Chapter 5 - part 2
Getting organised for supporting
self care as an individual professional
in the general practice team

Promoting effective use of health information by patients

Disease information should be specific to the needs of the individual (i.e. the right information for the right stage of the condition and the nature of the person). Health care professionals should be familiar with the variety of local self care support networks and peer-to-peer support groups that are available as sources of disease education. Patients want qualitative information – not just the facts and figures. They want to know what it is like to live with a particular condition, not just the treatment options. They want to know how their condition will affect their ability to work, their usual activities, their family relationships, and their sex life.

At present, there is an enormous amount of information about health and medicines available from many different sources but it is not always easy for patients to access.29,30 Nor is it always clear how reliable, authoritative or up-to-date such sources of information are. Information about medicines and disease states, and suggestions for self care, are provided:

in doctors’ surgery waiting rooms, pharmacies, hospitals and clinics
by professional bodies
by health charities and patient support groups
in libraries
via the internet
via the media.

We provide patients with information to:
help them understand what is wrong
gain a realistic idea of their prognosis
make the most of consultations
understand the process and likely outcomes of possible tests and treatments
assist in self care
provide reassurance and help to cope
help others understand
legitimise help seeking and concerns
identify further information and self care support networks and groups
identify the ‘best’ health care providers.31

Information about risks and benefits of medicines, safe use of medicines and what actions people can take for themselves may not be explicit. Information may not be phrased in language or presented visually in ways that the majority of patients easily comprehend. Information leaflets or other media do not necessarily cater for non- English speakers or people from different cultures.

A good-quality publication about treatment choices will:

have explicit aims and achieve them
be relevant to consumers
make date and sources of information explicit
be balanced and unbiased
refer to areas of uncertainty
describe how treatment works – its benefits, the risks and what would happen
without treatment
describe effects of treatment choices on overall quality of life
make it clear about range of treatment choices
provide support for shared decision making
list additional sources of information.32

You can use the DISCERN instrument to determine whether your patient literature
fulfils the quality criteria listed above.32

When judging the impact of patient literature, consider the:

writing style
typeface
design and layout
headings
use of colour
use of symbols.29

See Box 5.13 for a good example.

Box 5.13:

A brilliant example of literature for the general public

The Haynes Owners Workshop Manual is a cleverly produced practical guide to healthy living and weight loss for men. It is modelled on the Haynes’ manuals for various makes of car, and entitledHGVMan – reducing all large sizes; all shapes and colours. It is easy to read, colourful and informative with great appeal for men.33

Information that aims to communicate risks to patients, should cover the harmful effect(s) itself, the probability of it occurring, how to minimise this risk if possible, and what actions to take in the event of a problem arising. So:

put the most important information first
include information about benefits too
use the right words that readers can understand
use numbers appropriately to convey risk (see p. 74 for more about how to communicate risk effectively).

The Plain English Campaign and the Royal National Institute of the Blind (RNIB) are useful sources of advice and guidance on writing about health topics for various readerships.34,35

Online resources

Guiding individual or groups of patients on the use of appropriate websites will be of value. Health on Net gives details of its accreditation service for websites that adhere to its code of practice to help standardise the reliability of medical and health information available (www.hon.ch/HONcode). The StaRNeT website assessment tool (SWAT) is a rating instrument to evaluate general practice websites providing health information for patients.36 When you can print off relevant pages from sites of proven quality you feel safe recommending the sites to patients (e.g. www.patient.co.uk, run by two GPs in Northumberland). Patients’ awareness of NHS Direct Online services for instance, such as Best Treatments (www.besttreatments.co.uk) and the self help guide (www.nhsdirect.nhs.uk), are low and could be encouraged. You can signpost patients to online resources of self care support networks (e.g. that of the UK-based Addison’s disease self helpgroup www.adshg.org.uk containspractical information,andstories of patients’ experiences). One of the websites with alisting of the largest number of self care support groups is www.ukselfhelp.info. Some websites are for both health professionals and the general public (e.g. Midwives Online www.midwivesonline.com). The MyPil resource at www.mypil.com provides patient information leaflets in several languages, such as Hindi, Urdu and Bengali.

New IT technology

The National Programme for Information Technology should fulfil people’s wish to become involved in, and informed about, their care, through readily available information about health services, particular diseases and conditions and their own specific care plans.37 Patients will have their own personal online health organiser, HealthSpace, that they can use to record personal health details such as blood pressure. It will incorporate a ‘find’ facility, allowing patients to look up reliable health related information, and provide guidance and information on healthy lifestyles. It will store self care programmes such as for stopping smoking or managing diabetes.

If patients with health concerns utilise the range of health information available, they may no longer need to become patients by consulting a health professional. They can investigate health issues themselves, before, or instead of, a consultation. A computer literate personmay be able to find a satisfactory answer to their health issues online or on digital TV; many people will still need the expertise from health professionals they trust to interpret the data and information for them.38

Revising your personal development plan to focus on supporting self care for patients

Many health professionals and managers use personal learning plans as a way of thinking about planning and managing their learning: to consider their practice, define their learning needs and review progress. You probably have your own template already, but if not take a look at www.pdptoolkit.co.uk.

Tool 10 is a simple model for assessing your own educational needs in respect of supporting self care. Tool 17 helps you check that the learning you have identified is really a priority for you or your practice. Educational needs in this instance will encompass evolving a culture of self care in your practice or workplace, as well as the knowledge and skills for any particular role or responsibility you hold.

Use a range of methods to identify your training or information needs. No one method will give you reliable information about gaps in your knowledge, skills or attitudes. You can become more aware of your current gaps in knowledge, or your strengths and weaknesses in relation to supporting self care by:

self-assessment and reflection
peer review from work colleagues
asking patients, users and non-users of your service
comparing the way you support self care against best practice
asking colleagues from different disciplines about shortfalls in how your work interfaces with theirs.

Demonstrating your competence in relation to self care through a personal portfolio

Maintain a portfolio that describes the evidence of what you have learnt, starting from your personal plan arising from your learning objectives, the process of gaining the knowledge or skills and the demonstration of your competence – with respect to supporting self care, in this instance. Such a portfolio may be useful in your annual appraisal or re-accreditation of your professional qualifications, to obtain credits for Prior Learning with higher degree courses at universities, or to prove experience and competence for a new role or cataloguing within the NHS Knowledge and Skills Framework component of Agenda for Change.

The steps in portfolio based learning are:39

identifying significant experiences to serve as important sources of learning
reflecting on the learning that arose from those experiences
demonstrating that learning in practice
analysing the portfolio (see Box 5.14) and identifying further learning needs and ways in which these needs can be met.

Box 5.14:
Your portfolio

Your portfolio will have a varied content:

workload logs
case descriptions
videos
audiotapes
patient surveys
research surveys
audit projects
report of a change or innovation
notes from formal teaching sessions or action learning set
commentaries on published literature or books
records of critical incidents and learning points
patient narratives or stories.

Analysis of the experiences and learning opportunities should show demonstrable learning outcomes and any further educational plan to meet educational needs or development still outstanding. Much of the learning emanating from a portfolio is from individual reflection and self-critique in the analysis stage.

Being competent as a health professional in supporting self care

Developing competency: novice to expert

Competence is about being ‘able to perform the tasks and roles required to the expected standard’.40 So, knowledge and skill are components of competence. Capability is a term that describes ‘what a person can think or do’. Whether or not a person’s capability makes them competent in a particular job such as being a practice nurse depends on thembeing able to meet the requirements of that job.41 Capability implies that individuals can develop sustainable abilities that allow them to adapt to a changing environment and react appropriately to unfamiliar situations.

You should set out the evidence of your competence in your portfolio to show that you knowabout self care, know how to promote and support it, can show how you are competent to promote and support it, and how you have done so (your performance). 42

The standard expected to be able to judge someone as ‘competent’ will vary with their experience and level of responsibility, and take into account the need to keep upto- date with changes in practice. Different people will have varied expectations ofwhat counts as competence – managers, staff, individuals, patients, clients, etc.

There can be a gap between competence (what a person can do) and performance (what a person actually does). This gap can be caused by personal matters such as an individual’s attitude or personality or mood, environmental factors such as workload,

time pressures or working conditions, or situational factors such as a lack of resources or support.

You will become aware of what self care means, how to support self care, the risks and benefits, and how you can expect patients to practise it. As you become more familiar with the concept of self care and how various patients can apply it with their various health conditions and diverse circumstances, you will become competent at supporting self care. With more experience and continued learning and reflection about what works in supporting self care for patients, and what does not, you will become expert. This progress is described in Box 5.15.

Box 5.15: A health professional’s competence in relation to supporting self care

Aware

Understands the importance of self care in generating health and wellbeing
benefits to all people, and those with minor ailments and/or long term conditions.
Able to signpost people who would benefit from self care to appropriate
resources and an appropriate health professional.

Competent

In addition to the descriptor of being ‘aware’ of self care:

has the knowledge and skills and positive attitude to promote and support self care for all patients consulting them in their everyday work role
knows role within the practice team and is good team member in respect of self care, adhering to agreed messages and protocols
is pro-active in supporting self care to all patients at every opportunity over and above the specific reason for their consultation
takes into account self care activities the patient may be undertaking that might impact on a particular consultation (e.g. consuming OTC medicines, alternative therapies, healthy lifestyle behaviours)

Expert

In addition to the descriptor of being ‘competent’ in self care:

has an intuitive grasp of the benefits of self care support and applies expert knowledge and skills about self care to patients at every opportunit

knows how and has skills to initiate self care support activities and protocols with other members of the practice team and attached community nurses, AHPs and pharmacists
knows how and has skills to initiate self care activities for the local population of the practice.

The stages of competence

Conscious or unconscious competence should be your goal

You should strive to be consciously or unconsciously competent – the two upper quadrants in Figure 5.4. It is unprofessional to be consciously incompetent and a failure of your review of evidence for your portfolio to be unconsciously incompetent.

Matching your knowledge and skills to the Agenda for Change Framework

The NHS Knowledge and Skills Framework (KSF) covers everyone, except doctors working in general practice, who is employed by PCTs, and those working in general practice where practice employers take up the option under Agenda for Change.43–46 The type and extent of knowledge and skills that define specific roles in supporting self care apply to most members of a general practice team. The six generic core dimensions of everyone’s roles listed in Box 5.16 demonstrate how relevant they are to self care support.

Box 5.16:
Brief descriptions of the six core dimensions of the NHS

Knowledge and Skills Framework as relevant to the promotion and support of self care43

1 Communication: consistently practise good communication skills

2 Personal and people development: develop own skills and knowledge and provide information and advice to others to help their development

3 Health, safety and security: assist in maintaining others’ health, safety and security

4 Service development: contribute to the improvement of NHS services

5 Quality improvement: demonstrate personal commitment to quality improvement, offering others advice and support

6 Equality and diversity: act in ways that support equality and value diversity

Illustrative example of evidence to demonstrate that you are competent at enabling patients to adopt self care

You might use or adapt the following example to gather evidence that you are performing well in relation to the promotion of self care by someone with back pain.47

Focus: complementary medicine, back pain, clinical care; evidence based practice

Case study 5.1

Ms Hope consults you (you might be a GP, practice nurse, pharmacist, physiotherapist or occupational therapist for this case study) to ask for advice about what complementary therapies she might try to help her back pain, as conventional medicines she has tried (paracetamol and ibuprofen) do not give her enough pain relief. She wants to know if acupuncture, glucosamine or massage are safe and worth trying.

Stage 1: Set your aspirations for good practice

The excellent health professional:

knows about the nature and reliability of common treatments, whether they are conventional or complementary treatments
maintains their knowledge and skills, and is aware of their limits of competence.

Stage 2: Set the standards for your outcomes

Outcomes might include:

a protocol in relation to self care of back pain
a strategy that is implemented in respect of self care support (for back pain)
meeting recommended standards in respect of self care support.

Be able to explain the evidence base for interventions (conventional NHS care and self
care) that give benefits for low back pain.

Stage 3A: Identify your learning needs

Self-assess your knowledge of the benefits/risks of complementary treatments, especially acupuncture, glucosamine and massage for back pain.
Try to find reliable evidence about the complementary interventions in question within 5 minutes – either from the PC in your consulting room or a nearby book. Do you know the websites or publication to access easily for the evidence base?
Once you have learnt enough about the effectiveness of these interventions (see Stage 4) explain the evidence to the patient – and then ask for feedback from the patient as to whether they understood your explanation or have anymore questions.

Stage 3B: Identify your service needs

Any of the needs assessment exercises in 3A may also reveal service needs.

Check if there is any patient literature about self care of back pain in the waiting room or consulting rooms. Does it cover complementary treatments? Do you or others in the team know any websites covering self care, to which patients can be directed ?
Find out what local services exist to provide acupuncture or massage through the NHS or privately.

Stage 4: Make and carry out a learning and action plan

Read up about the effectiveness of interventions for acute and chronic back pain from a reliable source.
Discuss with two patients, patient literature that you have accessed from reliable websites as to the relevance and readability of the material.

Stage 5: Document your learning, competence, performance and standards of service delivery

Place photocopies of the evidence for treatments for back pain in your portfolio so that you can refer to it in future if other patients ask you the same questions about the effectiveness of complementary treatments.
Include copies of relevant patient literature.

Case study 5.1 continued

Ms Hope listened to the evidence you relayed that the effectiveness of acupuncture and massage is unknownas regards back pain, and that there is some evidence that glucosamine may be beneficial for osteoarthritis. She decided to give acupuncture a go, as it seemed reasonably safe to do so, and found that her pain subsided considerably as a result of her self organised care.

Communicating risk to patients in relation to self care

In order for people to make well-informed decisions about their self care or medical management, they need to understand the risks and benefits resulting from choices that they make.48 They need to compare those risks with other risks in their lives.

Your advice to a patient must fit with the way they look at the world, and take into account their personality and understanding. The language you use to describe risk is as important as the way you rate and present it. Risk is the probability that a hazard will give rise to harm. But the extent to which a person judges that the harmful outcome is likely to occur and the extent to which they judge the likely outcome to be harmful are subjective. Personality type will influence the way in which risk is allowed to influence behaviour. Some people have a tendency to optimism despite the evidence. Pessimistic people tend to assume that risks are greater than they really are, maybe as a self protection mechanism.

Misperceptions about risk

On the whole, people tend to be over-optimistic about the risks they face. Most smokers acknowledge the connection between smoking and disease but generally underestimate the extent to which they feel that risk applies to them. If asked to estimate the risk we feel we face from heart disease, for example, or being involved in a car accident there will be a bias towards optimism. Outcomes with a high probability tend to be underestimated, whereas the risk from rare events such as nuclear accidents tends to be overestimated.

So a misperception exists. People tend towards the illusion of relative invulnerability, even complacency where more common risks exist, and towards unnecessary concern for less likely, but more newsworthy, events. Since perception of risk is a prerequisite for changes in behaviour, misplaced optimism may hinder preventative action. An increased sense of risk, especially when combined with low expectations for being able to deal with that risk, may provoke a ‘helplessness reaction’ and obstruct intentions to adapt or modify behaviour. This has implications for the way doctors and nurses talk to patients about risk in an attempt to modify unhealthy behaviour and promote self care.

Tolerating risk

We tend to build in an element of uncertainty to our life to prevent boredom or to increase reward. Our risk ‘thermostat’ is not set at zero. The setting of the ‘thermostat’ varies from one individual to another and for one individual over time, as their circumstances and life events change. We also consider the effect that that harm would have on us if it were to occur. Variously known as the ‘dread factor’ or ‘fright factor’, these can be more important than the statistical probability of occurrence.

Communicating risk to patients

Patients may modify their own behaviour as their perception of risks and benefits changes, rather than in response to your exhortations as a health professional. A person who feels that change will have no effect on the inevitability of a poor outcome may be as unlikely to change as one unrealistically optimistic about his or her chances. What influences the reaction of any individual to information about risk are that:

the impact of the anticipated outcome must matter to them
the action required to influence such an outcome must fit their view of the ‘world’
they must agree that a particular outcome is possible
the source of the information must be trustworthy.

You need to find a way to communicate risks as well as benefits from OTC medicines – as in Box 5.17. You might use a visual scale to demonstrate risk to patients. For instance, an online risk calculator can help GPs and specialist diabetes nurses assess cardiovascular risk in patients with type 2 diabetes. You could look at this together with the patient.49

Box 5.17:

Example of risks from complementary medicines

There can be potentially dangerous consequences from combining OTC medicines with prescribed drugs. For example, the herbal drug St John’s wort reacts adversely with some commonly prescribed drugs such as warfarin, oral contraceptives and some antidepressant drugs.

Explaining the level of risk

There is an inbuilt difficulty in using probability to measure risk for anyone who is not good with numbers. Is a side-effect of a drug with a risk of 1:10 000 something we need to be concerned about? What if there is a risk of death of 50% from that side-effect, or a 12% risk of impotence?

Thewayin which a consequence is presented is termed its ‘frame’, and this can affect the choices patients make, clouding or enhancing the true consequences of an action.

Would you choose an intervention with a 40% failure rate or a 60% success rate? The actual risk of the two interventions is the same – but many would choose the one ‘framed’ in terms of gains. Health professionals use framing almost instinctively to discourage patients from certain activities, framing in terms of negative outcomes while still giving correct facts.

Time management

Time pressures are a barrier to health professionals encouraging part in decision making and supporting self care.26,48,50

The many ways to manage your time better fall into three main categories:

1 reducing the amount of work to be done by refusing it in the first place, delegating it, or doing less of it. Reviewing how work is delegated from GPs to nurses, and from practice nurses to health care assistants perhaps?

2 doing work more quickly by doing it less thoroughly or processing it more efficiently. Making more use of the computer and working more efficiently perhaps?

3 allowing more time for a particular piece of work with less time pressure on completing it – altering the way you book patients perhaps?

Prioritise your time: do not allow yourself or others to waste it

Be clear about your goals in your work. Then structure sufficient time around those
priorities. When an activity arises over which you have choice, match it against your

goals. If it takes you further away from your goals, then refuse to take it on, but if it coincides with your goals, consider whether you have time to fit it in.

Make sure that you spend your quality time doing the most important or complex jobs. A high-priority task has to be done, a medium-priority job may be delegated, and a low-priority task should only be done if you have no medium- or high-priority tasks waiting. The majority of your time should be devoted to pursuing your most important goals, and a small proportion of your time spent on less important matters.

Try to allow at least 10% of your time for dealing with unexpected tasks. In the unlikely event that everything goes smoothly and you do not need the extra time, it will be a bonus to have that additional space to catch up on your backlog, or simply spend that time talking to people about how they are feeling or what they are doing.

Delegate whatever and however you can

Only accept delegated work if you have the necessary skills, time and experience. If you are in a position to delegate work and responsibilities, decide what only you can do, and delegate as much as possible of the rest to others. If you are more usually on the receiving end of delegated work, try to make sure you understand what is required, and that you have the time, skills and experience, before agreeing or acquiescing to taking on the new work.

Self care for you too as a health professional or manager

You cannot work effectively if you are over-pressured or under mental or emotional strain. Apply the principles and practice of self care to yourself too.

The problem with stress

Stress is equivalent to a person’s perception of the pressure upon them, or the ‘threeway relationship between demands on a person, that person’s feelings about those demands, and their ability to cope with those demands’.51 In other words, a particular event or task can be stressful for you one day but not on another – depending on how you are feeling and what other pressures are being exerted on you.

In general, stress occurs in situations where the workload is high, control over the workload is limited, and too little support or help is available. A moderate amount of stress is necessary to perform well at work and to maintain a zest for life; zero stress may lead to boredom, whereas too much stress over too long a period will render you indecisive, exhausted or ‘burnt out’.

There are three types of responses to stress – physiological, psychological and behavioural reactions. The ways we respond depend on personal factors such as age, gender, personality, previous family and personal experiences, as well as coping ability and other organisational options.

Dealing with stress

The kind of practical methods people can use to cope with stress at work are:

seeking support from colleagues
sharing problems with colleagues
adopting better time management practices
more appropriate booking times for appointments and meetings
increased protected time off-duty, limiting working hours to those for which contracted
admitting doubts and worries to others
achieving a better balance between work and home commitments.

Stress itself is not the damaging factor but rather your inability to cope with it. In a changing world, people need to learn new ways of coping. That way lies survival.

Seek support

People with the best social support interact well with other people, are able to cope with stress and are the least affected by it. Look at Tool 18 to consider the range of sources of support in your life. Be prepared to ask for help. That is not a sign of weakness or ignorance.

Balance your work and leisure time successfully

Timetable enough free time during your day to have space for rest and relaxation to counteract stresses and strains. Try and complete work activities within your normal working hours, so that you have enough time for non-work-related activities in your life. Make regular time and space for yourself for fun, relaxation, hobbies and enjoying simple pleasures throughout your life as a stress proofing measure.

References

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part 1

Chapter 5 - part 2 Getting organised for supporting self care as an individual professional in the general practice team