Evidence Based Practice and Patient Needs

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Introduction

Step one of the evidence based practice (EBP) model is to determine the needs of the patient 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 will be useful in formulating the clinical question. This step correlates with the Ask component of the 5 A’s of EBP.

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 condition and recovery rate
  • In an assessment of patient perspectives on patient-centredness the following aspects are noted as most important to patients:
    • being taken seriously
    • receiving competent treatment with empathy
    • being recognised as individuals in exceptional circumstances
    • enough time during treatment sessions
    • timely access to care

• 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 distinctively via non-verbal communication than verbally, making good non-verbal communication an integral, often overlooked part of the medical interview. Empathy is expressed by acting warm, friendly and reassuring, and has been linked with better patient satisfaction and recovery rates, and subsequently better health outcomes.

• Amount of information
  • Avoid information overload  - more information is not always better as patients can forget between 40 – 80% of the medical information that 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 healthcare professional to enhance the self-efficacy of patients
    • healthcare professional – patient relationship
    • professional experience of 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 feels 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 leads to building a better relationship with your patient. It also builds trust and this leads to a patient feeling safe and comfortable enough to volunteer information that you need to formulate an accurate clinical question. Healthcare providers can built patients’ trust by:

• effective communication
• caring about their patients
• demonstrating competence

Subjective Interview

Ask an open question: “For which problem did you come to physiotherapy today?” or “Do you want to just 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 can differ within different healthcare professions.

Table 1. Overview of considerations in the subjective examination

Patient context and their perspective	Allow 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 severity and irritability of condtion 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 received?
Family and socio-economic 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 (Psychosocial factors that can increase the risk of developing chronic pain) to consider: Patient attitudes and beliefs about pain Behaviour of patient when experiencing pain Compensation issues Previous diagnosis and treatments and how patient feels about the process Emotions Family support Influence on work
Patient expectations	What does the patient want to gain from treatment?

            

Patient expectations; What does the patient want to gain from treatment

Self administered questionnaire

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Physical Examination

A short overview of the physical examination is shown in Table. Note that this will differ in different healthcare professsions. This one is more related to physiotherapy.

Observation

             Posture, muscle bulk, muscle tone, soft tissue, gait, function and patient’s response

Range of motion

Active physiological movement

             Active movements

             Can adapt – repeated movements, sustained positions, functional or combined

Passive physiological movement

             Passive physiological accessory moveemtns

Passive physiologiicla intervertebral movemtns

Joint integrity tests

Musles tests

Strength

Control

Length

Isometric contractions

Nerve

Neurological tests, Neurodymancie tests

Special tests

Vascular

Soft tissue

Palpation

Soft tissue, bone, joint, ligament, muscle tendon, nerve

Joint tests

Accessory movements to test joint glides in different diractions

Formulating the clinical question

Once you have gathered all the relevant information through the subjective and physical examination, you can formulate a clinical question.

PICOT clinical question model

P – Patient, population, problem

I – intervention

C -Comparator

O – Outcomes

T – Type of intervention question Treatment and type of studies or time

Refer to PICOT AND ANSWERABLE QUESTION PAGES

Resources

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