Toward Mutual Engagement: A Narrative-based Model of Shared Decision-making

Abstract

Background
In the past 20 years, shared decision-making (SDM) has become an increasing worldwide medical ethics and practice. Shared decision-making emphasizes information provision, mutual engagement, and decision-making based on patients’ preferences. However, the current research mainly focuses on exchanging medical information and understanding patients’ preferences, little is discussed about mutual engagement. Knowledge difference as divided narratives between physicians and patients produces power imbalance in communication, which hinders mutual engagement in shared decision-making. Thus, the entanglement of narrative, power, and agency influences the high quality of shared decision-making.

Objective
This study investigates the interplay between divided narratives, power imbalance, and mutual engagement in shared decision-making to develop a substantive theory that can be applied in the medical context and other contexts of transformative communication.

Theoretical Framework
The theoretical framework mainly draws on the ideas of relational agency conceptualized by Mustafa Emirbayer and Ann Mische, knowledge/power from Michel Foucault, and narrative co-construction perspective from Sally Jacoby and Elinor Ochs. From a relational perspective, shared decision-making is a narrative co-construction process in which physicians and patients negotiate the meanings of illness and treatment, the problems to solve, and their preferred identities.

Methodology
This thesis project adopted a qualitative design and was conducted in two top-level hospitals in north-western China: a state-owned hospital with over 4,000 beds and a private hospital with 3,000 beds. To understand the shared decision-making process, I conducted three months of ethnographic fieldwork in the hospitals, observing the communication between physicians and cancer patients. I interviewed 32 cancer patients and 26 physicians in total. A combined methodology of grounded theory and narrative inquiry was applied in this study to generate research findings.

Findings
The findings present the characteristics of divided narratives between physicians and patients during shared decision-making on cancer treatment. This study further explores the process of narrative integration in shared decision-making. Moreover, this study’s investigation of narrative co-construction reveals four stages and three modes of narrative co-construction in shared decision-making on cancer treatment. This study identifies a core social process of narrative recontextualization among the three modes of narrative co-construction.

Discussion
This study contributes to a group of literature. First, this study can significantly contribute to shared decision-making research and practice. The findings in this study can conceptualize mutual engagement and further develop a narrative-based model of shared decision-making. Second, this study enriches the theoretical concepts of power, narrative, and agency. The descriptions of mutual engagement and privilege equilibrium extended Foucault’s discussion of power and agency. The narrative analysis of context provides a fundamental framework of narrative recontextualization. This study also contributes to the literature on relational agency by discussing the boundary of context and engagement orientations. Third, this study proposes a narrative perspective of structure and agency, which dissolves the micro and macro dualism in sociology. The core social process of recontextualization explains the mechanism of meaning-making and transformation, reflecting the production and reproduction of society at various scales. Therefore, this study has a solid potential to richly fertilize the ground of narrative sociology.

Conclusion
Agency in communication is an issue closely related to power and narrative. The existing sociological discussions cover the relationships between power and agency, narrative and agency, power and narrative in the ideas of power and the subject, structure and agency, narrative co-construction, and relational agency. However, no theory investigates the interplay between narrative, power, and agency in the agentic process. This study investigates this interplay in the context of shared decision-making on cancer treatment. This study unfolds a core social process of narrative recontextualization, which navigates preferred identity construction and mutual engagement as agency in communication and the boundary of relations as structure. Thus, the findings indicate a narrative-based model of shared decision-making and inform a narrative perspective of sociology.

Date of Award	11 Sept 2024
Original language	English
Awarding Institution	City University of Hong Kong
Supervisor	Sing Wing Dennis WONG (Supervisor), Oi Wah Esther CHOW (Supervisor) & Chau Kiu Jacky CHEUNG (Co-supervisor)