Creative Education
2012. Vol.3, Special Issue, 1031-103 3
Published Online October 2012 in SciRes (
Copyright © 2012 SciRes. 1031
Chilean University Students’ Call for Participation and
Engagement in What Matters to Them: Is It Possible to Achieve a
Shared Decision Making Process in Education Policy?
Paulina Bravo1, Baltica Cabieses2
1School of Nursing, Ponti fi cia U ni ve rs i d a d C a t ol i c a d e Chile, Santiago, Chile
2Faculty of Medicine, Universi dad del Desarrollo Chile, Santiago, Chile
Email: bravop17@gmail. com
Received August 30th, 2012; revised September 30th, 2012; accepted Oc tober 12th, 2012
Chile is facing one of its major intellectual revolutions in the last century: organised high school, college
and university students have led the most salient educational reform since the one that took place during
the dictatorship period. This phenomenon is a pacific revolution based on the power of sound, evi-
dence-based, clear and robust ideas. The purpose of this short essay is to reflect some ideas on the con-
ceptualization of a shared decision making (SDM) process and how they could be transferred to the cur-
rent students’ educational revolution in Chile. It provides a reflection on how SDM might concretely con-
tribute to this educational reform and on what future steps could be taken to truly achieve a “participa-
tory” democracy in Chile. According to the authors, this debate illustrates the extent to which the level of
participation must rely not on particular individuals but on the establishment of a partnership between
Keywords: Higher Education; Revolution; Democracy; Chile; Shared Decision Making Process
The Current Students’ Pacific Revolutionary
Movement in Chile, “Nothing about US without US
Chile is facing one of its major intellectual revolutions in the
last century: organized higher education students have led the
most salient educational reform since the one that took place
during the dictatorship period. As reported by different journal-
ists all over the world, hun dreds of thousands of high-school and
university students have refused to go to lessons s ince early June
2011, calling for better and more affordable education and an
end to a two-tier s ystem that creates a few wealthy, el ite colleges
amid many under-funded public ones.
This phenomenon is a pacific revolution based on the power
of sound, evidence-based, clear and robust ideas. It is also based
on profound and well-known social inequalities in Chile. As
Commander Camila Vallejo said in an interview outside the
presidential palace “We don’t want violence… our fight is to
recover the right to education, on that we have been emphatic
and clear” (Franklin, 2 011). What has been so con vincing of this
manifestation, not only to politicians but the entire civil society
in Chile is that this is a well-informed, thoughtful and pacific
protest, chall enging one of the gr eatest soc ial ineq uities in Chile,
opportunity to and quality of public education.
Education inequalities in Chile are significant and pervasive
over time. In 2006, 7% of the total Chilean population reported
no education at all, 35% primary level only, 30% secondary
education and the rest higher education (Cabieses et al., 2010).
The higher the educational level, the better health status and
general wellbeing; the higher living standards; and the longer the
life expectancy in the country. These patterns are maintained
after adjusting by age, sex and ethnicity. For example, between
1998 and 2006, life expectancy at age 20 increased by 1.5 years,
but this increase was not homogeneous by educational level. Life
expectancy at age 20 for men with out schooling increased by 0.8
years, while for the group with 13 or more years of education,
the increase was 2.8 years (Chilean Ministry of Health, 2011).
Education affects life opportunities, health and wellbeing from
early life and it is usually maintained over generations. Poor
people in Chile cannot afford adequate education since pre-
school onwards, and that affects other significant dimensions of
their development through the life span. Those in wealthy
families in turn, experience great opportunities and education
from early in their lives, which supports their healthy de-
velopment and the one of their future generations.
This revolution represents the existence of a well-informed
and empowered civil society in Chile, possibly a partial conse-
quence of the country’s socioeconomic instability and democra-
tic development in the past three decades. What is particularly
interesting of this situation is the consistent claim of students to
develop a real “participatory” democracy in Chile. They have
been challenged several times in the past weeks to explain what
they refer to exactly when they use this phrase, and they have
systematically approached this debate in a quite convincing way.
For them, Chile has not yet achieved true democracy, because
there is no real participation of different parts of society in the
decision making process of any policy or law in the country.
They insist in a s hared decision making (SDM) process from the
very early stages of any social process, and define such partici-
pation in the broadest possible way. To them, every individual
living in Chile should somehow have a clear voice to represent
them in the Senate and any other institution of the Government.
The purpose of this short essay is to reflect some ideas on the
conceptualization of a shared decision making process and how
they could be transferred to the current students’ revolution in
Chile. The key questions this essay aims to answer are the fol-
1) What is SDM, what are its components and stages?
2) How can the current knowledge on SDM contribute to the
debate held by the Chilean Government and the students in the
3) In opinion of the authors, what future steps shou ld be taken
to contribute to achieve true “participator y” democracy in Chile?
The Shared Decision Making Process (SDM), a
Conceptual Overview
SDM has been defined as a style of leadership (Kuhns and
Chapman, 2006). It provides empowerment to all parties in-
volved in a decision (Liontos, 1994) (North Central Regional
Educational Laboratory). This style of leadership has been most
studied in the health care context. Wi th almost 30 years of histor y,
researchers on S DM in health have stat ed that this is an approach
which involves people in the process of making decisions, con-
sidering people’s preferen ces, values and autonomy ( Hårter et al.,
2011). SDM in health has highlighted that the importance of
involving people in the d ecision making process is based on trust,
truthfulness and respect for people’s choices (Niemira, 2009). It
has been defined as an ethical imperative, because people have
the right to participate in decisions that matters to them (Elwyn,
2010). SDM does not support paternalistic approach, where
health providers are the “experts” and the only responsible for
the decision making process. Neither it is restricted to an in-
formed choice model, where sufficient information is provided
to the patient but health professionals abandon the decision
making process (Elwyn et al., 1999). SDM advocates for the
involvement of people in their health-related decisions, as they
become partners of the health provider. Health practitioner will
support the patient by providing the best evidence available to
inform patient about options, exploring their values and prefer-
ences in order to make the best decision for them (Edwards and
Elwyn, 2009).
In 1997, Charles, Gafni and Whelan proposed a model for
SDM. The model described characteristics and requirements
needed to achieve a SDM process. There is number of he althcare
contexts where patients face difficult, preference-sensitive de-
cisions (O’Connor et al., 2009). The health provider and the
patient become involved in the decision as they share informa-
tion (professionals will offer the best evidence available and
patient will share his experiences, values and feelings). Consider-
ing that SDM seeks to ensure that the patient has adequate and
accurate information, decision support interventions have been
developed to provide information about the options and prob-
abilities of risks and benefits of each alternative (Elwyn et al.,
2009). These interventions might help to build consensus and
achieve agreement. Figure 1 summarizes the model (Charles et al.,
How Can the SDM Contribute to the Debate
Held by the Chilean Government and the
Students in Chile?
Little has been described in Chilean literature about people’s
participation in SDM. A recent paper described that there is a
growing interest in involving people in SDM. Some efforts
includes the general consultation and public discussion of the
Shared Decision Making
(1) Two or more participants are involved
(patient and health provider)
(2) Participan ts share information
(evidence-based, values and preferences)
(3) Participants build a consensus about
preferred option
(4) Agree ment is reached
Figure 1.
The SDM in health model.
Health Reform (Bravo et al., 2011). However, it seems those
efforts are restricted to health related issues and have not reach
other areas of social concern.
The Overseas Development Institute stated that it is essential
to incorporate different sources o f knowledge to inform decision
making in policy (Jones et al., 2009). Participatory knowledge,
which involves people’s participation through experiences and
local understanding, is a key element for effective interventions
(Jones et al., 2009). Moreover, the effectiveness of changes
increases when tho se dir ect l y aff ect ed b y th e cha nge f eel r eons i-
bility for the process and have a sense of ownership for what is
happening (Liontos, 1994).
Shared decision making could be an effective approach to deal
with the current politica l situation in Chile. Similar to the me di ca l
encounter—where a “medical expert” provides services to the
“patient”—the current debate includes in a major scale the ex-
pert (government) and the patient (students). The young gene-
ration is claiming for a voice and for balance in power. They feel
they hold political responsibility (Jones et al., 2009) and they
want to be pa rt of the deci sion maki ng to impr ove the e d u ca t i o n a l
We believe the student educational revolution is a great op-
portunity to develop a SDM process and that students and the
government can benefit from the knowledge from this model.
This multidimensional theoretical approach has been conceptu-
alized from sound evidence developed in the past decades and
might lead the path to success in this complex and unsolved
conflict in Chile.
Students and the whole nation have identified a sensitive di-
lemma that is whether or not to reform the educational system.
The two parties, citizens and government are willing to be in-
volved in the decision making process. However, it seems that
the “sharing information” step is not strong enough to give the
sense of inclusion and value of participatory knowledge. Con-
sequently, the consensus has not been reached, and agreement
seems to be far to achieve. In 2012 students continue organizing
pacific protests to demand change and participation, but little
progress is perceived as communication pathways between
Copyright © 2012 SciRes.
Copyright © 2012 SciRes. 1033
parties are someone resenting the long-term debate.
What Future Steps Should Be Taken to
Contribute to Achieve True “Participatory”
Democracy in Chile?
As healthcare p r oviders a nd rese archers we bel ieve th at th is is
an excellent opportunity to begin changing the “passive” nature
of Chilean society towards a “participatory and engaged” one.
The students are the new generation, and this sense of responsi-
bility of issues that matters to them (such as education) could
help to improve other areas in which people’s participation has
proved to be a key element for success. Having empowered and
active students today can help us to have empowered and active
adults in the future. These empowered young adults may be
more willing to take responsibilities on health-related issues,
public economy and policy making. This is why we believe that
a great attention should be given to how the students’ demands
are responded to.
Following the SDM in health model, we propose that some
changes take place to reach agreement. First, as information has
not been shared adequately, both parties might feel a sense of
power imbalance. Therefore, it is important to reassure that
information will be clear, evidence and practice-based and
equally available for both parties. Secondly, and only once
information is pr operly shared an d agreed, then pa rticipants (that
is, the students in Chile) should develop a series of recommen-
dations on the preferred decisions to make to improve t he pub lic
educational system in the country. The current situation could
adopt some engaging strategies that have been used in health-
related issues. In 2003 the Health Reform proposed the creation
of steering committees (known as Council Care Network Integra-
tors). These committees involved professionals and community
participants who provided support and advice to health services
and proposed community-tailored local health policies. This
strategy has proven successful with over 30 committees actively
operating across the country (Bravo et al., 2011).
Currently, stude nts hav e alr ead y pres ented c lear stat em ents of
what commitments they require the government to fulfill in
order to reach agreement and return to usual activities, but the
government has denied the ability to respond to them. Further
efforts need to be made from both sides in order to identify a
shared goal that can be truly achieved in the near future. Fol-
lowing the knowledge from SDM, this could be done by a clear
establishment of a partnership between both parties. So far,
Chile has shown a more “domination” orientated culture (Eisler
and Corral, 2005), where repression, fear and violence have led
the dialogue regarding education. Government and students
should be considered equally important for the decision making
process, and both are expected to contribute with solutions and
alternatives to the problem. It is this sense of partnership and
inclusion that co uld agreeme nt will b e reached. A ccording to t he
SDM approach, only when a clear partn ership is established and
all parties involved in the decision can contribute with know-
ledge, values and feelings in regards to the options, the con-
sensus can be achieved in an unbiased and democratic way.
In conclusion, the students’ movement in Chile is a strategic
opportunity to develop a shared decision making process in the
country. The current government needs to truly understand the
real importance of the opinion of those directly involved in the
policy decisions that are made every day, and this educational
manifestation sets the case for etter development of a formal,
well-informed, SDM process in Chile. This essay provides a
reflection on how the SDM contribute to the debate held by the
Chilean Government and the students and also on what future
steps should be taken to contribute to achieve true “participa-
tory” democracy in Chile. The debate should not only include
information exchange, as the level of participation must rely on
the establishment of a partnership between parties, which dem-
onstrate all views, feelings and contributions are equally valu-
able and respected, and where people can freely state “what
matters to them.
Bravo, P., Cabieses, B., Bustamante, C., Campos, S., & Stacey, D.
(2011). Shared decision making in Chile: Supportive policies and re-
search initiatives. Zeitschrift für evudenz, fortbildung und qualitåt im
Gesundheitswesen, 105, 254-258. doi:10.1016/j.zefq.2011.04.007
Cabieses B., Tunstall H., & Pickett K. E. (2010). Describing social
determinants of health of the Chilean-born and international immi-
grants in Chile. Oral presentation. PILAS Conference 2010. Man-
chester: University of Manchester, 8.
Charles, C., Gafni, A., & Whelan, T. (1997). Shared decision-making in
the medical encounter: What does it mean? (or it takes at least two to
tango). Social S c i en c e M e d i c in e , 44, 681-692.
Chilean Ministry of Health (2011). Objetivos sanitarios de la decada
2011-2020. URL (last checked April 2012).
Edwards, A., & Elwyn, G. (2009). Shared decision-making in health
care: Achieving evidence-based patient choice. In: A. Edwards, & G.
Elwyn (Eds.), Shared decision-making in health care: Achieving evidence-
based patien t choic e (pp. 3- 10). Ne w York: Ox ford University Press.
Eisler, R., & Corral, T. (2005). From domination to partnership: Meet-
ing the UN millennium goals. Convergence, 38, 75-94.
Elwyn, G. (2010). Salzburg statement on shared decision making. BMJ,
342, d1745. doi:10.1136/bmj.c5146
Elwyn, G., Edwards, A., Gwyn, R., & Grol, R. (1999). Towards a fea-
sible model for shared decision making: Focus group study with
general practice registrar s. BMJ, 319, 753-756.
Elwyn, G., Frosch, D., & Rollnick, S. (2009). Dual equipoise shared
decision making: Definitions for decision and behaviour support in-
terventions. Implementation Science, 4, 75-82.
Franklin, J. (2011). Chile’s Commander Camila, the student who can
shut down a city. The Guardia n o n l i n e.
Hårter, M., van der Weijden, T., & Elwyn, G. (2011). Policy and prac-
tice developments in the shared decision making: An intrnational
perspective. Zeitschrift für evudenz, fortbildung und qualitåt im Ge-
sundheitswesen, 105, 229-233. doi:10.1016/j.zefq.2011.04.018
Jones, N., Datta, A., & Jones, H. (2009). Knowledge, policy and power.
In: O. D. Institute (Ed.), Types of knowledge (pp. 6-8). London:
Overseas Development Institute.
Kuhns, D. E., & Chapman, P. E. (2006). How does shared decision
making impact inclusion. National Forum of Special Education
Journal, 17, 1-17.
Liontos, L. B. (1994). Shared decision-making. Eugene, OR: ERIC
Clearinghouse on Educational Management.
Niemira, D. (2009). Ethics conflicts in rural communities: Shared deci-
sion-making. In: W. A. Nelson (Ed.), Handbook for rural health care
ethics: A practical guide for professionals (pp. 142-163). New Ham-
pshire: University Press o f N e w Engla n d .
O’Connor, A. M., Bennett, C. L., Stacey, D., Barry, M., Col, N. F.,
Eden, K. B., Entwistle, V. A., et al. (2009). Decision aids for people
facing health treatment or screening decisions.