To be an evidence-based practitioner one must find the best evidence available, include one’s clinical expertise as an additional source of evidence, and then incorporate patient preferences and values into a recommendation for care.
A few weeks ago I talked about EBP in general terms. I deconstructed the major components of EBP and dove a little deeper into the meaning of Best Evidence and Clinical Expertise. Today, I’ll review the third major component of Patient Preferences (i.e., values, beliefs).
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After searching and evaluating the evidence, and considering that evidence in light of your clinical expertise, incorporating patient preferences in the mix sounds like the easy part! But this last construct tends to be a sticking point for many clinicians. What we are really asking here is: “Do healthcare providers really seek the patient’s input into the decisions about the patient’s care?” Partly due to the limited amount of time healthcare providers spend with patients, all too often the answer is No.
What Are Patient Preferences?
Let’s start out defining what we mean when we talk about Patient Preferences. This construct is made up of several concepts including the patient’s preferences about inclusion in their own healthcare decisions; patient’s religious or spiritual values; social and cultural values (including family involvement in care decisions); values around quality of life; personal priorities; and beliefs about health and personal responsibility.
Guyatt, Jaeschke, Wilson, Montori, and Richardson (2015) defined patient values and preferences as: “The collection of goals, expectations, predispositions, and beliefs that individuals have for certain decisions and their potential outcomes” (p. 12). If the goal of EBP is to provide excellent care for individual patients, we must make sure we have the skills needed to elicit these preferences and then to consider them in shared decision-making with the patient.
The beneficiary of EBP is the patient. The patient is the one who will benefit from clinicians who can interpret research findings, understand the patient’s unique circumstances, and then work with the patient to construct a plan of care that will be in the patient’s best interest, however the patient defines it (Guyatt et al., 2015).
Newer conceptual models of patient and family engagement are being developed to bring the patient and family into more of a partnership with the healthcare team. One, the Conceptual Model for Patient and Family Engagement, proposes to involve the patient and family in evaluating the research findings for the patient’s own healthcare decisions; and then extrapolated to the whole healthcare system (Carman & Workman, 2017).
How to Elicit Patient Preferences
Interpersonal skills are important to successful EBP practice. Explaining the risks and benefits of a choice of interventions is not always easy. There seems to be a lot of uncertainty and a certain level of discomfort for some clinicians as to how to elicit and integrate the patient’s preferences most effectively into clinical decisions.
Clearly, the clinician needs good communication skills to elicit the patient’s preferences and values. The clinician’s attempt to understand the patient’s point of view and sociocultural perspective is important to patient engagement in the decision-making process. Additionally, according to many research studies, the patient’s family may be very influential in the patient’s decisions (Hawley & Morris, 2017; Siminoff, 2013); so, if the patient desires family involvement, don’t forget to include them in this process.
Developing a good rapport with the patient engenders trust. Many research studies have shown that healthcare providers do not make the same choices as patients when presented with the same set of facts. A trusting relationship between the patient and clinician can make it easier for the patient to share their goals and expectations with the clinician and for the clinician to have an honest discussion with the patient about their care.
Here’s an important key to shared decision-making: you need to have a conversation with the patient, not just offer information (Hargraves, LeBlanc, Shah, & Montori, 2016). This seems like a “duh” moment, doesn’t it? But think about the last encounter you had with a patient — were you just asking rote questions or were you having a conversation? When’s the last time you sat down with the patient and family to mutually develop a plan of care? I was in the hospital once for 9 days — the day of discharge the nurse brought me my care plan to sign!
Conversations are important to shared decision-making “because evidence is intended to offer a dispassionate presentation of what medical science knows and doesn’t know about disease and treatment in the population in general” (Hargraves et al., 2016, p. 627, emphasis added). So it’s not enough to just offer evidence, risks, and benefits. “Just the facts, ma’am” is not a caring intervention.
Having a conversation with patients and families, instead of talking to them, allows them to think about and debate options, ask questions, and mutually determine with the clinician the best path for the individual patient. Hargraves et al. pointed out that patient-clinician conversation is not a “nice-to-have moment” but that it is a bona fide “instrument of care” (2016, p. 628). Patient-clinician conversation has been shown to be an effective technique for true shared decision-making (Hargraves et al.).
“Providing patients with information or evidence alone isn’t sufficient to support patients who are making a decision” (Hargraves et al., 2016, p. 628).
There certainly are many challenges to involving patients in healthcare decisions. Patient literacy levels and previous knowledge also will affect the patient’s ability to be involved in decision-making. Gender, race, sociocultural influences, socioeconomic status, and educational levels may impact the patient’s ability to voice their preferences or concerns. Patients go to the Internet for information about their conditions, but many don’t have the skills required to discern the validity of Internet sources they encounter, which may lead to false hope or unreasonable expectations.
Clinicians and patients may have dissimilar expectations of what information to share, the priorities of care, or of how to treat the patient’s condition (Montgomery & Fahey, 2001; Schattner & Fletcher, 2003). This incongruence can lead to conflict and mistrust of healthcare providers and the healthcare system itself (Hawley & Morris, 2017; Siminoff, 2013).
Some patients want the clinician to share all relevant information – all the risks and benefits associated with a certain intervention; while other patients, due to personal or cultural beliefs, may not want to participate in the decision-making process at all (Hawley & Morris, 2017; Say & Thomson, 2003). However, many studies show that patients desire information, even if the patient does not want to be involved in making healthcare decisions (Say & Thomson, 2003).
Listen to Your Patients!
The patient plays an important role in the process of shared decision-making. But the patient can only play this role well if they are well-informed – that’s part of your responsibility to the patient. To apply the appraised evidence, the clinician needs to provide information in a way that makes sense to the patient. I realize that providing details about best evidence is usually considered the physician’s or advanced practice nurse’s purview, but the bedside nurse may have to help the patient interpret the information. So, it’s important that all members of the healthcare team understand how to make sure that the patient is not left out of the process!
The key to this important EBP component is not to forget the patient! Clinicians need to listen to their patients! As nurses, we are already tuned in to our patients, so talking with the patient and finding out what is important to them is not a stretch for us. But I’m not talking about rote questions from the admission assessment. To involve the patient in decisions, we need to understand our patients’ lives, their values, and what’s important to them. Patients are “experts with a unique knowledge of their own health and their preferences for treatments, health states, and outcomes” (Say & Thomson, 2003, p. 542). Again, that’s why evidence alone is not enough to guide clinical practice.
Also, do not assume that you know what’s best for the patient! The clinician cannot assume that their decisions will mirror the decisions of their patients; and in fact, research bears out the opposite (Hunink, 2003; Montgomery & Fahey, 2001; Schattner & Fletcher, 2003). Many other authors have shown that patient and provider priorities for care often are dissimilar (Hargraves et al., 2016; Say & Thomson, 2003).
We need to know our patients for our care to be truly caring. This is a hallmark of excellent nursing practice. And if we are honest with ourselves, this is a component for which we all could do better!
How Much Information Does the Patient Want?
For the patient and family to be knowledgeable consumers, those with “western” world mindsets characteristically believe that the patient should be provided with as much information about the risks and benefits of treatment, as possible. If this is your patient, make sure that the information being provided is at an appropriate level for the patient to truly understand the care options.
However, keep in mind that not all patients want information or to be involved in making their healthcare decisions (Hawley & Morris, 2017; Say & Thomson, 2003). We make a lot of assumptions as educated health care providers – that do not always ring true for our patients. Guyatt et al. (2015) pointed out that some patients believe that the responsibility for medical decision-making rests with the healthcare provider, not the patient. The decision to be an active participant in clinical decision-making, or not, is the patient’s!
“The decision to be an active participant in clinical decision-making is the patient’s!”
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Dixon-Woods, Jackson, Windridge, and Kenyon (2006) were interested in whether research subjects wanted to know the results of the trials in which they participated. They conducted a qualitative study of women involved in a research trial of antibiotic use to prevent preterm labor/premature rupture of membranes. These researchers pointed out that best practices are unknown and that “providing results of trials to trial participants is not straightforward and constitutes an intervention in its own right” (p. 4, emphasis added).
Being aware of your patient’s cultural values and expectations is important. In some cultures, any medical information, especially bad news, may be considered a burden to the patient; family members make the decisions as to which information will be shared. Sharing personal information with family members of the opposite sex may be prohibited in some cultures. There are wonderful resources for healthcare providers regarding culturally competent care of cultural groups, such as the text by Purnell (2014).
Nursing and Patient Preferences
As a nurse, you are expected to be a theory-guided, evidence-based practitioner. One of the benefits of using theory is that it can guide our processes and help us predict outcomes. There are nursing theories that you could use to help guide you to involve the patient and family in their care (e.g., Watson, Orem, Leininger). There are also theories specific to patient and family engagement (e.g., Carman & Workman, 2017). Find a theory that resonates with you and use it to direct your nursing process for eliciting patient preferences and engaging the patient in care.
The ASK (AskShareKnow) Patient–Clinician Communication Model (Shepherd et al., 2015) is an intervention directed at teaching consumers three questions to ask to get information they needed to make healthcare decisions. The questions are
What are my options?
What are the possible benefits and harms of those options?
3. How likely are each of those benefits and harms to happen to me? Including ‘What will happen if I do nothing?’
Shepherd and colleagues (2015) tested this intervention using a short video clip to introduce the questions to the patients before the patient met with the healthcare provider. This education resulted in patients asking one or more of these questions to their provider during the course of the consultation; patient recall of these questions weeks later was good.
What is your responsibility if the patient does not want to be involved in the decision-making process?
Bottom Line: you would want to ensure that any decisions made by the healthcare team about care interventions would be congruent with what you know about the patient and their preferences.
Evidence-based practice is an ethical, best-practice, and patient-centered approach to health care– if the patient is not forgotten in the process! There are many articles directed at how to engage the patient in the the decision-making process.
Critical strategies to demonstrate your commitment to incorporating patient preferences, values, and beliefs into your practice include:
Making time to listen to your patients and showing interest by maintaining eye contact and using affirmative head gestures or phrases. Be aware of nonverbal cues (yours and the patients). Be empathetic.
Asking the patient to what extent they want to be involved in their healthcare decisions. Who else should be involved in the process? How is information is shared and processed among the patient and family?
Asking the patient what their goals for care are – what are their priorities? What’s important to them? What expectations do they have?
Recognizing that cultural values influence the decision-making process.
Asking patients for their opinions on what is causing their symptoms or ailment. Do they have preferences about treatment? Find out where they obtained their information (e.g., Internet sources) and correct inaccurate information or understandings. Redirect patients to credible sources, if needed.
Using validation and reflective responses to verify concerns and clarify viewpoints.
Tailoring your communication style and interventions to the patient’s cultural background and beliefs, as appropriate.
Providing patients with the best research findings and other evidence and “invit[ing] them to choose a treatment option” (Hargraves et al., 2016, p. 627).
Explaining treatment options, risks, and benefits in a way the patient can understand.
Providing patients with informative materials about treatment options.
Using the “teach back” method to validate the patient’s understanding of your explanations and materials.
(Adapted from Carman & Workman, 2017; Hargraves et al., 2016; Hawley & Morris, 2017; Schattner & Fletcher, 2003; Siminoff, 2013).
There’s tons more to the topic of involving patients in clinical decision-making, including how to communicate risks and benefits and how to use patient decision aids. Both of these topics are complicated and a thorough discussion is beyond the scope of this particular post – but these are on my list of future blog posts.
Don’t forget to download my free Evidence-Based Practice guide — print it out and use it as a quick resource for clinical practice.
