8.1 Shared Decision-Making
Key Takeaways
- Shared decision-making is named on the current TCO under Domain IV Implementation (therapeutic communication, with motivational interviewing) and is how Domain III Planning puts preference-sensitive choices on the plan.
- Classic FNP preference-sensitive decisions: statin primary prevention, PSA (USPSTF Grade C ages 55–69), mammography at the age-40 and age-75 edges, anticoagulation in older atrial fibrillation with fall risk, and physical therapy versus arthroscopy for a degenerative meniscus tear.
- Use the three-talk model conceptually: team talk (partnership), option talk (compare reasonable options), decision talk (values → a named choice or a planned delay).
- Communicate risk with absolute numbers and a shared denominator and time horizon — never a relative-risk headline such as “cuts your risk in half.”
- SDM stops when delay is the harm or the law governs the next act: unstable emergency (ACS, anaphylaxis, stroke in window) and mandatory abuse reporting are not preference menus.
The current FNP-BC Test Content Outline lists shared decision making by name under Domain IV Implementation, skill 4: therapeutic communication (the official parenthetical is motivational interviewing and shared decision making). Domain III Planning — 29 scored items, 19% through October 18, 2026 and still 29/19% beginning October 30, 2026 — does not print those three words, but Planning is where preference-sensitive choices actually land on the care plan: whether a statin is started, whether a PSA is drawn, whether a 42-year-old books a mammogram this year, whether an 84-year-old with atrial fibrillation starts a DOAC, whether a 58-year-old with a degenerative meniscus tear goes to physical therapy or to the operating room. Treat the overlap as a feature. If the stem asks what belongs on today’s plan after values are elicited, you are in Planning. If the stem asks how you talk — the three-talk sequence, teach-back, absolute-risk language — you are in Implementation. The same visit is often both.
ANCC will not ask you to cite Elwyn. It will give you a preference-sensitive stem and a set of FNP moves, one of which is paternalism dressed as “the guideline says so,” and one of which is abandonment dressed as “whatever you want.” Shared decision-making (SDM) is the third path: more than one medically reasonable option exists, the trade-offs depend on what this person values, and you and the patient (or surrogate) decide together using understandable evidence.
When a choice is preference-sensitive
A choice is preference-sensitive when guidelines leave a range, when two options have similar benefit but different harms, or when the benefit is modest and the harm is personal (bleeding, incontinence, another pill, a month of missed work). It is not preference-sensitive when only one option is safe (epinephrine for anaphylaxis) or when the law, not the preference, governs the next act (mandatory abuse reporting).
| Decision | Why it is preference-sensitive | What the FNP must not do |
|---|---|---|
| Statin for primary prevention | USPSTF Grade B is an offer of a statin to adults 40–75 with ≥1 CVD risk factor and 10-year risk ≥10%; Grade C at 7.5% to <10%; Grade I after 75. ACC/AHA still wants a risk discussion, not a reflex prescription. | Start high-intensity atorvastatin because “everyone over 10% gets a statin,” or refuse to discuss it because “statins are controversial online.” |
| PSA screening | USPSTF Grade C for men 55–69 (individual decision); Grade D at 70 and older. False positives, biopsy, overdiagnosis, incontinence, and erectile dysfunction are real. | Order PSA on every 58-year-old “just to be safe,” or refuse it for an informed 62-year-old who wants it after a decision-aid conversation. |
| Mammography at the edges | Current USPSTF is biennial screening ages 40–74 (Grade B). Historically 40–49 was Grade C. After 75 remains Grade I. Annual versus biennial, start-now versus start-later, and continue-after-74 are still value-laden. | Tell a 41-year-old that starting now is mandatory, or tell a vigorous 76-year-old that screening is forbidden. |
| Anticoagulation in older AF with falls | Annual stroke risk (CHA2DS2-VASc) versus bleed risk. Isolated falls rarely outweigh stroke prevention; many older adults still benefit from a DOAC. Fear of falling is a preference, not an automatic contraindication. | Withhold apixaban solely because “she fell last year,” or start warfarin without discussing bleed, monitoring, and diet. |
| Surgery versus PT for degenerative meniscus | In middle-aged and older adults with degenerative tears, arthroscopy is often no better than structured physical therapy. A locked traumatic knee in a younger adult is a different disease. | Refer every MRI-positive meniscus to orthopedics “because there is a tear on the film.” |
The three-talk model (conceptually)
Use Elwyn’s three talks as a checklist, not a script you recite on the exam.
1. Team talk. Make it explicit that this is a partnership and that doing nothing, or delaying, is on the table when it is medically reasonable. “There is more than one reasonable way to handle this. I want us to decide together. I will bring the medical facts; you bring what matters in your life.” Team talk also names who else belongs in the room (adult child, interpreter, spouse) and that you will not abandon the patient if they choose the less aggressive option.
2. Option talk. List the live options, including watchful waiting. Describe benefits and harms with the same denominator and the same time horizon. Do not stack the deck by describing only the benefits of the option you prefer. Decision aids, icon arrays, and printed USPSTF or specialty-society summaries belong here when they exist.
3. Decision talk. Ask what matters: avoiding a bleed, avoiding a heart attack, staying off another pill, seeing a grandchild graduate, not spending a month in physical therapy. Check understanding with teach-back. Then name the decision or name the delay: “We will start a moderate-intensity statin and recheck in 6–12 weeks,” or “We will not draw a PSA today; we will revisit at the next wellness visit.” A deferred decision is still a decision if it is informed and documented.
Do not confuse three-talk SDM with motivational interviewing. MI (listed under the same TCO communication skill) is for ambivalence about a behavior the person already has reason to change — tobacco, alcohol, missed insulin. SDM is for choosing among medically reasonable plans. You can use both in one visit. You cannot substitute a pep talk for option talk.
Risk communication: absolute numbers, not relative scare
Candidates lose items when the FNP in the stem says “this statin cuts your heart-attack risk in half.” Relative risk is how press releases sell drugs. Patients hear “half” and picture a coin flip.
Use natural frequencies and a shared denominator:
- Statin, primary prevention: “Without a statin, about 12 in 100 people with your risk have a heart attack or stroke in the next 10 years. With a statin, that number is lower by a few people per 100 over that same 10 years. About 1 in 100 will have muscle symptoms that make them stop, and a smaller number will develop diabetes they would not otherwise have had.”
- PSA: “If 1,000 men 55–69 are screened for 10–15 years, a handful of prostate-cancer deaths may be prevented, and many more will have a false-positive, a biopsy, or treatment for a cancer that would never have harmed them. Some of those treated men will have lasting urinary leakage or erectile problems.”
- Anticoagulation: “With your CHA2DS2-VASc score, untreated annual stroke risk is the number that score predicts — several people per 100 per year at higher scores. A DOAC cuts that substantially. The extra major-bleed risk is smaller than the stroke risk for most people with your score, including many people who have fallen. We still have to talk about what a bleed would mean for you.”
Do not invent a precise unpublished number if the stem does not give one. Use the stem’s risk score, or speak in “about X in 100” language. Never convert a relative-risk headline into a guarantee.
Same-denominator rules: one time horizon (10 years for primary-prevention ASCVD; 1 year for AF stroke); include the option of no intervention; name both benefit and harm; avoid adjectives (“huge,” “tiny”) without a number; offer a written or pictorial aid when literacy, language, or anxiety is high.
Teach-back is how you know the talk worked
Teach-back is not a pop quiz and not “do you understand?” — everyone says yes. It is: “I want to make sure I explained this clearly. When you get home, what will you tell your partner about the two choices and what we decided?” If they cannot restate the options, the numbers, or the next step, you did not finish option talk. Re-explain in a different way — shorter sentences, a drawing, an interpreter — and teach-back again. Document the decision and that understanding was confirmed.
Teach-back also catches the family member who is deciding against the patient’s stated values, and the patient who heard only “cancer” from a PSA discussion.
When SDM is not the next move
SDM requires time, capacity, and more than one reasonable option. It is the wrong tool when delay itself is the harm or when the law, not preference, governs.
| Situation | Why SDM does not pick the destination | What the FNP does |
|---|---|---|
| Unstable emergency — STEMI-equivalent chest pain, anaphylaxis, tension pneumothorax, status epilepticus, active hemorrhage, stroke in the thrombolysis or thrombectomy window | Implied consent. Only one safe path. | Activate EMS / ED / the code. Explain while you act if the patient is conscious. Do not hold epinephrine to “discuss options.” |
| Mandatory abuse or neglect reporting (child, elder, vulnerable adult); some intimate-partner situations with imminent danger | Reporting is a legal duty, not a menu item. | Report. You may still use therapeutic communication about how you support safety. You do not ask permission to report. |
| Reportable disease when statute requires public-health notification | Same: duty, not preference. | Treat the patient, notify public health, protect contacts as required. |
| No decision-making capacity and no time to find a surrogate | Emergency exception. | Treat the threat. Find the surrogate as soon as the patient is stable. |
| A request that is not a medically reasonable option (antibiotics for a viral URI as a “choice,” or a demand to keep driving after an unreported seizure) | SDM is among reasonable options. You may refuse a harmful act. | Explain why that option is not on the table. Offer the reasonable alternatives. |
Capacity is decision-specific. A person may have capacity to refuse a screening PSA and lack capacity to refuse hospital transfer during hypoxia. If the patient has capacity and refuses a recommended emergency transfer after you have explained the risk, that is informed refusal — document it, involve a supervisor or ethics resource if the risk is extreme, and do not pretend they “chose” by nodding.
Vignettes the exam style rewards
Statin. A 58-year-old man has a 10-year ASCVD risk of 12%, hypertension, and no prior event. He hates pills and wants to “try diet for a year.” Team talk: this is a partnership. Option talk: lifestyle alone versus moderate-intensity statin plus lifestyle, with absolute 10-year numbers; Grade B is an offer, not a court order. Decision talk: he chooses a 3-month intensive lifestyle trial with a firm revisit, or a statin now. Either can be correct if informed. “I will just put it on your med list so we stay at target” is not SDM.
PSA. A 64-year-old asks for “the prostate blood test” because his brother had Gleason 7 disease. You do not refuse and you do not swab the lab slip on the way to the door. You use a decision aid, name overdiagnosis, and let him choose. A 72-year-old with limited life expectancy and the same request gets a Grade D conversation: screening is not recommended; you still listen, but you do not treat his preference as a trump card over harm.
Mammography edges. A 41-year-old at average risk is anxious after a coworker’s diagnosis. Current USPSTF supports offering biennial screening from 40. You still do option talk: start now versus start in a few years, biennial versus the annual some societies prefer, false-positives and callbacks. A 76-year-old with advanced frailty and a 3-year prognosis does not get a reflex mammogram because “we always order it in October.”
AF and falls. An 84-year-old with nonvalvular AF, CHA2DS2-VASc 5, one mechanical fall in the bathroom, and a HAS-BLED that is not prohibitive. Daughter says “no blood thinners — she falls.” You do not let the daughter’s fear close the case. You give annual stroke versus bleed numbers, note that many people need a very high fall frequency before fall-related bleed outweighs stroke prevention, offer a DOAC rather than warfarin if anticoagulation is chosen, and fix the bathroom, vision, and orthostatics. Falls are a problem to treat, not an automatic veto.
Meniscus. A 57-year-old with medial knee pain, no locking, MRI degenerative meniscus tear, BMI 32. Option talk: structured PT, weight reduction, and activity modification versus arthroscopy, with the trial evidence that surgery often adds no lasting benefit. Decision talk may still end in an orthopedic visit if function is collapsing — but the MRI tear is not itself an operative indication.
When you cannot decide whether the stem wants SDM, ask: Is more than one option medically reasonable, and does the next act depend on this person’s values? If yes, the correct FNP move is team talk, option talk, decision talk, teach-back, and documentation. If no — the chest pain is ACS, the toddler has petechiae, the 8-year-old disclosed abuse — you act, transfer, or report, and you do not put the destination up for a vote.
In which situation is shared decision-making the wrong tool for choosing the next FNP action?
A 55-year-old has a 10-year ASCVD risk of 12% and no prior atherosclerotic event. Which statement is the correct FNP risk communication for a statin discussion?
An FNP is planning a PSA discussion with a 61-year-old who has heard that “the blood test finds cancer early.” Which sequence matches the three-talk model?
A 41-year-old at average breast-cancer risk is deciding whether to start biennial mammography now. Current USPSTF supports offering biennial screening from 40 to 74, but the start-now versus later and annual versus biennial edges remain preference-sensitive. Which FNP action is the best shared decision?