Evidence Based Practice and Patient Needs

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Introduction[edit | edit source]

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[edit | edit source]

  • 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.”[1] 
    • Patient-centredness is positively associated with[2]:
      • 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[2]:
      • 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[3]:
      • 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.[3]
  • 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.” [4]
    • Factors that may influence patient adherence to treatment include[5]:
      • 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.[6]

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[7]:

  • effective communication
  • caring about their patients
  • demonstrating competence

Subjective Interview

Ask an open question: “For which problem did you come to physiotherapy today?”

Another example is “Do you want to just tell me a little bit about your [problem presentation] first of all Chester et al 2014

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.

Patient context and their perspective

Allow patient to explain in their own words why they are there

What are there expectations, beliefs and goals

How does their experience impact their quality of life

Patient’s age, lifestyle (at home and at work), leisure activities

Physical activity level

Body Chart

             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

             Aggravating factors (what makes it worse)

             Easing factors (what makes it better)

             Coping strategies

             Assess severity and irritability of scondtion

             24 hour behaviour of symptoms

             Risk factors for chronicity

Medical screening questions

Medical history:

             General health

             Weight change

             Medication

             Existing conditions DEARTH

             Diabetes

             Epilepsy

             Arthritis

             Respiratory diseases     

             Thyroid abnormalities

Special questions (Red Flags)

General health

Unexplained weight loss

Mediciation

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)

Family and socio-economic history

             Employment

             Dependents

             Home environment

             Activities of daily living

             Lifestyle choices

Yellow flags (Psychosocial factors that can increase the risk of developing chroni pain)

Patient attitudes and belief about pain

Behaviour of patient when experiencing pain

Compensation issues

Previous diagnosis and treatments and how patient feels about the process

Emotions

Family support

Work influence

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

History of present condition

How did symptoms start

When did symptoms start

How does symptoms behave over time

Self administered questionnaire

PUT THESE IN ORDER AS VIDEO

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


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References[edit | edit source]

  1. ↑ Edgman-Levitan S, Schoenbaum SC. Patient-centered care: achieving higher quality by designing care through the patient’s eyes. Israel Journal of Health Policy Research. 2021 Dec;10:1-5.
  2. ↑ 2.0 2.1 Zeh S, Christalle E, Zill JM, Härter M, Block A, Scholl I. What do patients expect? Assessing patient-centredness from the patients’ perspective: an interview study. BMJ open. 2021 Jul 1;11(7):e047810.
  3. ↑ 3.0 3.1 Vogel, D., Meyer, M., Harendza, S., 2018. Verbal and non-verbal communication skills including empathy during history taking of undergraduate medical students. BMC Med. Educ. 18, 157.
  4. ↑ WHO. World Health Organisation. Adherence to Long Term Therapies – Evidence for Action. WHO Library Cataloguing-in-Publication Data. 2003.
  5. ↑ Alt A, Luomajoki H, Luedtke K. Which aspects facilitate the adherence of patients with low back pain to physiotherapy? A Delphi study. BMC Musculoskeletal Disorders. 2023 Jul 27;24(1):615.
  6. ↑ Drossman DA, Chang L, Deutsch JK, Ford AC, Halpert A, Kroenke K, Nurko S, Ruddy J, Snyder J, Sperber A. A review of the evidence and recommendations on communication skills and the patient–provider relationship: a Rome foundation working team report. Gastroenterology. 2021 Nov 1;161(5):1670-88.
  7. ↑ Greene J, Ramos C. A mixed methods examination of health care provider behaviors that build patients’ trust. Patient Education and Counseling. 2021 May 1;104(5):1222-8.
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