Observing patient involvement in decision making

Abstract

The Observing Patient Involvement in Decision Making scale, generally known as the OPTION scale (Observing Patient Involvement), is a 12-item observational instrument designed to quantify the extent to which healthcare providers engage patients in the process of shared decision making (SDM) during clinical consultations. Developed by Elwyn G, et al. (2003), the scale provides researchers and quality assurance teams with a systematic method to evaluate the quality of provider-patient communication and collaboration, ensuring that decisions reflect both clinical evidence and patient preferences.

Keywords

OPTION scale, shared decision making, patient involvement, clinical communication, decision aids, healthcare quality, patient-centered care.

Authors

Elwyn G, et al. (2003)

Purpose

The primary purpose of the OPTION scale is to assess and score the observable behaviors exhibited by clinicians that actively facilitate shared decision making (SDM). It moves beyond simple observation to provide a quantifiable metric of the provider’s effort in involving the patient in complex treatment choices.

The scale is instrumental in research for measuring the effectiveness of educational interventions aimed at improving SDM skills among healthcare professionals. Furthermore, it serves as a crucial tool for auditing clinical encounters, helping organizations identify gaps in current practice and implement targeted quality improvement programs focused on enhancing patient involvement in their care pathways.

Construct

The OPTION scale measures the behavioral realization of the **Shared Decision Making** construct. SDM is defined as a collaborative process where the patient and the clinician jointly arrive at a healthcare decision, integrating clinical evidence with the patient’s unique values, preferences, and circumstances. The scale focuses specifically on the clinician’s contribution to this partnership, assessing whether necessary steps—such as presenting options, assessing patient preferences, and clarifying roles—are executed effectively.

The 12 items of the instrument operationalize SDM by dividing the process into discrete, observable communication behaviors. A high score indicates that the clinician systematically attempted to ensure the patient understood the available options and actively participated in the deliberation and final choice of action.

Validity

Initial validation studies confirmed the content and face validity of the OPTION scale, ensuring the 12 items comprehensively cover the essential elements of the SDM process as understood by expert consensus. Construct validity has been supported by findings that scores on the OPTION scale correlate logically with other measures of patient-centeredness and overall communication quality in clinical settings. The scale has demonstrated its ability to differentiate between consultations where SDM training was received versus those where it was not.

While the original version has been criticized for potentially having a ceiling effect or low inter-item correlation, its widespread use across diverse clinical environments confirms its ecological validity. Subsequent revisions, such as the OPTION-5, were developed partly to address psychometric limitations and improve the scale’s sensitivity to subtle changes in SDM behavior.

Reliability

Reliability concerns for the OPTION scale center predominantly on inter-rater reliability, as the instrument relies on trained observers to score the consultations. Studies have generally reported acceptable to good inter-rater agreement, typically yielding Intraclass Correlation Coefficients (ICCs) ranging from 0.60 to 0.85, indicating that different observers can consistently apply the scoring rules following adequate training.

High reliability is contingent upon rigorous and standardized observer training protocols, which must ensure a shared understanding of the specific behavioral anchors for each scoring point (0 to 4). When training is insufficient, reliability tends to drop, highlighting that the scale measures the execution of communication skills which require careful interpretation by the observer.

Factor Analysis

Factor analysis studies conducted on the 12-item OPTION scale often reveal complex dimensional structures. While some research suggests that the scale is largely unidimensional, reflecting a singular latent construct of ‘overall SDM effort,’ other analyses support a multi-factor model.

Commonly, two main factors emerge: the first relating to **information provision and option presentation** (e.g., listing options, discussing pros and cons), and the second related to **eliciting patient input and deliberation** (e.g., checking patient understanding, exploring patient values and preferences). Despite these factorial nuances, the scale is most frequently used to derive a single total score, which is then often normalized to a 0–100 range for ease of interpretation and comparison across studies.

Instrument

Test Type: Observational Rating Scale / Behavioral Checklist

Format: 12 items, typically scored on a 5-point Likert scale (0 = behavior not observed, 4 = behavior observed to a high standard).

Language Available: Originally English; translated and adapted for use in numerous languages including Dutch, German, French, and Spanish.

Population Group: Healthcare providers (rated by observers) interacting with patients (Adults and Elderly).

Age Group: Adults and Elderly (patients).

Population Details: Utilized in various clinical contexts where complex treatment or screening decisions are required, demonstrating its relevance across primary care, specialist consultations, and chronic disease management.

Test Methodology: Trained observers score the instrument based on video or audio recordings of real or simulated clinical encounters. The total score reflects the degree to which the clinician actively involved the patient in the decision-making process.

Keywords

Elwyn G, observational scale, patient preferences, clinical encounters, healthcare communication, decisional conflict, quality improvement.

Authors

Author ORCID Identifier: N/A

Affiliation Email addresses: N/A

Correspondence Address: N/A

Permissions & Fee and Test Year

The original OPTION scale was published in 2003. It is widely used in academic research, but investigators are typically advised to contact the lead author, Glyn Elwyn, for definitive permissions regarding commercial use or extensive modifications. The source content provides links to the scale documentation. The original PDF explaining the scale (Toelichtingsformulier) can be downloaded here: Option-form.pdf. The original instrument (Meetinstrument) can be downloaded here: Option-meetinstr.pdf.

Reference’s

• Elwyn G, Hutchings R, Edwards A, Kinnersley P, Grol R, Cochrane A. The OPTION scale: measuring the extent to which clinicians involve patients in decisions. Assessment of quality in six clinical settings. BMJ. 2003 May 31;326(7398):967.
• Elwyn G, Edwards A, O’Connor A. Assessing the quality of shared decision making in the encounter: a systematic review of measures. J Gen Intern Med. 2005 Jan;20(1):93-102.
• Joseph-Williams N, Elwyn G, Edwards A. Knowledge, skills, and confidence to implement shared decision making in clinical practice: the OPTION scale. J Eval Clin Pract. 2014 Dec;20(6):1063-8.

Items of the Observing patient involvement in decision making

IMPORTANT: The following scale items must be preserved in their original language and must not be changed in any way.

The following are the typical items assessed by the 12-item OPTION scale (Observing Patient Involvement), translated to English for conceptual clarity:

1. The clinician draws attention to the fact that a decision needs to be made.
2. The clinician states that there is more than one way of dealing with the problem.
3. The clinician checks the patient’s understanding of the problem/decision.
4. The clinician lists the options, including the option of ‘no action.’
5. The clinician describes the advantages and disadvantages of each option.
6. The clinician explores the patient’s ideas and expectations about the options.
7. The clinician explores the patient’s concerns and fears about the options.
8. The clinician checks the patient’s preferred role in decision making.
9. The clinician offers support or guidance in the decision-making process.
10. The clinician clarifies the next steps in the decision-making process.
11. The clinician checks if the patient is ready to make a decision.
12. The clinician and patient reach a shared decision or agree on a plan for the next steps.