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Chapter 5
Getting organised for supporting
self care as an individual professional
in the general practice team
This chapter shows you how you can best promote and support self care as a health professional as part of your everyday work, linking in with others in your practice team.
GPs and other health professionals working in primary care share similar core
competencies: primary care management, person-centred care, specific problem
solving skills, comprehensive approach, community orientation and holistic modelling
which include the psychosocial and cultural dimensions of a person’s life.1
The six competencies shown in Figure 5.1 are rooted in:
- the attitudes of health professionals and patients
- the evidence base or science of medical management and treatment
- the context of the primary care setting and the person.2,3
As patients become better informed, the GP, nurse, allied health professional (AHP), pharmacist or other health professional should encourage patients to use their expertise in taking care of their own illnesses and in changing to more healthy behaviour. The general practice team can build their relationship with thepatient, deal with health problems in their physical, psychological, social, cultural and existential dimensions, and reinforce consistent health messages.
How the health care practitioner can enable patients
to self care
According to patients, health care professionals can enable self care by:
- establishing effective two-way communication between health care professional and patient
- building a good relationship between practitioner and patient: treating patients
holistically and establishing trust
- providing patients with information on their disease and signposting other local
resources
- developing self care plans for individual patients
- sharing decision making with patients about their management and care
- using motivational techniques with patients
- signposting or recommending over-the-counter medicines
- encouraging patients to access reliable health information4
- referring patients to self care skills training
- directing patients to self care support networks in the community.
Developing and sustaining an effective communication style
Key aspects of effective communication include rapport, empathy, listening, questioning, being non-judgemental, being consistent and using the same type of language as that of the patient (see Box 5.1). Some patients like to know detailed medical terms, in part so that they can undertake theirown research. You should understand cultural diversity, since diseases are viewed differently by various groups of patients, and those differences can have an impact on individuals’ motivation to self care. Be flexible, i.e. adapt your own style according to the needs of the individual patient. Communication needs to be uniformly good – between all types of health professionals, and by an individual health professional whether or not they are having a pressured day or are on ‘top’ form.
Box 5.1:
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Use Tool 19 to assess your consultation skills and style, to check that you are taking up opportunities to promote self care to patients and are providing them with a wide choice of self care support. Or try Tool 20 to ensure that you are being as patient centred as you think you are in your everyday consultations with patients.
Limited consultation time emphasises the importance of effective communication. Areas to include are: listening, questioning (relevant to understanding motivational issues and treating the patient holistically), building rapport, use of appropriate language, and providing consistent communication. You need to be able to communicate across cultural boundaries to engage with patients of all backgrounds.
Look at the content of Figure 5.2. Have good eye contact at the beginning of the consultation and at reasonable intervals throughout; ask about the patient’s perceptions and feelings; use active listening to clarify what patients are concerned about, and avoid interrupting the patient before they have finished giving you the essentials. Knowing about the signs indicating someone’s background mental state helps you to understand not just what is said but the feelings behind the words.
The meaning of language
Most of the time you understand what people say, but sometimes your ‘wires get
crossed’.5 Some examples of poor language skills are:
- action meanings: people often use action statements when they do not like to ask
directly for things. Saying ‘It’s very fresh in here with the window open’ can be a
request for the window to be shut, and the speaker will be quite offended if you reply ‘Yes, it’s nice to have fresh air coming in’
- taking things literally: the answer to ‘Have you seen that file I put down?’ is not ‘Yes’
but ‘It’s over there on the table’
- connotative meanings: these can suggest emotions but express what is said and what
is meant differently. Many people remember their full name being used when
someone was telling them off. People who use metaphors implying that the
workplace is a war zone may be expressing their inner feelings about it being a
battlefield
- using jargon: the use of jargon can sometimes be an unconscious attempt to prevent communication and understanding – after all if you do not understand what I am talking about you cannot possibly do my job! More often, it is the failure to use feedback (or lack of it) to modify what is being said to the level of understanding of the listener.
Building a positive relationship and developing trust
Two important aspects of the patient/health care professional relationship are: being
treated holistically as a whole person and developing trust (see Box 5.2).
Treating the patient holistically means evaluating all the factors that can influence
a patient’s behaviour, including their overall health status, mental wellbeing (such as
mood and self-esteem) and their personal circumstances. Undertake an evaluation of
all of a patient’s health conditions when deciding with them on their treatment. Look
at all the factors likely to impact on their ability to self care (including their mood),
your style of communication, and other health options such as complementary
medicine. Use goal setting (e.g. as part of a self care plan), positive feedback and
positive thinking approaches to build up their confidence and self-efficacy.
Box 5.2: Treat the patient holistically
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Building trust is closely linked to effective health professional–patient communication. Trust should be a central focus in relationship building with patients and building rapport. Building trust includes: good communication skills (e.g. consistency of communication), honesty (e.g. being honest about uncertainties of the condition and admitting to not knowing everything) and practical elements such as confidentiality. See how a patient describes the need for trust in Box 5.3 and what people value in Box 5.4.
| Box 5.3: A patient describing the need to build a trusting relationship with their family doctor ‘Trust is actually vital, it’s really important, I think for me. In my doctor’s surgery there are certain doctors I do trust but there are others I would not see. It’s the way they talk to me, it’s showing respect. They actually listen to what I have to say. It’s also for them to realise that even though you are a doctor, it’s like every profession, you don’t know everything, there’s always something new that you need to learn. With my doctor the thing that I like about him is that he constantly updates his knowledge . . . I’m always passing information to him, he says ‘‘that’s wonderful I didn’t know about that.’’ ’ |
You can encourage people to trust you if you:
- do what you say you will do and do not make promises you can’t or won’t keep
- listen to people carefully and tell themwhat you think they are saying. People trust
others whom they believe understand them
- understand what matters to people. People trust those who are looking out for their best interests.
| Box 5.4: Relationships with health professionals in primary care are mostly good A survey of 117 000 patients by the Healthcare Commission gave broadly positive impressions of their experiences of primary care services, including care by doctors and dentists.6 Patients want fast access to good care. They want to have a say in their care and be enabled to help themselves. Seventy-six per cent of patients reported that they definitely had confidence and trust in the doctor whom they saw; 75% were confident in their dentist; 92% of people said the doctor whom they saw always treated them with dignity and respect, but 18% felt they had not been given enough information about potential side-effects by their GP. Sixty-nine per cent said they were involved as much as they wanted to be by GPs in decisions about their care and treatment; 70% said their dentist involved them enough. |
Patients want to see the same person over several visits. Otherwise, seeing different individuals on various occasions can mean that patients have to repeat the same information and may receive conflicting advice.
Providing reliable information
You need to focus on providing disease information that is tailored to the individual patient, encompassing both detailed background on their condition as well as self care skills (e.g. self-monitoring and managing diet). Highlight other sources of information, such as local self care support networks, free exercise programmes, especially tailored information for individual cultures/nationalities, such as local diet sheets (e.g. for West/East African, Asian nationalities etc). Signpost them to reliable resources on the internet too (see ‘Promoting effective use of health information by patients’, p. 66).
Practice nurses and nurse practitioners, diabetes specialist nurses and other specialist nurses, in particular, provide useful, in-depth, information on a patient’s disease as well as giving practical advice on self care in a style to which patients respond well (e.g. in an interactive way). Patients value health professionals taking the time to provide detailed information that is relevant to them, and not taking for granted what they may or may not already understand about their condition.
Emphasise the following elements of disease education with individual patients: basic knowledge of their disease, individual risk factors, long term implications of their disease, and the consequences of not self caring. Guide them about the types of questions to ask when pursuing further knowledge of the disease, for example, with hospital specialists.
Encouraging patients’ self care skills
If you are able to establish effective patient-centred communication then you are more likely to encourage and support patients in taking decisions and in their self care actions to take optimal care of their health condition outside of health service settings.7 The skills that you should use as part of the patient-centred approach are described in Box 5.5.
| Box 5.5: The patient-centred approach to promote and support self care 1 Exploring the disease and illness experience: – what are they worried or unhappy about? – personal and psychological impact of disease – how to recognise and treat flare-ups immediately – recognise situations when help is needed 2 The whole person – understanding their role and position in life: – how do treatment regimes fit in with their working and personal lives? – can they work during a flare-up? – any problems in self treatment? 3 Finding common ground between them and you: – what decisions (shared decision making) have to bemade about: lifestyle, drug treatment, living with side-effects, surgery, surveillance, quality of disease management versus medical efficacy? – make entries in patient held records together: test results, everyday maintenance treatment, how to recognise symptoms of flare-ups and treatment regime for self care of flare-ups. 4 Prevention and health promotion: – starting treatment fast – removing unnecessary stresses from life – importance of routine medication – how to access others e.g. dietitian 5 Enhancing the patient–professional relationship: – acknowledge areas of uncertainties – allow patients to take responsibility for self care – write down an overall self care plan including a personal treatment plan – make follow-up appointments on request – recognise the legitimacy of patients’ non-medical approaches to care 6 Being realistic, ensure understanding: – making sure patients understand and are happy with joint management and decisions – not dumping all uncertainties on patients7 |
The development of self care support programmes requires joint decision making between the patient and health professional, which in turn helps to promote self care – as in Box 5.6. Currently, self care plans appear to focus mainly on treatment issues (e.g. self administration of medication for asthma patients). Self care training should cover: medical issues, emotional and psychological issues, how to work with various health care professionals providing care for their disease, and making lifestyle changes. Cognitive techniques and support from other patients in self care support networks and peer-to-peer groups are options that are particularly useful for patients with mental health problems. Cognitive behavioural therapy (CBT) skills can be applied in all consultations. CBT encourages patient involvement, autonomy and increased concordance. Health professionals and patients work together to understand ongoing problems. This technique could be included in self care plans, to encourage joint decision making, tailored to the individual.
| Box 5.6: A practice nurse encourages self care with a self care plan for asthma ‘With my asthma patients what I do is I give them an action plan. I try to encourage them to recognise what brings the asthma on and be able to avoid it when they can, and once they can do that it means they can stop and start their treatments at the right time . . . an action plan that they can follow in terms of adding in and taking out medication . . . about when to contact their doctor, how to avoid an emergency . . . there’s no point in taking an inhaler all year round . . . it’s about teaching them to self-monitor . . . They also get a peak flow meter . . . if they feel any deterioration they just blow into the little machine and it gives them an idea of what’s happening and what they might be able to do.’4 |
In one study, cognitive behavioural-based self help mental health care facilitated by practice nurses was as effective as ordinary care, with similar costs; patients participating were more satisfied with facilitated self help too.8
You could use Tool 21 to review the various stages you go through in a typical consultation with a patient, and check that you are challenging, guiding, suggesting, encouraging, stimulating and generally optimising the promotion of self care. Or guide patients to the ‘Self care for people’ training course (see Box 5.7).
Box 5.7:
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Sharing decision making
As a health professional, you should respect the values and beliefs of patients and not try to impose your own attitudes upon them. The feelings of loss of control, vulnerability and isolation that accompany illness leave people open to manipulative behaviour by their carers and health workers. A potential imbalance of power is created by your superior knowledge as the provider of services. Shared decision making is the middle ground between informed choice, where decisions are left entirely to the patient, and traditional, paternalistic medical decision making. It involves two-way information giving (medical and personal) between the clinician and patient concerning all options available, with the final decision being made jointly with both parties in total agreement.9 To share information and relate well requires you to consider how you interact with a patient in respect of:
- partnership: help for someone with a problem through partnership between that
person and professionals
- empowerment: help for those with problems to find the best ways of helping themselves
- judgement: beware of judgement – the person with the problem is the only one who really understands their experience and problem
- values: people’s values and priorities change with time; they may be quite different
from your values, but no less valid
- autonomy: autonomy should be a fundamental right of everyone. Illness, disability,
low income, unemployment and other forms of social exclusion mean a loss of some
aspects of autonomy in society
- listening: active non-judgemental listening is core to helping people, and crucial to
gain an understanding of people with problems
- shared decision making: people with ongoing problems need to be able to take their
own decisions about the care of their clinical condition, based on expert information
communicated to them by professionals. Patients do value shared decision
making, but not as much as other key attributes of consultations such as having a
doctor who listens, and being provided with easily understood information.10
Shared decision making leads into concordance, which should be the goal of all shared decision making encounters between health professional and patient11
- concordance: a negotiated agreement on the management of a clinical problem between the person with the problem and the professional allows the patient to take an informed decision on the degree of risk or suffering that they themselves wish to take on.12 In contrast ‘compliance’ with treatment, lifestyle or other changes, implies that the patient follows instructions from professionals to a greater or lesser degree. See Box 5.8 for more on this.
Box 5.8: 3 patients are supported in taking medicines: |
Involving patients in making treatment decisions poses concerns for their health professionals. These include the extra time needed and difficulties in eliciting patients’ preferences, exacerbated by limited appropriate information to support patient involvement. Health professionals may not have the appropriate competencies (see p. 70) such as ability to communicate risk effectively or accept patient preferences that are different from their own or evidence based guidelines. Some clinicians prefer to retain the imbalance of power between themselves and their patients; some patients may be reluctant to express their preferences if they perceive their doctor or nurse as being more powerful and knowledgeable.15,16
Certain catchphrases and open questions have been advocated as being useful for involving patients in decision making. Examples are given in Box 5.9.
Box 5.9: Exploring patient expectations‘What do you want to get out of our appointment today?’ Exploring patient ideas‘What are your thoughts as to what is going on here?’ Exploring patient concerns‘Is there anything else you would like to know about?’ Identifying options‘Have you thought about any alternatives?’ Determining patient preferences for information‘What do you know about it?’ ‘How would you like this information? Some people like to read things, others Determining a patient’s preference for their role in decision making‘How would you feel if we both thought through the various options together?’ |
There are a variety of consultation models that you might consider and adapt in supporting self care. Most start with establishing rapport with the patient, exploring their reasons for the consultation, being aware of the doctor’s agenda, reaching a shared understanding and formulating an action plan together.
Enhancing patients’ motivation to self care
Personal motivation is one of the main characteristics of the patient that determines the level of self care they attain. Motivation is influenced by the individual patient’s personality type, age, level of education, and social class. Motivation is also affected by mental wellbeing, knowledge about their disease, type of support from others and their cultural background. Motivation can either be intrinsic or extrinsic. Intrinsic motivation might be about someone enjoying learning about self care and practising it, for their own sake; feeling confident that they have the tools to self care. Extrinsic motivation might be either in the form of a ‘carrot or a stick’, rewards or adverse events.
The main approaches appear to be:
- treating the patient holistically, which involves exploring all current reasons for
their low motivation to self care (e.g. mood, social circumstances)
- building confidence and ‘self-efficacy’ by setting achievable goals and then providing
positive feedback and encouragement (see Box 5.10)
- being flexible in approach: negotiating with patients and adopting a different style
in order to achieve the desired outcome
- providing knowledge of the disease (see p. 66)
- developing a range of self care support options.4
| Box 5.10: Tips on boosting patients’ motivation to self care ‘Some people have poor motivation because they have never achieved . . . so they don’t feel in control so it’s about showing them the small things that they can achieve . . . so that they can have that self-efficacy.’4 (GP) ‘We are trying to initiate self care . . . Patients need to learn about their illnesses and how to monitor them, as well as where to go for more education. We are encouraging themto take more responsibility.’18 (GP prize winner of enterprise award) |
To motivate patients, you need to use techniques to build patients’ self confidence and self-efficacy which involve goal setting and providing positive feedback and encouragement. You could also use approaches such as re-framing (changing negatives into positives) and positive self-talk to help motivate those with a ‘negative outlook’. These sort of approaches and techniques for listening and questioning are described in neuro-linguistic programming (NLP), motivational interviewing, and social cognitive theory.19,20
Heron’s six categories of intervention describe the different help-giving approaches that you can adopt when face-to-face with an individual patient.21 The first three represent energy flowing from the health professional, who is actively intervening to alter the patient’s thinking or behaviour. In the other three categories, the health professional is playing a less active role, attempting to induce the patient to think or behave differently:
1 prescriptive: giving advice, being critical, making suggestions and generally
attempting to direct the behaviour of the individual
2 informative: instructing, informing and generally imparting factual information to
the individual
3 confronting: being challenging or giving direct feedback to a patient to challenge
their attitudes, beliefs or behaviours, while assuming a supportive manner
4 cathartic: helping someone to express their feelings and emotions to enable them to
gain new insights into their condition
5 catalytic: drawing the other person out through the use of open questions, reflection
and empathy, encouraging them in learning more about themselves and
problem solving
6 supportive: approving, confirming or validating someone’s experience, qualities,
attitudes or actions, in a genuine way.
Thinking of the pros and cons of the various options open to a person and visualising what that means in real life is a great way to motivate people – as in Box 5.11.
| Box 5.11: Motivational advice from a health column in a local newspaper Q: I desperately want to lose weight and have taken out gym membership but never been to use the facilities. Please help me get motivated. A: Make a list of the pro and cons for the current situation you’re in. So on the plus side, you have more time at home, and are not risking pulling a muscle at the gym. On the minus side, you’re wasting the money you paid to join the gym, you’re overweight and you’re unfit. Next, make a list of the pros and cons if you start going regularly to the gym. On the plus side, you’ll get fit, meet new friends, regain your self-esteem, take pride in your appearance. On the minus side – difficult to think of anything. Lastly, work out what is stopping you going to the gym when there are self-obviously so many pluses to be had. Think out how you will do it, and make a personal action plan.22 |
Helping people change
The model in Figure 5.3 describes the stages in the cycle of change through which an individual moves, and how they must be motivated to change.23 It was initially developed for smoking cessation, then used for many other health behaviour programmes. Behaviour change is not a linear movement through these stages though. It can be progressive, regressive, spiralling or static; people may skip one or more stages or stick in one for a long time.
It is essential to choose an appropriate time to motivate a person to change, such as from risky habits to a healthy lifestyle. Hopefully, individuals pass through the stage of contemplation and onto the stage of taking action for themselves. You should set realistic targets for that change that are achievable so as not to demotivate the person or allow them an escape route (‘I knew I couldn’t do it’). It can be difficult to assess what stage someone is in – especially if the health professional is pressed for time. You can make assumptions and mistakenly rate someone as being ready to change, so the more you can involve the other person in rating where they are themselves, the better.
Everyone likes to get feedback and encouragement about how they are doing. Do not just leave it until an annual health check, give the patient praise when and where it is due at any time.
Signposting or recommending over-the-counter (OTC) medicines
Signpost people to the various range of treatments they can buy themselves without a prescription. Use an evidence based resource to make your recommendations.24 See Chapter 6 for more on this. Increased switching from prescription only medicines (POM) to pharmacy medicines (P) has meant that the public can self treat more conditions, e.g. emergency contraception as described in Box 5.12.25 It has implications for training of patients, doctors and nurses about what is possible, and pharmacists about their increased role.26 There is more to be done in educating the public – one study found that an estimated 8% of adult attendances at an accident and emergency department could have been managed by a community pharmacist.27
| Box 5.12: Greater use of pharmacies to access emergency contraception Emergency contraception became available without a prescription from community pharmacies in 2001. The percentage of women obtaining emergency contraceptive pills from a pharmacy has increased markedly from 27% in 2003–2004 to 50% in 2004–2005. Over the same time period, the proportions of women getting the ‘morning after pill’ from a GP or practice nurse fell to 33%, from a walk-in centre or minor-injuries unit fell to 3%, and from a family planning clinic remained stable at 11%.25 OTC medicines bring both benefits and risks. Benefits include enabling people to take more responsibility for their own health or that of their dependants with rapid and convenient access to treatments and use health professional capacity more efficiently. Potential risks include adverse effects (see Box 5.17, p. 76) and possible misuse of certain medicines.28. |