdm. sagepub. com by guest on July 22, 2012 Deyo and others22 2000; Phelan and others23 2001, United States 2/5 Dodin and others24 2001, Canada 50 + 47 adults: colon cancer screening 3/5 2/5 3/5 143 + 144 parents: infant polio vaccine schedules 112 + 114 men: PSA testing 190 + 203 patients: herniated disc or spinal stenosis treatment 52 + 49 women: HRT Pamphlet + decision analysis PtDA Usual care Written materials, PtDA, and audiotape of consultation Usual care Audiotape and booklet Pharmacist consultation Interactive videodisc PtDA Simple PtDA pamphlet Audiotape booklet PtDA Simple PtDA pamphlet Dolan and Frisina25 2002, United States Dunn and others26 1998, United States Frosch and others27 2003, United States — X — X X X X X X X — X — X X — — — — — — X — X X — — — — — Computer: analytic hierarchy process and pamphlet PtDA Usual care Video and pamphlet PtDA Usual care Video PtDA Internet presentation mirroring content of video continued) Gattellari and Ward28 2003, Australia 3/5 3/5 3/5 X X — X — X — X X — X X — X — X X — — X — — — — — X X — — — X — — X — — — X — X â⠂¬â€ X — X — X X X X X X — X — X — X — — — — — X — — — — — X — X — X — X — X — X — — — — — 140 + 140 men: PSA testing 86 + 50 women: breast cancer surgery 1/5 126 + 122 men: PSA testing Gattellari and Ward29 2005, Australia Goel and others30 2001, Canada Green and others31 2001, United States 3/5 CD-ROM PtDA plus counseling Genetic counseling Pamphlet PtDA Usual care Pamphlet PtDA General information leaflet Pamphlet PtDA General information leaflet Audiotape and booklet PtDA Simple PtDA pamphlet CD-ROM PtDA plus counseling Usual care Green and others32,33 2004, United States 0/5 2/5 Herrera and others34 1983, United States Hunter and others35 2005, Canada 3/5 3/5 2/5 3/5 Audiotape and booklet PtDA Usual care Audiotape and booklet Individual genetic counseling Decision board PtDA Usual care Video plus booklet PtDA Usual care Booklet PtDA Personal risk profile X — X — X — X — X X X — 2/5 X X X — X — X X X — X X X — X X 9 + 14 higher risk women: breast cancer genetic testing 106 + 105 higher risk women: breast cancer genetic testing 56 + 47 parent(s): circumcision of male newborns 116 + 126 women: prenatal diagnostic testing X — X — X X X — X X X — X X — — X — X — X — X — X — — — Downloaded from m dm. sagepub. com by guest on July 22, 2012 Johnson and others36 2006, United States Kennedy and others37 2002, United Kingdom Lalonde and others38 2006, Canada — — X — X — X — X — X — — — — — X — X — X — X — X — X — (continued) Laupacis and others39 2006, Canada 2/5 Legare and others40 2003, Canada 122 + 164 women: breast cancer genetic testing 100 + 101 women: prenatal diagnostic testing 1/5 32 + 35 patients: dental surgery 300 + 298 women: menorrhagia treatment 13 + 13 patients: cardiovascular health treatment 60 + 60 patients: preoperative autologous blood donation 97 + 87 women: HRT erman and others41 1997, United States Leung and others42 2004, China Audiotape booklet PtDA Simple pamphlet PtDA Discussion PtDA and counseling Usual care wait list control Interactive multimedia PtDA Video and pamphlet 559 Table 1 Elements in DAs continued) 560 Number of Enrollees in Intervention + Comparison: Options Considered Quality Rating (Jadad) Others’ Experiences Comparison of Most and Least Intensive Intervention Options and Clinical Outcomes Problem Explicit Outcome Values Probability Clarification Guidance in Steps of DM Source, Year, Location Man-Son-Hing and others43 1999, Canada — X X X X — — — 3/5 1/5 2/5 X X X X X X — X — X — X — X — X — X — X — X — X — X — — — X — X 3/5 Audiotape and booklet PtDA Usual care X X X X X — X — X — — — — — — X — X — X — — — — — — McAlister and others44 2005, Canada McBride and others45,46 2002, United States Miller and others47 2005, United States 139 + 148 aspirin users in atrial fibrillation trial: move to warfarin 219 + 215 patients: antithrombotic therapy 289 + 292 women: HRT 279 women: BRCA1 BRCA2 gene testing Montgomery and others48,49 2003, United Kingdom 52 + 55 + 51 + 59 adults: hypertension treatment 3/5 Downloaded from mdm. sagepub. com by guest on July 22, 2012 Morgan and others50 2000, Canada 3/5 3/5 — X — X — X — X X — X — X — X — X X — X — X — X — — — — — — — — — — X — — X — X — X — — — — — — — — — — X — Murray and others51 2001, United Kingdom 3/5 2/5 Murray and others52 2001, United Kingdom Myers and others53 2005, United States 121 + 121 men: PSA testing 120 + 120 patients: ischemic heart disease treatment 57 + 55 men: benign prostate hypertrophy treatment 102 + 102 women: HRT Audiotape and booklet PtDA Usual care Pamphlet PtDA Usual care Discussion PtDA and general information pamphlets General information pamphlets Decision analysis PtDA Video and booklet PtDA Decision analysis, video and booklet PtDA Standard care Interactive videodisc PtDA Usual care Interactive videodisc PtDA Usual care O’Connor and others54 1998, Canada 81 + 84 women: HRT 1/5 X X X X X — X — X — X — Interactive videodisc PtDA Usual care Discussion PtDA and general information pamphlet General information pamphlet Audiotape and booklet PtDA Simple PtDA pamphlet O’Connor and others55 1999, Canada 3/5 X X X X X X 1/5 3/5 0/5 — X — X — X — X — X — — — — — — — X — — X X X X X X — X X X X X — — — X 16 + 17 women: osteoporosis treatment 384 + 384 men: PSA testing 37 + 37 patients: dental orthognathic surgery 3/5 3/5 X X X — X — X — X — — — — — — — — X — X 101 +100 women: HRT Oakley and Walley56 2006, United Kingdom Partin and others57 2004, Canada Phillips and others58 1995, United States Pignone and others59 2000, United States Audiotape and booklet PtDA DA without explicit values clarification Audiotape and booklet PtDA Usual care Video PtDA Usual care Video imaging of facial reconstruction PtDA Usual care Video PtDA Usual care — — — X Rostom and others60 2002, Canada X X X X X X — X X X X X X X X X — X — — — 125 + 124 adults: colon cancer screening 25 + 26 women: HRT X X X X — — — — — — — — — — X X — — — — — 83 + 89 women: HRT 1/5 Computer PtDA with testing + feedback regarding knowledge Audiotape with booklet Lecture with personal decision exercise PtDA Simple PtDA pamphlet Booklet PtDA Simple PtDA pamphlet Booklet PtDA Usual care Rothert and others61 1997; Holmes-Rovner and others62 1999, United States Schapira63 2000, United States 1/5 2/5 Downloaded from mdm. sagepub. com by guest on July 22, 2012 Schwartz and others64 2001, United States 2/5 Booklet PtDA Usual care Shorten and others65 2005, Australia X — X — X — X — — — X — Street and others66 1995, United States 1/5 22 + 135 men: prostate cancer screening 191 + 190 Ashkenazi Jewish women: breast cancer genetic testing 85 + 84 pregnant women: birthing options after previous cesarean delivery 30 + 30 women: breast cancer surgery Interactive multimedia PtDA Simple PtDA X X X X — — — — X — X — (continued) 561 562 Table 1 Elements in DAs (continued) Source, Year, Locat ion Number of Enrollees in Intervention + Comparison: Options Considered Quality Rating (Jadad) Comparison of Most and Least Intensive Intervention Options and Clinical Outcomes Problem Explicit Outcome Values Probability Clarification Others’ Experiences Guidance in Steps of DM VanRoosmalen and others67,68 2004, the Netherlands X X — X — X — X — X — X — X — X X — — X — X — X — — X — — X — X — X — X — X — X — X X X X — — — — — — — — — — — — — X — 44 + 44 women with BRCA1/2 mutation: prophylactic surgery 3/5 X X X X — — X — — — — — — — X — — — — — X X — — — — — — — — — — — — — — Volk and others69,70 1999, United States 3/5 3/5 3/5 80 + 80 men: prostate cancer screening Vuorma and others71,72 2003, Finland Video and brochure PtDA with decision analysis Same video and brochure PtDA pamphlet Video with pam phlet PtDA Usual care Booklet PtDA Usual care Whelan and others73 2003, Canada 3/5 2/5 184 + 179 women: menorrhagia treatment 82 + 93 women: breast cancer chemotherapy Downloaded from mdm. sagepub. com by guest on July 22, 2012 Whelan and others74 2004, Canada Wolf and others75,76 1996, United States 1/5 2/5 Script PtDA Usual care Pamphlet PtDA Usual care 94 + 107 women: breast cancer surgery 103 + 102 men: prostate cancer screening Decision board PtDA and booklet Usual care with booklet Decision board PtDA Usual care Script PtDA Usual care Wolf and Schorling77 2000, United States Wong and others78 2006, United States 266 + 133 seniors: colon cancer screening 162 + 164 women: pregnancy termination Note: DM = decision making; PtDA = patient decision aid; HRT = hormone replacement therapy; PSA = prostate-specific antigen. Table 2 Cumulative Studies Still in 2007 Review Reporting Outcome in Each Cochrane Review Update Year % n/N Lead Author 15 50 18 Trials Measuring Outcomes That Map onto the International Patient Decision Aid Standards (IPDAS) Criteria Outcome Decision quality 2007 1999 2003 15 27 2/13 8/30 49 27/55 Knowledge scores 999 2003 54 57 7/13 17/30 Realistic expectations, accurate risk perceptions Barry, Morgan, Bernstein, Lerman,41 Rothert,61 O’Connor,54 Street66 As above plus Schwartz,64 Man-Son-Hing,43 Volk,69 Dunn,26 Green,31 Goel,30 Shapira,63 Rostom,60 Phelan,23 Dodin24 As above plus Bekker,16 Gattellari,28 Johnson,36 Whelan,73 Shorten,65 Montgomery,48 Gattellari,29 Laupacis,39 Wong,78 Hunter35 OConnor,54 Lerman41 As above plus Wolf,77 McB ride,45 Man-Son-Hing,43 Rostom,60 Shapira,63 Dodin24 As above plus Whelan,74 Whelan,73 McAlister,44 Gattellari28 Value congruence with chosen option Decisional Conflict Scale (DCS) 2007 1999 2003 2007 1999 2003 2007 80 2007 1999 2003 2007 1999 2003 57 15 30 27 15 33 24 15/55 2/13 10/30 13/55 2/13 9/30 17/30 Downloaded from mdm. sagepub. com by guest on July 22, 2012 22 0 10 5 15 30 12/55 0/13 3/30 3/55 2/13 9/30 Decision process leading to decision quality Feeling informed, subscale of the DCS Feeling clear about values, subscale of DCS O’Connor,55 Holmes-Rovner,62 Dodin24 As above OConnor,54 Morgan50 As above plus Murray,51 Murray,52 Dolan,25 Man-Son-Hing,43 Dodin,24 Goel,30 OConnor55 As above plus Montgomery,48 Shorten,65 Laupacis,39 Whelan,74 McAlister,44 Lalonde,38 Legare,40 Hunter35 O’Connor,54 Morgan50 As above plus Murray,51 Murray,52 Dolan,25 Man-Son-Hing,43 Dodin,24 Goel,30 OConnor55 As above plus Montgomery,48 Laupacis,39 McAlister,44 Wong,78 Bekker,16 Lalonde38 O’Connor,54 Morgan50 As above plus Murray,51 Murray,52 Dolan,25 Man-Son-Hing,43 Dodin,24 Goel,30 OConnor55 As above plus Montgomery,48 Laupacis,39 McAlister,44 Lalonde38 Note: Trials included in 1999 and 2003 but not in 2007 are Davison and others (measuring feeling informed, clear values); Maisels and others,81 Michie and others82 (measuring knowledge scores), and Thornton and others. 83 These authors were eliminated because we were unable to verify what was in their decision aid to meet the IPDAS definition of a decision aid. 563 O’CONNOR AND OTHERS Study or subcategory y Bekker 2004 Gattellari 2003 Johnson 2006 Whelan 2003 Schwartz 2001 Man-Son-Hing 1999 Morgan 2000 Shorten 2005 Montgomery 2003 Gattellari 2005 Laupacis 2006 Volk 1999 Lerman 1997 Barry 1997 Wong 2006 Bernstein 1998 Dunn 1998 Green 2001 N Decision Aid Mean (SD) 74. 00(14. 50) 50. 00(18. 40) 92. 60(11. 00) 80. 20(14. 40) 65. 71(14. 29) 75. 91(15. 72) 76. 00(32. 04) 75. 33(15. 00) 75. 00(17. 00) 57. 20(21. 30) 83. 00(19. 50) 48. 00(22. 40) 68. 90(19. 00) 75. 00(45. 00) 85. 00(26. 70) 83. 00(16. 00) 83. 67(23. 13) 95. 00(7. 00) N Usual Care Mean (SD) 71. 50(16. 00) 45. 00(15. 90) 85. 20(15. 60) 71. 70(13. 30) 57. 14(15. 71) 66. 46(16. 07) 62. 00(32. 04) 60. 53(17. 07) 60. 00(18. 00) 42. 20(16. 70) 67. 40(17. 00) 31. 00(18. 30) 49. 00(21. 70) 54. 00(45. 00) 60. 00(21. 70) 58. 00(16. 00) 55. 53(22. 80) 65. 00(21. 00) W MD (random) 95% CI W eight % 5. 68 6. 3 5. 49 6. 16 6. 41 6. 24 4. 61 6. 04 5. 43 6. 03 5. 32 5. 50 6. 00 3. 84 5. 81 5. 61 5. 83 3. 97 100. 00 W MD (random) 95% CI 2. 50 [-3. 31, 8. 31] 5. 00 [0. 39, 9. 61] 7. 40 [0. 98, 13. 82] 8. 50 [4. 37, 12. 63] 8. 57 [5. 55, 11. 59] 9. 45 [5. 68, 13. 22] 14. 00 [4. 81, 23. 19] 14. 80 [10. 23, 19. 37] 15. 00 [8. 39, 21. 61] 15. 00 [10. 40, 19. 60] 15. 60 [8. 64, 22. 56 ] 17. 00 [10. 61, 23. 39] 19. 90 [15. 17, 24. 63] 21. 00 [9. 25, 32. 75] 25. 00 [19. 60, 30. 40] 25. 00 [18. 95, 31. 05] 28. 14 [22. 83, 33. 45] 30. 00 [18. 71, 41. 29] 15. 22 [11. 71, 18. 73] 50 106 32 82 191 137 90 99 50 131 53 78 122 104 154 61 143 29 6 108 35 93 190 136 97 92 58 136 53 80 164 123 159 48 144 14 Total (95% CI) 1712 1786 Test for heterogeneity: ? 2 = 130. 32, df = 17 (P ; 0 . 00001), I? = 87. 0% Test for overall effect: Z = 8. 50 (P ; 0. 00001) -50 Favors Usual Care 0 50 Favors Decision Aid Figure 2 Effect of patient decision aids on patients’ mean scores on knowledge tests: decision aid versus usual care. WMD = weighted mean difference; CI = confidence interval. Study N Goel 2001 Rothert / H-Rovner O'Connor 1998-RCT Hunter 2005 Schapira 2000 Street 1995 Rostom 2002 Deyo / Phelan Dodin 2001 Total 77 83 81 116 122 30 25 41 52 627 Detailed DA Mean (SD) 81. 67(11. 1) 86. 79(11. 34) 75. 00(20. 00) 64. 53(19. 61) 83. 33(12. 78) 82. 60(11. 60) 93. 80(9. 00) 71. 76 (17. 06) 71. 04(15. 45) N Simple DA Mean (SD) 80. 00(12. 22) 83. 75(11. 54) 71. 00(21. 00) 60. 13(19. 00) 78. 33(15. 00) 76. 40(13. 80) 87. 10(11. 80) 62. 35(23. 53) 61. 20(17. 90) WMD (random) 95% CI Weight % 14. 31 21. 90 6. 62 10. 92 22. 45 6. 23 7. 85 3. 67 6. 06 100. 00 WMD (random) 95% CI 1. 67 [-2. 59, 5. 93] 3. 04 [-0. 40, 6. 48] 4. 00 [-2. 26, 10. 26] 4. 40 [-0. 47, 9. 27] 5. 00 [1. 60, 8. 40] 6. 20 [-0. 25, 12. 65] 6. 70 [0. 95, 12. 45] 9. 41 [1. 00, 17. 82] 9. 84 [3. 30, 16. 38] 4. 63 [3. 02, 6. 24] 48 87 84 126 135 30 26 49 49 634 Test for heterogeneity: ? 2 = 7. 18, df = 8 (P = 0. 52 ), I? = 0% Test for overall effect: Z = 5. 63 (P < 0. 00001) -50 Favours Simple 0 50 Favours Detailed Figure 3 Effect of patient decision aids (DAs) on patients’ mean scores on knowledge tests: detailed versus simple decision aids. WMD = weighted mean difference; CI = confidence interval. 564 †¢ MEDICAL DECISION MAKING/SEP–OCT 2007 Downloaded from mdm. sagepub. com by guest on July 22, 2012 DECISION AIDS â€Å"EFFECTIVENESS CRITERIA OF DECISION AIDS† Study or subcategory y Decision Aid n/N 90/122 189/266 73/94 109/265 82/122 33/52 58/81 47/82 70/187 88/139 57/106 1516 Usual Care n/N 108/164 72/133 62/107 82/274 62/135 21/49 39/84 34/92 27/165 40/148 11/108 1459 RR (random) 95% CI W eight % 11. 11 10. 83 10. 55 10. 01 10. 16 7. 66 9. 45 8. 54 7. 54 9. 04 5. 12 100. 00 RR (random) 95% CI 1. 12 [0. 96, 1. 31] 1. 31 [1. 10, 1. 56] 1. 34 [1. 10, 1. 63] 1. 37 [1. 09, 1. 73] 1. 46 [1. 17, 1. 83] 1. 48 [1. 01, 2. 17] 1. 54 [1. 18, 2. 02] 1. 55 [1. 12, 2. 15] 2. 29 [1. 55, 3. 38] 2. 34 [1. 75, 3. 14] 5. 28 [2. 93, 9. 50] 1. 61 [1. 35, 1. 92] Lerman 1997 Wolf 2000 Whelan 2004 McBride 2002 Schapira 2000 Dodin 2001 O'Connor 1998-RCT Whelan 2003 McAlister 2005 Man-Son-Hing 1999 Gattellari 2003 Total (95% CI) Total events: 896 (Decision Aid), 558 (Usual Care) Test for heterogeneity: ? 2 = 52. 06, df = 10 (P ; 0. 00001), I? = 80. 8% Test for overall effect: Z = 5. 34 (P ; 0. 00001) 0. 1 0. 2 0. 5 1 Favours Usual Care 2 5 10 Favours Decision Aid Figure 4 Effect of patient decision aids on the proportion of patients classified as having accurate risk perceptions. RR = relative risk; CI = confidence interval. congruence. Holmes-Rovner and others62 measured the correlation between the subjective expected value of hormones and women’s likelihood of taking HRT, converted here to the percentage of variance in likelihood explained by alues. Dodin and others24 measured the percentage of variance in decisions explained by values. O’Connor and others55 used logistic regression to estimate the percentage agreement between values and choice. PtDAs improved value congruence with the chosen option in 2 of 3 studies. In the trial by Dodin and others,24 24% of the variance in HRT decisions wa s explained by personal values when a detailed PtDA with explicit values clarification was used; in contrast, 14% of the variance in decisions was explained when a simpler PtDA was used (P = 0. 003). In the study by Holmes-Rovner and others,62 the percentage of variance in the likelihood of choosing HRT that was explained by women’s expected values was greater when a more detailed PtDA was used (13%–14%) than when a simpler PtDA was used (0. 09%–2%). O’Connor and others55 found that the addition of an explicit values clarification exercise in a PtDA did not improve agreement between values and the chosen option. However, in the subgroup of women who chose HRT, women who used the PtDA with explicit values clarification DECISION AIDS: PAST, PRESENT, AND FUTURE ad a trend toward better agreement (40%) than did those who used an identical PtDA without explicit values clarification (0%, P = 0. 06). Decision Processes Leading to Decision Quality There were no trials evaluating the extent to which PtDAs helped patients to recognize that a decision needs to be made, understand that values affect the decision, and discuss values with their practitioner. Althoug h 8 trials evaluated effects on patient participation, none focused on helping patients become involved in preferred ways. Some studies measured patients’ self-reports about feeling informed and clear about personal values. The measures used to evaluate these 2 criteria were 2 subscales of the Decisional Conflict Scale (DCS). The DCS is reliable, discriminates between those who make or delay decisions, is sensitive to change, and discriminates between different decision support interventions. 54,79 The scores are standardized to range from 0 (no decisional conflict) to 100 points (extreme decisional conflict). Scores of 25 or lower are associated with follow through with decisions, whereas scores that exceed 38 are associated with delay in decision making. 54 When PtDAs are compared with usual care, 565 Downloaded from mdm. agepub. com by guest on July 22, 2012 O’CONNOR AND OTHERS Study or subcategory y Decision Aid N Mean (SD) 22. 17(9. 47) 27. 56(10. 51) 16. 25(13. 75) 29. 93(17. 26) 15. 75(13. 00) 20. 00(21. 50) 15. 75(13. 25) 15. 00(12. 50) 21. 67(15. 83) 32. 50(15. 00) Usual Care N Mean (SD) 58 45 54 93 37 94 148 215 159 56 959 49. 14(25. 40) 38. 88(20. 02) 27. 25(15. 00) 38. 89(22. 53) 24. 50(21. 25) 27. 50(21. 50) 21. 00(14. 75) 20. 00(15. 00) 25. 83(19. 17) 31. 67(14. 17) WMD (random) 95% CI Weight % 8. 64 9. 09 10. 03 9. 73 7. 93 9. 28 11. 82 12. 25 11. 33 9. 90 100. 00 WMD (random) 95% CI -26. 97 [-34. 1, -19. 93] -11. 32 [-17. 83, -4. 81] -11. 00 [-16. 43, -5. 57] -8. 96 [-14. 73, -3. 19] -8. 75 [-16. 67, -0. 83] -7. 50 [-13. 79, -1. 21] -5. 25 [-8. 49, -2. 01] -5. 00 [-7. 60, -2. 40] -4. 16 [-8. 05, -0. 27] 0. 83 [-4. 74, 6. 40] -8. 35 [-11. 89, -4. 80] 02 Uninformed Subscale Montgomery 2003 50 Murray BPH 2001 52 Laupacis 2006 54 Murray HRT 2001 93 Dolan 2002 41 Morgan 2000 86 Man-Son-Hing 1999 139 McAlister 2005 219 Wong 2006 154 Bekker 2004 50 Subtotal (95% CI) 938 Test for heterogeneity: 48. 12, df = 9 (P ; 0. 00001), I? = 81. 3% Test for overall effect: Z = 4. 61 (P ; 0. 0001) -50 0 Favours Decision Aid 50 Favours Usual Care ?2 = Figure 5 Effect of patient decision aids on patients’ scores on the Uninformed subscale of the Decisional Conflict Scale: d ecision aid versus usual care. WMD = weighted mean difference; CI = confidence interval. Study or subcategory y Detailed DA N Mean (SD) 22. 50(17. 50) 17. 50(12. 50) 20. 75(10. 75) 22. 50(17. 50) 38. 25(12. 00) Simple DA N Mean (SD) 84 49 45 100 12 27. 50(20. 00) 22. 25(14. 75) 24. 00(16. 00) 20. 00(17. 50) 31. 25(10. 75) W MD (random) 95% CI W eight % 20. 52 21. 72 22. 00 23. 42 12. 34 100. 00 W MD (random) 95% CI -5. 0 [-10. 73, 0. 73] -4. 75 [-10. 10, 0. 60] -3. 25 [-8. 51, 2. 01] 2. 50 [-2. 34, 7. 34] 7. 00 [-2. 12, 16. 12] -1. 32 [-5. 27, 2. 62] 02 Uninformed Subscale O'Connor 1998-RCT 81 Dodin 2001 52 Goel 2001 76 O'Connor Wells 1999 101 Lalonde 2006 12 Subtotal (95% CI) 322 290 Test for heterogeneity: ? 2 = 9. 24, df = 4 (P = 0. 06), I? = 56. 7% Test for overall effect: Z = 0. 66 (P = 0. 51) -50 0 Favours Detailed DA 50 Favours Simple DA Figure 6 Effect of patient decision aids on patients’ scores on the Uninformed subscale of the Decisional Conflict Scale: detailed ve rsus simple decision aid (DA). WMD = weighted mean difference; CI = confidence interval. a negative score indicates a reduction in decisional conflict, which is in favor of the PtDA. In our review, 15 trials used the DCS subscale for feeling informed and 13 trials used the DCS subscale for feeling clear about values. Because this DCS subscale measures self-reported comfort with knowledge and not actual knowledge, we elected to consider it a process measure and to reserve the gold standard of objective knowledge tests in assessing decision quality. The WMD in feeling uninformed about options, benefits, and harms was –8. (95% CI = –11. 9 to –4. 8) in the 10 trials16,25,39,43,44,48,50–52,78 that compared the PtDAs to usual care (Figure 5). The 5 trials that compared detailed with simpler PtDAs24,30,38,54,55 had a WMD in feeling uninformed of –1. 3 (95% CI = –5. 3 to 2. 6; Figure 6). Eight trials comparing PtDA to usual care25,39,43,44,48,50–52 had a WMD of –6. 3 (95% CI = –10. 0, –2. 7) for feeling clear about values (Figure 7). Five trials compared detailed to simpler PtDAs. 24,30,38,54,55 For these trials, the WMD in feeling clear about values was –1. 1 (95% CI = –4. 8 to 2. ; Figure 8). 566 †¢ MEDICAL DECISION MAKING/MON–MON 2007 Downloaded from mdm. sagepub. com by guest on July 22, 2012 DECISION AIDS â€Å"EFFECTIVENESS CRITERIA OF DECISION AIDS† Study or sub-category Decision Aid N Mean (SD) 50 54 41 82 53 139 219 86 724 28. 50(12. 50) 18. 75(16. 50) 19. 75(15. 75) 37. 50(15. 00) 35. 38(12. 33) 16. 25(12. 50) 15. 00(12. 50) 30. 00(3. 25) Usual Care N Mean (SD) 58 55 37 84 45 148 215 94 736 51. 29(25. 73) 30. 00(17. 00) 29. 25(24. 00) 42. 85(16. 57) 40. 56(16. 44) 19. 00(14. 75) 17. 50(15. 00) 30. 00(3. 25) WMD (random) 95% CI Weight % 9. 8 11. 11 8. 15 12. 88 11. 64 14. 75 15. 30 16. 40 100. 00 WMD (random) 95% CI -22. 79 [-30. 26, -15. 32] -11. 25 [-17. 54, -4. 96] -9. 50 [-18. 61, -0. 39] -5. 35 [-10. 16, -0. 54] -5. 18 [-11. 02, 0. 66] -2. 75 [-5. 91, 0. 41] -2. 50 [-5. 10, 0. 10] 0. 00 [-0. 95, 0. 95] -6. 33 [-9. 98, -2. 69] 03 Unclear Values Subscale Montgomery 2003 Laupacis 2006 Dolan 2002 Murray HRT 2001 Murray BPH 2001 Man-Son-Hing 1999 McAlister 2005 Morgan 2000 Subtotal (95% CI) Test for heterogeneity: 57. 71, df = 7 (P ; 0. 0 0001), I? = 87. 9% Test for overall effect: Z = 3. 40 (P = 0. 007) -50 Favours Decision Aid 0 50 Favours Usual Care ?2 = Figure 7 Effect of patient decision aids on patients’ scores on the Unclear Values subscale of the Decisional Conflict Scale: decision aid versus usual care. WMD = weighted mean difference; CI = confidence interval. Study or sub-category y Detailed DA N Mean (SD) 81 77 52 12 97 25. 00(17. 50) 24. 00(12. 50) 25. 00(13. 75) 39. 50(10. 75) 22. 50(15. 00) N 84 45 49 12 100 Simple DA Mean (SD) 32. 50(17. 50) 25. 75(15. 75) 24. 75(13. 50) 37. 50(13. 00) 20. 00(15. 00) W MD (random) 95% CI W eight % 21. 23 21. 09 21. 32 10. 94 25. 42 100. 0 W MD (random) 95% CI -7. 50 [-12. 84, -2. 16] -1. 75 [-7. 13, 3. 63] 0. 25 [-5. 07, 5. 57] 2. 00 [-7. 54, 11. 54] 2. 50 [-1. 69, 6. 69] -1. 05 [-4. 81, 2. 70] O'Connor 1998-RCT Goel 2001 Dodin 2001 Lalonde 2006 O'Connor Wells 1999 Subtotal (95% CI) 319 290 Test for heterogeneity: ? 2 = 9. 02, df = 4 (P = 0. 06 ), I? = 55. 7% Test for overall effect: Z = 0. 55 (P = 0. 58) -50 0 Favours Detailed DA 50 Favours Simple DA Figure 8 Effect of patient decision aids on patients’ scores on the Unclear Values subscale of the Decisional Conflict Scale: detailed versus simple decision aid (DA). WMD = weighted mean difference; CI = confidence interval. Post hoc Analysis Effects of study quality. To examine the effect of possible bias from including trials of low methodological quality, the 13 trials15,21,31,34. 41,45,54,56,58,61,63,66,77 with Jadad scores of 0 or 1 were excluded from the analysis. Overall, the results remained the same. There was a significant improvement in knowledge scores for the comparison of PtDAs to usual-care controls (WMD = 14. 0%, 95% CI = 2. 4, 8. 6) and for the comparison of detailed to simpler PtDAs (WMD = 5. 5%, 95% CI = 2. 4, 8. 6). The proportion of patients having accurate risk perceptions was greater for patients receiving PtDAs with information on outcome probabilities (RR = 2. 0, 95% CI = 1. 4, 2. 8). Publication bias. There were too few studies to explore potential publication bias for all of the outcomes, with the exception of knowledge for the comparison of PtDAs to usual care. The funnel plot for this outcome (Figure 9) points to the absence of smaller negative studies. DECISION AIDS: PAST, PRESENT, AND FUTURE Downloaded from mdm. sagepub. com by guest on July 22, 2012 567 O’CONNOR AND OTHERS Comparison: 01 Decision Aids versus Usual Care Outcome: 0 07 Knowledge: Decision Aids vs Usual Care SE(WMD) 2 4 6 8 -100 -50 0 50 100 WMD (fixed) Figure 9 Funnel plot of all 18 randomized controlled trials comparing patient decision aids to usual care (knowledge). WMD = weighted mean difference. Heterogeneity. There was statistically significant heterogeneity when PtDAs were compared with usual care for 4 outcomes: knowledge test scores, realistic risk perceptions, feeling uninformed, and feeling unclear regarding personal values (Table 3). It should be noted that the heterogeneity of the effect was not in the direction but in the size. When we explored the potential factors contributing to heterogeneity (Table 3), we found that none of the factors eliminated heterogeneity for the outcomes of knowledge scores. When grouped into treatment and screening decisions, the WMD for knowledge scores was slightly higher for the treatment group (16. 6% v. 13. 1%), but there was still statistically significant heterogeneity. For the outcomes of accurate risk perceptions, heterogeneity was not significant when we removed 3 studies with lower accurate risk perception scores in the usual-care control group (P = 0. ). 28,43,44 For the outcome of feeling uninformed, heterogeneity was no longer significant with 1) removal of 3 studies with higher uninformed scores in the usual-care control group (P = 0. 11), 2) inclusion of only audio booklet/ pamphlet decision aids (P = 0. 06), and 3) removal of an outlier48 (P = 0. 06). None of the factors eliminated heterogeneity for the outcomes of unclear values scores. DISCUSSION The majority o f trials report on at least 1 IPDAS effectiveness measure, predominately knowledge test scores. Of those reporting IPDAS measures, we found that PtDAs were superior to usual practices in 568 †¢ MEDICAL DECISION MAKING/SEP–OCT 2007 meeting the new IPDAS standards 1) for decision quality and 2) for 2 process measures (feeling informed and feeling clear about personal values). Detailed PtDAs had superior effects over simpler PtDAs on value congruence with the chosen option and on accurate risk perceptions but not on knowledge test scores or on self-reports about feeling informed and feeling clear about values. We also identified the gaps in the use of measures of effectiveness endorsed by IPDAS, notably, value congruence with the chosen option and most of the decision process measures. There are some study limitations. Study quality ratings of all trials included in the review were low because they all lost 2 points for lack of blinding. Although not an a priori exclusion criterion for this review, in the future, we may consider using study quality ratings for the selection of included trials. The conclusions of this review are limited by 1) inadequate power to detect important differences in effectiveness in subgroups and 2) the wide variability in the decision contexts, the elements within the PtDAs, the type of comparison interventions, the targeted outcomes, and the evaluation procedures. This article focuses solely on measures of effectiveness, not harms. The small number of studies for most outcomes did not allow for analysis of publication bias because of the failure to publish negative studies. Moreover, there may have been publication bias because of failure to report all negative findings in a published study. Lastly, several of the outcomes demonstrated statistically significant heterogeneity. It reflects differences across clinically diverse studies; therefore, the pooled effect size and CI should be interpreted as a range across conditions, which may not be applicable to a specific condition. There are several implications for future research. Studies are needed to evaluate the effects of PtDAs on congruence between values and chosen options. Moreover, the methods for quantifying value congruence should be explored. The IPDAS decision processes criteria leading to decision quality should also be measured. It would be helpful to develop a standardized approach to measurement. With the addition of more trials to the database, it may be possible to tease out the reason for heterogeneity of results, including variability in 1) study quality, 2) comparison intervention, 3) elements within PtDAs, 4) decision type, and 5) format of decision aid (e. g. , video, Internet, booklet). The degree of detail in PtDAs that is required for positive effects on IPDAS criteria should also be explored. Downloaded from mdm. sagepub. com by guest on July 22, 2012 Table 3 Exploration of Potential Factors Affecting Heterogeneity Outcome Overall Effect Treatment Decision Screening Decision Video/Computer Decision Aid Audio/Pamphlet Decision Aid Baseline Risk in Usual-Care Groupa Removal of Outliers Knowledge 1. 6 (1. 4, 1. 9) –3. 5 (–12. 9, 5. 8) 1. 6 (1. 1, 2. 3) No data 15. 2 (11. 7, 18. 7) 16. 6 (12. 0, 21. 2) 13. 1 ( 7. 7, 18. 5) 21. 4 (16. 5, 26. 2) 11. 9 (8. 3, 15. 6) 1. 6 (1. 4, 1. 9) 15. 6 (11. 3, 19. 9) 1. 3 (1. 2,1. 5)* 1. 6 (1. 4, 1. 9) 17. 316,28,36 (13. 7, 20. 9) 1. 528 (1. 3, 1. 7) –8. 4 (–11. 9, –4. 8) –9. 4 (–13. 3 –5. 5) 12. 6 (–19. 5, –5. 8) –4. 9 (–7. 6, –2. 3)*** –5. 4 (–7. 7, –3. 2)** –6. 248 (–8. 4, –4. 1)*** –8. 0 (–15. 1, –1. 0) –4. 5 (–8. 4, –0. 6) –3. 6 (–6. 8, –0. 5) –4. 0 r48 (–6. 7, –1. 3) Downloaded from mdm. s agepub. com by guest on July 22, 2012 Accurate risk perceptions Uninformed Subscale of the Decisional Conflict Scale Unclear values subscale of the Decisional Conflict Scale –6. 0 (–9. 8, –2. 3) Insufficient data –6. 3 (–10. 0, –2. 7) Note: Values are presented as the weighted mean treatment effect (95% confidence interval). Chi-square heterogeneity test P value