Formulating and Implementing the Treatment Plan and Evaluation

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Introduction

Step four of the evidence-based practice process encompasses discussing options with the patient. Step five involves the formulation of an agreed-upon treatment plan, step six considers the implementation of this plan and step seven is where you evaluate the effectiveness of the treatment plan. When thinking about the 5 A’s of evidence-based practice, these steps cover the A’s for Apply and Assess.

Discussing the Options with the Patient

A short summary of step 4 of the evidence-based practice process: (Benita)

• The discussion with the patient should be interactive
• Consider the patient's preferences, beliefs, values, circumstances and goals
• Share the best available evidence that is applicable (also admit where there is not great evidence)
• Engage the patient in this discussion
• As clinician, reflect and consider own biases to ensure objectivity
  • Cognitive biases that clinicians may be prone to include:
    • optimism bias (inaccurate expectations about the benefits and harms of treatment)
    • sunken cost bias (when the clinician has invested time, training and resources in an intervention and is reluctant to discontinue this specific course of treatment)
    • commission bias ("the tendency towards action rather than inaction")
    • mechanistic bias (focus on how or why a treatment should work, instead of looking at the evidence that shows whether the specific treatment does work)
• Come to an agreement on the best way forward (i.e. treatment, referral)

This step in the evidence based practice process is an opportunity to build a therapeutic alliance with the patient and also to enhance adherence to treatment.

You can read more on therapeutic alliance and its components here.

Important Considerations in Discussion of Options

Patient-Centred Care

Patient-centred care is defined as "a particular approach to the health-professional-patient relationship that implies communication, partnerships, respect, choice and empowerment, and a focus on the patient rather than their specific clinical condition.” (Hoffman et al Key considerations to this approach is:

• to treat patients with dignity
• to respond quickly and effectively to patient needs and concerns
• to provide patients with enough information to enable them to make informed decisions about their health care.

This is crucial to informed shared decision making.

You can read more on patient-centred care here.

Shared Decision-Making

Informed decision making is defined as "decisions that are shared by doctor and patient and informed by best evidence. Not only about the risks and benefits, but also the patient-specific characteristics and values. It occurs in a partnership that rests on explicitly acknowledged rights and duties and an expectation of benefit to both.”

Hoffman et al defines it as follows: "Shared-decision making is a consultation process where a health professional and a patient jointly participate in making a health decision, having discussed the options, their benefits and harms, and considered the patient's values, preferences and circumstances." Hoffman 2014

Shared-Decision Making and Evidence-Based Practice

The patient is central in evidence based practice, however incorporating patient needs, values and preferences still is lacking. This is where shared decision making steps in. This provides an opportunity for the healthcare professional to introduce the evidence into a consultation and then discussing this with the patient. This is necessary so that a patient can construct their own informed preferences. This requires of healthcare professionals to know what the best available evidence is or to find it, discuss the benefits and harms with patients.

What is NOT shared decision making?

Shared decision-making is NOT (Hofmman 2023):

• an extra or single step to be added to a consultation
• to provide patient education
• simply providing a patient with a decision aid
• presentation of the healthcare professional’s findings and recommendations and asking the patient if they are okay with this

Shared decision making is a process and can sometimes involve sharing of patient education material and decision aids, but it is not dependent on these. (Hoffman)

Shared decision-making involves a partnership between the healthcare professionals and patients and requires communication both ways.

Elements of Shared Decision-Making

Elements of shared decision making can include (Hoffman 2023):

• explanation of problem, condition and why it is necessary to make a decision
• allowing and inviting the patient to engage
• explanation of the options, benefits and harms of each option
• exploring and considering patient needs, circumstances, values, preferences
• making sure both parties understand each other and sufficient answering of questions
• “engaging in collaborative deliberation and consensus”
• making or deferring of a decision

“It is not about who wins in the conversation, or who is right, or whose opinion is being chosen as the winning option in the end. We have to remain professional and remember to put the patient’s values and preferences and goals in the centre of the conversation.” Benita

You can read this article When shared decision making and evidence based practice clash to gain insight into how informed decision making is different for each patient and situation.

The Importance of Shared Decision Making

• Improved communication: Shared decision making enhances communication between the healthcare professional and the patient.
• Knowledge translation: It is a useful step in knowledge translation by integrating the best available evidence and patient preferences into a health related decision.
• Patient preferences: There are not always one clear treatment option or test to do once the evidence is considered, therefore patient preferences play an important role in shared decision making, in that it is the patient's preference that "should influence the decision on how to proceed."
• Enhanced patient buy-in and adherence: Acknowledging and incorporating patient preferences often leads to better patient buy-in and adherence thereby improving treatment effectiveness.
• Addressing Expectations: Shared decision making also provides a way to address patient expectations around specific treatments and outcomes.

You can read more on shared decision making and an example of a process for shared decision making here.

Formulating and Implementing the Treatment Plan

Step 5 in the evidence-based practice decision-making model is to formulate a treatment plan. Step 6 involves the implementation of this treatment plan. These steps including step 4 are all mixed together and it is possible to move forwards and backwards as necessary in the management of a patient.

Factors to consider with Implementation

• Patient Consent
  • Informed consent refers to the patient's right to be informed about their condition, and the risks and benefits of treatment options. It requires healthcare professionals to include their patients in their clinical reasoning process to reach a shared decision. Roles and regulations are different from one country to another and in some circumstances you will find yourself challenged by the available resources, culture and your patient's capacity to make their own decisions.
  • You can read more on informed consent here.

"Consent is not something we obtain, but rather something that we receive from a patient" Benita

• Documentation
  • remember these patient notes can be used in legal situations
  • notes should be clear, accurate, legible
  • relevant clinical findings should be reported
  • record decisions made and by whom
  • record the patient's decision for treatment
  • record risks, benefits and alternatives discussed
  • record information given to patient
  • record if patient disagrees and if reasons were provided, record this as well
  • record the process of evidence-base practice model which you used to make a decision
  • record treatment prescribed

Evaluation

Continuous evaluation (Assess) is important throughout the implementation phase. Evaluate treatment outcomes and the treatment process. Consider if the treatment and patient goals were achieved. Assess the evidence-based practice process that you followed. (Drisco and Grady) Ways to assess or audit the process of care can include (Herbert et al ):

clinical audit - "a method of comparing what is actually happening in clinical practice against agreed standards or guidelines"

peer review - evaluation of clinical performance by a peer

reflective practice - thinking critically about practice

Table 1 provides some examples of questions to ask when evaluating the performance of evidence-based practice.

Reflection on practice	Do I ask myself why I do the things I do in my clinical practice? Do I discuss with colleagues the basis for our clinical decisions?
Determining the patient’s needs to formulate a clinical question	Am I asking clinical questions? Are my clinical questions well-formulated? Do I use different types of clinical questions for diagnosis, interventions, prognosis, etc?
Locating the knowledge resources	Am I searching for evidence? Do I know the best sources of current evidence for my clinical discipline? Do I have access to knowledge resources? Are my searching strategies becoming more efficient?
Appraising the quality of the knowledge resources	Do I read papers? Do I use critical appraisal checklists for the different study designs? Am I integrating my critical appraisals into my clinical practice?
Discussing the options with the patient Formulating the treatment plan Implementing the treatment plan	Do I discuss all options with my patient without any cognitive biases? Do I use high-quality evidence to inform clinical practice?
Evaluating the effectiveness of the treatment plan and the evidence-based practice process	How did the patient respond to treatment? Did the patient manage to adhere to treatment plan? Were my clinical sessions effective or were there any modifications along the way? Do I audit my performance of evidence-based practice? Where do I encounter challenges in the evidence-based practice process?

You can read more about a series of questions to facilitate introspective self-evaluation for the evidence-based practitioner here: Reflective evaluation

Revise, Review, Reflect