Evidence-based practice: methods to evaluate individual patient improvement

The expectations and demands associated with evidence-based practice in medical rehabilitation require the use of research procedures that are practice based and practitioner oriented. Traditional research methods, including randomized clinical trials, are powerful techniques for determining the efficacy of rehabilitation interventions; however, randomized clinical trials have some practical and ethical limitations when applied to many research questions important to the field of medical rehabilitation, and alternative methods are needed to fully examine the effectiveness of treatment techniques for individual patients and to document clinical accountability. This paper examines the use of single-system designs and N of 1 research strategies. The advantages and limitations of single-system methods are described, and examples relevant to the documentation of clinical outcomes in medical rehabilitation are presented.     

Using a competency-based approach to patient education: achieving congruence among learning, teaching and evaluation

Millions of Americans are living with, and managing, their chronic health problems. Patient education plays an essential role in promoting safe self-management practice. To ensure that patients attain the required abilities, patient education needs to be competency-based. When developing and applying a competency-based patient education lesson/program, each nurse must answer questions concerning essential competencies, optimal teaching methods, best method to evaluate patient achievement, and documentation of evidence. This article describes how the authors used these questions as a guide to achieve congruence among intended learning, instruction, and evaluation to design and implement a patient education program, Managing Heart Failure, at a local hospital.     

A guide to choosing technology to support the measurement of patient outcomes

Personal computers, scanning systems, and hand-held computing devices are the latest tools being used to support the management of patient outcomes. Nurse executives can choose technologies needed to place nurses at the fore of multidisciplinary groups charged with improving the quality and cost-effectiveness of patient care. The authors review three types of patient data management technologies and answer questions executives may have in selecting systems for their departments.     

Cultural competence: reflections on patient autonomy and patient good

Terms such as 'cultural competence' and 'transcultural nursing' have comfortably taken their place in the lexicon of health care. Their high profile is a reflection of the diversity of western societies and health care's commitment to provide care that is responsive to the values and beliefs of all who require treatment. However, the relationship between cultural competence and familiar ethical concepts such as patient autonomy has been an uneasy one. This article explores the moral foundations of cultural competence, ultimately locating them in patient autonomy and patient good. The discussion of patient good raises questions about the moral relevance of a value's rootedness in a particular culture. I argue that the moral justification for honoring cultural values has more to do with the fact that patients are strongly committed to them than it does with their cultural rootedness. Finally, I suggest an organizational approach to cultural competence that emphasizes overall organizational preparedness.     

Scale to measure patient satisfaction with physical therapy

BACKGROUND AND PURPOSE: Patient satisfaction can be one indicator of quality of care. In this study, a patient satisfaction questionnaire for physical therapy was developed. SUBJECTS: The subjects were a consecutive sample of 1,024 patients who received physical therapy between January and March 1999 at a teaching hospital in Geneva, Switzerland. METHODS: A cross-sectional mail survey was conducted in which a structured questionnaire measuring patient satisfaction with various aspects of physical therapy followed by open-ended questions was sent to the subjects. RESULTS: Overall, 528 of 1,024 patients (52%) responded (patient demographics for 501 respondents who provided demographic data: mean years of age=58.6, SD=18.9, range=15-95; 258 men, 243 women). Factor analysis was used to identify main domains of satisfaction, and a scale was constructed to measure satisfaction with each dimension: treatment subscale (5 items), admission subscale (3 items), logistics subscale (4 items), and a global assessment subscale (2 items). All subscales had good acceptability and small floor and ceiling effects. Internal consistency coefficients varied between.77 and.90, indicating good reliability for all subscales. Scale validity was supported by a logical grouping of items into subscales, according to their content, and by correlations of satisfaction scores with the patient's intention to recommend the facility and with the number of positive and negative comments to open-ended questions. Younger patients were less satisfied than older patients for 2 of the subscales (admission and logistics). DISCUSSION AND CONCLUSION: The 14-item instrument is a promising tool for the evaluation of patient satisfaction with physical therapy in both inpatients and outpatients.     

The importance of abdominal pressure during colonoscopy: techniques to assist the physician and to minimize injury to the patient and assistant.

This article outlines techniques that can be used to assist the physician's ability during colonoscopy to achieve cecal intubation in both standard situations and in specific conditions such as the obese patient. When applied properly, abdominal pressure can help shorten the length of the procedure, minimize the angle of turns in the colon, and minimize discomfort to the patient. A Mayo physician survey unanimously concluded that abdominal pressure is beneficial during colonoscopy. This article addresses the ergonomics of applying pressure and suggests techniques that minimize risk of injury to both the patient and the assistant. In addition, questions that new assistants may ask are addressed.     

Developing empathy to improve patient care: a pilot study of cancer nurses

Empathy has been identified as an important communication skill that can improve psychological outcomes for patients with cancer and palliative care patients; as such there is a need for cancer nurses to be empathic. The majority of research that has been carried out has been concerned with the definition and measurement of empathy. Exploration into the concept of empathy has shown that there is a need to examine the nature of it and to identify exactly where it succeeds and fails. The questions of how empathy is nurtured and sustained and under what conditions it flourishes and diminishes need to be addressed. This study aimed to investigate how cancer nurses interpret and acquire empathy, and to identify the conditions that influence it. It was also important to establish what cancer nurses considered to be the benefits and disadvantages of expressing empathy. The findings demonstrated that nurses are aware of the concept of empathy and do use their empathic skills; however, there are barriers that could inhibit the expression of empathy, including lack of time, poor environment and communication difficulties. This study highlights the recognition of empathy as a discrete communication skill and the need for more structured courses.     

Inappropriate patient sexual behaviour in physiotherapy practice: a qualitative analysis of questionnaire comments

It has been reported that over 80% of physiotherapists and physiotherapy students have experienced inappropriate patient sexual behaviour (IPSB). This paper reports the results of a qualitative analysis of written comments respondents made to four open-ended questions that were part of a survey on IPSB. Quantitative analyses of the responses to the remainder of the questions have been reported previously. The objectives of this study were to determine the content required for educational programs and to explore the strategies and suggestions respondents have made relevant to IPSB. A questionnaire was sent to 118 physiotherapists and 87 physiotherapy students. Completed questionnaires were returned by over 70% in each group. The questions asking for comments on how respondents have learned to deal with IPSB and what information about IPSB is important for in-service and undergraduate education were coded into themes to characterize the responses. Respondents described their experiences with IPSB, identified the knowledge areas that they consider to be important, emphasized the importance of prevention, getting and giving support, the specific ways that they have learned to cope, and the skills to handle IPSB. This emphasized the importance of a comprehensive educational strategy to respond to IPSB.     

Validation of a simple patient questionnaire to assist self-detection of overactive bladder. A study in general practice

OBJECTIVE: To develop and validate a simple patient questionnaire for the detection of overactive bladder (OAB). DESIGN: An open, non-randomized multicentre study. SETTING: A pilot study (n = 133) was conducted to bring forward five questions from initially 14 questions, for detection of OAB. These five questions were subject to further validation in the main study (n =520). SUBJECTS: 531 adults responding to a newspaper advertisement regarding symptoms of OAB and patients seeing a physician for other reasons were attending 28 general practitioners. MAIN OUTCOME MEASURES: Agreement rate, sensitivity, and specificity. RESULTS: The agreement rate between the patients' own diagnosis based on the patient questionnaire, and the physicians' diagnosis based on medical history, urine analysis, and micturition chart, was 0.78 (kappa =0.89). Sensitivity and specificity were 0.98 and 0.90, respectively. CONCLUSION: The validated questionnaire may become a useful tool to decide whether a patient has overactive bladder. The questionnaire corresponds well with the physicians' diagnosis.     

Impact of patient selection in various study designs: identifying potential bias in clinical results

Many different study designs are used to address different types of clinical questions. The two broad categories are the experimental study, which is the randomized controlled trial, and observational studies, which includes all of the other basic study designs (cohort [prospective and retrospective] studies, case-control [etiologic] studies, cross-sectional [prevalence] studies, case series, and case reports). These study designs address basic categories of clinical questions: treatment, diagnosis, prognosis, and harm. This article focuses on some of these study designs, highlighting the impact of patient selection, inclusion, and exclusion criteria on results and outcomes through the use of specific examples.     

Educating the patient: challenges and opportunities with current technology

Patients using the Internet are inundated with abundant information on health care that may be correct and may be incorrect. It is becoming the role of clinicians to enable patients to educate themselves by providing information about accurate and reliable Web sites, and to answer questions from literature that patients encounter. In addition, there is a myriad of technological advances to help patients and clinicians access, retrieve, and file information, and numerous communication tools to foster the patient-clinician dialog. This article provides an overview and some recommendations for clinicians to help patients better use information to achieve better outcomes.     

Validation of a simple patient questionnaire to assist self-detection of overactive bladder A study in general practice

Objective – To develop and validate a simple patient questionnaire for the detection of overactive bladder (OAB).

Design – An open, non-randomized multicentre study.

Setting – A pilot study (n=133) was conducted to bring forward five questions from initially 14 questions, for detection of OAB. These five questions were subject to further validation in the main study (n=520).

Subjects – 531 adults responding to a newspaper advertisement regarding symptoms of OAB and patients seeing a physician for other reasons were attending 28 general practitioners.

Main outcome measures – Agreement rate, sensitivity, and specificity.

Results – The agreement rate between the patients’ own diagnosis based on the patient questionnaire, and the physicians’ diagnosis based on medical history, urine analysis, and micturition chart, was 0.78 (κ=0.89). Sensitivity and specificity were 0.98 and 0.90, respectively.

Conclusion – The validated questionnaire may become a useful tool to decide whether a patient has overactive bladder. The questionnaire corresponds well with the physicians’ diagnosis.     

Could knowledge of patient demographics facilitate a personalized approach to radiation therapy patient education?

IntroductionUsing patient demographics to tailor cancer patient education processes results in improved patient outcomes. However, there is little information on how to successfully tailor radiation therapy (RT) educational content and delivery. The aim of this quality improvement project was to describe the information preferences of a diverse group of patients undergoing RT and determine if different RT education processes were associated with certain patient demographics.Materials and MethodsAn educational needs assessment questionnaire, based on a validated tool, was offered to all patients undergoing RT on a single day. Questionnaire sections included demographics and questions regarding the importance of topics related to RT treatments, desired mode of information delivery, quantity of information, desired timing of information, and satisfaction with information received. Patients were also asked to answer qualitative questions focused on what was working well and what could be improved. Participants’ responses were cohorted based on demographic groupings (age, gender, education level) and were tested for statistically significant differences and associations.Results130 patients completed the questionnaire. Compared to those over 60 years, more participants who were 50 – 59 years old thought the topics were ‘very important’ (96% vs 77%, p<0.001) and wanted a higher quantity of information about the topics (80% vs 66%, p<0.001). More participants over 70 years old preferred pamphlets compared to those less than 70 years (48% vs 30%, p<0.047) while more participants under 50 years old preferred one-on-one sessions compared to those older than 50 years (40% vs 25%, p<0.038). Fewer participants <50 years wanted information at their first meeting with the Radiation Oncologist compared to those older than 50 years (57% vs 73%, p<0.001). Compared to the male cohort, more female participants felt the information topics were more important (83% vs 74%, p<0.0001) and had more unmet education needs (29% vs 17%, p<0.001). Compared to those with post-secondary education, more participants with primary or high school education desired a higher quantity of information (76% vs 65%, p<0.001), preferred to receive that information using pamphlets (43% vs 32%, p=0.006) and wanted all the information at the first opportunity (81% vs 67%, p<0.001).ConclusionsThis quality improvement project found that age, gender and education level influenced patient preferences for information quantity, delivery mode and timing of RT education. These findings are promising and support further evaluations to determine a more precise definition of the personal factors that could help to individualize our approach to educating patients receiving RT.     

The nurse''s role in patient education: incongruent perceptions among nurses and patients

The purpose of this study was to describe the amount of congruence in the perceptions of 38 matched nurse-patient dyads concerning the nurse's role in patient education. The perceptions of nurses and patients from two hospital settings were measured with two complementary sets of questions, developed for this study; t-tests were used to compare the mean responses of nurses and patients within and between the two settings to each set of complementary questions. The results indicated that incongruencies existed between nurses' and patients' perceptions of the nurse's role in patient education. Patients identified a general teaching function for nurses. When asked who they preferred to have teach them the specific information related to their condition, patients most frequently chose a physician. Nurses most frequently chose a nurse as the current and most desired patient teacher. Nurses incorrectly assumed that the desires of their patients for patient education were similar to their own. The results suggest that nurses need to develop a clear definition of their role in patient education, to validate patients' desires for teaching, and to examine organizational factors influencing their performance of the patient teaching role.     

The comatose patient

Consciousness and wakefulness require normal functioning of the cerebral cortex, as well as of the midbrain reticular formation and its ascending projections. Bilateral structural lesions or functional disturbances of these brain areas can impair consciousness and can produce coma. The bodily posture and brainstem reflexes of the comatose patient provide clues as to whether the lesion lies in the brainstem or in the cerebral hemispheres. Brainstem reflexes are usually preserved in coma due to bilateral hemispheric dysfunction, including metabolic, anoxic, and toxic coma. Ancillary tests are used to answer specific diagnostic questions. The treatment of coma depends on its etiology.     

Comprehensive pediatric care: the patient viewpoint.

Two meanings of the term comprehensive care are delineated. The first refers to a wide scope of health services, the second to a humanistic approach to the patient. Findings from a sample of patients from one pediatric practice suggest that the two meanings constitute two independent variables with respect to patient expeciations. Patient responses to questions regarding their expectations of the pediatrician revealed a tendency to hold a traditional disease orientation. Comprehensive care as a broad scope of health services that include mother guidance in child rearing is not a common goal for mothers utilizing the pediatric practice under study. On the other hand, a comprehensive approach by the pediatrician is a standard shared by most respondents in the sample: high priority is accorded the pattern of the personal physician with whom a patient forms a continuous doctor-patient relationship which instills in the patient trust that the physician's recommendations are based on thorough knowledge of the patient as an individual.     

Understanding hypertrophic cardiomyopathy: implications of diagnosis for the patient and family

Hypertrophic cardiomyopathy (HCM) may be a challenging condition for an internist. The algorithm for work‐up and treatment is fairly straight forward when the presentation is classic. However, in the real world, subtle and moderate forms of the disease occur more commonly. We analyse, step by step, diagnosis and management of a patient with mild HCM and review the literature on pertinent questions regarding diagnosis, risk stratification, treatment options and implications for patient’s lifestyle and for his family.     

A web-based patient activation intervention to improve hypertension care: Study design and baseline characteristics in the web hypertension study

BackgroundDespite the known health risks of hypertension, many hypertensive patients still have uncontrolled blood pressure. Clinical inertia, the tendency of physicians not to intensify treatment, is a common barrier in controlling chronic diseases. This trial is aimed at determining the impact of activating patients to ask providers to make changes to their care through tailored feedback.MethodsDiagnosed hypertensive patients were enrolled in this RCT and randomized to one of two study groups: (1) the intervention condition – Web-based hypertension feedback, based on the individual patient's self-report of health variables and previous BP measurements, to prompt them to ask questions during their next physician's visit about hypertension care (2) the control condition – Web-based preventive health feedback, based on the individual's self-report of receiving preventive care (e.g., pap testing), to prompt them to ask questions during their next physician's visit about preventive care. The primary outcome of the study is change in blood pressure and change in the percentage of patients in each group with controlled blood pressure.ConclusionFive hundred participants were enrolled and baseline characteristics include a mean age of 60.0 years; 57.6% female; and 77.6% white. Overall 37.7% participants had uncontrolled blood pressure; the mean body mass index (BMI) was in the obese range (32.4) and 21.8% had diabetes. By activating patients to become involved in their own care, we believe the addition of the web-based intervention will improve blood pressure control compared to a control group who receive web-based preventive messages unrelated to hypertension.