Evidence Based Practice and Patient Needs

Original Editor -Wanda van Niekerk based on the course by Benita Olivier

Top Contributors - Wanda van Niekerk and Jess Bell  

Introduction

Step one of the evidence-based practice (EBP) model is to determine the patient's needs to formulate a clinical question. This step involves assessing the patient and determining the extent of their condition, their values and beliefs, and their specific context and preferences. All of this information is useful when formulating the clinical question. This step correlates with the Ask component of the 5 'A's of evidence-based practice.

For more information on the evidence-based practice steps, please see: Defining the Evidence Based Practice Decision-Making Model.

Interview Principles

• Patient-centredness
  • Patient-centredness is defined as: “Health care that establishes a partnership among practitioners, patients and their families… to ensure that decisions respect patients’ wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care.” 
  • Patient-centredness is positively associated with:
    • patient satisfaction
    • well-being
    • adherence
    • health behaviour
    • knowledge about medical conditions and recovery rate
  • An interview study of patient perspectives on patient-centredness found the following areas are most important to patients:
    • being taken seriously
    • receiving competent treatment with empathy
    • being recognised as individuals in exceptional circumstances
    • having enough time during treatment sessions
    • timely access to care
  • You can read more about Patient-Centred Care here

• Non-verbal communication
  • This includes aspects such as:
    • eye contact
    • posture
    • tone of voice
    • head nods
    • gestures
    • postural positions
  • In cases where verbal and non-verbal messages contradict each other, non-verbal communication tends to outweigh the verbal message. Empathy and emotion are communicated more clearly via non-verbal communication than verbally. Thus, good non-verbal communication is an integral, often overlooked part of the medical interview. Empathy is expressed by being warm, friendly and reassuring. It has been linked with better patient satisfaction and recovery rates and, subsequently, better health outcomes.
  • Read more about Modes of Communication

• Amount of information
  • Avoid information overload  - more information is not always better, as patients can forget between 40 – 80% of the medical information they receive
  • Providing the patient with too little information will decrease patient satisfaction

• Adherence to advice/ treatment
  • Adherence is defined as: “the extent to which a person conforms to the the agreed-upon recommendations of a health care provider.”
  • Factors that may influence patient adherence to treatment include:
    • level of motivation
    • self-discipline
    • acceptance of specific treatments
    • perceived effectiveness of treatment
    • beliefs and attitudes
    • cultural background
    • communicative aspects
    • communication skills of healthcare professionals
    • motivation of the healthcare professional to enhance the self-efficacy of patients
    • healthcare professional-patient relationship
    • professional experience of the healthcare professional

• Patient concerns
  • Allowing patients to discuss their concerns about their health reduces emotional stress and increases symptom resolution. Patients who can share their concerns in a safe environment feel heard, valued and more hopeful. It also leads to the patient providing invaluable information on their experience of their illness, injury or condition.

All these principles lead to building a better relationship with your patient. It also builds trust. Trust helps to ensure that a patient feels safe and comfortable enough to volunteer the information you need to formulate an accurate clinical question. Healthcare providers can build trust in the following ways:

• effective communication
• caring about their patients
• demonstrating competence

Subjective Interview

Ask an open question: “What has brought you in to see me today?” or “Do you want to tell me a little bit about your [problem presentation] first of all?"

Table 1 provides an overview of some of the questions that can be asked as part of the patient interview. Note that these questions can differ across healthcare professions.

Table 1. Overview of considerations in the subjective examination (adapted from Petty's Musculoskeletal Examination and Assessment)

Patient context and their perspective	Allow the patient to explain in their own words why they are there What are their expectations, beliefs and goals? How does their experience impact their quality of life? Patient’s age, lifestyle (at home and work), leisure activities Physical activity level
Symptoms	Area of current symptoms Description of symptoms Distribution of symptoms Quality of symptoms Intensity of symptoms Abnormal sensations Relationship of symptoms
Behaviour of symptoms	How does it impact daily activities (functional limitations)? Aggravating factors (what makes it worse?) Easing factors (what makes it better?) Coping strategies Assess the severity and irritability of the condition 24-hour behaviour of symptoms Risk factors for chronicity
History of present condition	How did symptoms start? When did symptoms start? How do symptoms behave over time? Have you experienced something similar in the past? Response to previous treatment? What type of treatment was received?
Family and socioeconomic history	Employment Dependents Home environment Activities of daily living Lifestyle choices
Medical screening questions/ special questions	Red flags to consider: General health Unexplained weight loss Medication Steroid use (long-term use) Cord compression symptoms (bilateral weakness or bilateral pins and needles) Cauda equina compression symptoms (saddle anaesthesia, frequency or urinary retention) Details of any imaging (MRI, x-rays, etc) Other medical conditions to ask about (DEARTH) Diabetes Epilepsy Arthritis Respiratory diseases Thyroid abnormalities Hypertension Yellow flags to consider: Patient attitudes and beliefs about pain Behaviour of the patient when experiencing pain Compensation issues Previous diagnosis and treatments and how the patient feels about the process Emotions Family support Influence on work ** Yellow flags are psychosocial factors that can increase the risk of developing chronic pain
Patient expectations	What does the patient want to gain from treatment?

Physical Examination

A short overview of the physical examination is shown in Table 2. Note that this will differ across different healthcare professions.

Table 2. Overview of a physiotherapy physical examination (adapted from Petty's Musculoskeletal Examination and Assessment)

Observation	Posture Muscle bulk Muscle tone Soft tissues Gait Function Willingness to move Patient’s response Protective deformities
Movement Tests	Range of motion Active physiological movement Active movements Can adapt – repeated movements, sustained positions, functional or combined positions, movement speed Passive physiological movements Passive physiological accessory movements Passive physiological intervertebral movements
Joint integrity tests	Ligament stress tests
Muscle tests	Length Strength Control
Nerve tests	Neurological tests Neurodynamic tests
Special tests	Vascular
Palpation	Soft tissue Bone Joint Ligament Muscle Tendon Nerve
Joint tests	Accessory movements to test joint glides/ movement in different directions

Formulating the Clinical Question

Once you have gathered all the relevant information through the subjective and physical examination and applied clinical reasoning, you can formulate a clinical question. The PICOT clinical question model is a useful tool to use. It helps with:

• formulating a question which focuses on an essential issue for a patient or population
• identifying important terminology to use while searching for evidence
• filtering and selecting results related to the topic of interest

The different components of this model are:

Table 3. PICO(T) Research Question

P	Patient, population, problem	specific characteristics of the patient or population
I	Intervention	treatment approach conditions
C	Comparator	main alternatives to a specific intervention group, treatment or test that the intervention is compared to
O	Outcomes	result measured for example, quality of life, functional indexes
T	Type - type of intervention question; type of treatment; type of studies Time	Type diagnosis aetiology prognosis prevention treatment Time period or duration of effect

You can read more about the PICOT Research question here.

Resources

• Oxford Centre for Evidence-Based Medicine: Asking focused questions
• Northern Arizona University Library Guide: Ask: Write a focused clinical question