Supporting Self Management

1. Supporting Self Management ECCF 6th Feb 2013 Cheryl Harvey and Audrey Taylor(NES)

2. What do you know for sure about self management? What do you wonder?

3. A conversation tool To consider different perspectives

4. Scenes Introduce us to Anna, and reveal the impact ill health is having on her life. They show that Anna has a wide range of roles and responsibilities. They also show Anna’s own efforts to manage her symptoms and her and Bess’s uncertainty about what might be wrong. Scenes

5. Self Management The ground under our feet is changing. The…model of the external expert has hit diminishing returns… The Fifth Wave, Andrew Lyon, Scottish Council Foundation 2003. http://web.me.com/david.reilly/healing/5th_wave.html

7. ‘Waves’ in public health thinking Wave 1: Great Public Works, municipalism …(early/mid 1800’s) Wave 2: refinement of scientific approach ... germ theory of disease, hospitals, health visitors (later 1800’s early 1900’s) Wave 3: restructuring of institutions, welfare reforms, new housing, social security, NHS ... (early/mid 1900’s) Wave 4: focus on risk theory of disease, lifestyle issues - smoking, diet and physical activity ...(1970’s+) A shared characteristic of these is the relative unimportance of the individual and the human spirit. In the society we have created we behave as if organisations do the work regardless of human capacities, consciousness, energy, passion and effort The Fifth Wave, Andrew Lyon, Scottish Council Foundation 2003

8. The fifth wave? shift from organisational/ bureaucratic to individual/creative paradigms? This creates a challenge for health…how to take into account the impact of personal factors such as life experiences (good and bad), stress, resilience, emotional trauma, grief, hope, resourcefulness or loneliness on organic disease. Current approaches too often miss out a mindbody perspective . The Fifth Wave, Andrew Lyon, Scottish Council Foundation 2003

9. Parallels within health and across other sectors Recovery movement within mental health Education – curriculum for excellence Leadership and management theory – distributed leadership International Development agencies Points of Commonality Help must start from the present situation of the doers. Helpers must see the situation through the eves of the doers. Help cannot be imposed on the doers as that directly violates their autonomy. Nor can doers receive help as a benevolent gift, as that creates dependency. Doers must be in the driver's seat. David Ellerman the World Bank 2001

10. Yes, but… Well, it all sounds good in theory but wont work in my service because… Is SM all talk? Haven’t we always done this? There are so many things - what really makes the difference? How should clinical practice change? Has a place for certain people but noteveryone…

11. Helping people help themselves The Heath Foundation - May 2011

12. What have we been doing to support self management (at a clinical level)? Lots of things Tele-monitoring Provision of information (e.g. leaflets) Structured education Self help or support groups Self monitoring Health coaching, motivational interviewing, health behaviour change, solution focused Many more…addyour own

13. What is self management? Self management support may be viewed in two ways: as a portfolio of techniques and tools that help patients choose healthy behaviours; and as a fundamental transformation of the patient-caregiver relationship into a collaborative partnership. The purpose of self management support is to aid and inspire patients to become informed about their conditions and take an active role in their treatment. (Source: Bodenheimer T. Helping patients manage their chronic conditions 2005.)

14. But what works best? Well, it depends. Sorry, no simple answer! Overall, evidence seems to suggest that it is worthwhile to support SM, but some interventions may be more effective than others. Also (SM support is)…likely to work best when implemented as part of wider initiatives to improve care through educating practitioners, applying best evidence, and using technology, decision aids and community partnerships effectively.’ Health Foundation 2011

15. Key message (so far) The literature shows that proactive, behaviourally focused self-management support designed to increaseself-efficacy can have a positive impact on people’s clinical symptoms, attitudes and behaviours, quality of life and patterns of healthcare resource use. The Health Foundation May 2011

16. In it’s simplest form.. Focus on self-efficacy (a person’s confidence about looking after themselves) + Focus on behaviour change = Positive impact on clinical outcomes and emergency service use

17. Continuum of strategies to support SM Health Foundation 2011 Focus on self efficacy Motivational interviewing Telephone coaching Care plans Patient held records Goal setting Active group education Information provision Behaviour change Online courses Group education Written information Self monitoring Electronic information Focus on technical skills

18. But more research needed…especially to unpick and understand the range of behaviours and activities that come under the banner of self management, and to know more about what impacts on self management

19. www.selfmanagementsupport.health.org.uk

20. A conversation tool To consider different perspectives

21. Facilitated approach….not didactic Exploring ideas rather than giving pre-determined solutions Harnessing your current skills and experiences as health practitioners Mirroring self management conversations

22. Scenes Scenes Introduce us to Anna, and reveal the impact ill health is having on her life. They show that Anna has a wide range of roles and responsibilities. They also show Anna’s own efforts to manage her symptoms and her and Bess’s uncertainty about what might be wrong.

23. Scene • Shows the ‘roller coaster’ experience that can accompany a diagnosis. Anna’s fears about the impact her illness may have on her relationships. Her ‘hunger’ for information and Anna questioning her view of herself and self identity….she says she has ‘stepped over a line….’

24. Accessing and Understanding Information • Central to enabling people to make choices about SM, their health and their lives. Health practitioners can play a crucial role in influencing people’s ability to understand the info they receive and use it in a way that is meaningful to them.

25. Are we doing a good job on this one? • How do you make sure that the self management information that you share is meaningful to the person? • How could you check that the person can use and apply the information that you give?

27. Scene • Shows that Anna’s situation has an impact on the people around her, so when we talk about people adjusting to a LTC we need to remember that other people often need to adjust as well. Also it shows Anna and Bess weighing up the physical challenges of caring for Arran with the psychosocial benefits on wellbeing and self identity.

28. Looking after Arran is clearly what makes a ‘good life’ for Anna – but it does involve an element of risk taking. It might be easy to say she should pace herself, rest when required. However this may not fit easily with the reality of her role and aspirations as a grandparent. Risk – part of normal life

29. If it is reasonable, even normal, for us to take some risks, then surely we should acknowledge that it is the same for our patients. Our role is not to offer approval or disapproval, but to offer people information and resources….. National Diabetes support Team 2008 – Partners in Care: A Guide to Implementing a Care Planning Approach in Diabetes

30. Sometimes it is said that healthcare services tend to focus more on the negative aspects of risk which dissuades people from thinking about the positive aspects, such as opportunity for growth or achievement, satisfaction in accepting a challenge or the positive impact of helping others • In what way does this apply (or not) to you in your role?

31. Scene • Shows us Anna’s emotional response to her situation. The feeling of ‘losing control’ that is often part of the experience of living with a LTC. The tension Anna feels about knowing what she should be doing but not actually doing it. And how some information/advice given has made assumptions about Anna and been unintentionally unhelpful

32. Stronger sense of self-efficacy: View challenging problems as tasks to be mastered Develop deeper interest in the activities in which they participate Form a stronger sense of commitment to their interests and activities Recover more quickly from setbacks and disappointments Self Efficacy Matters • Lowered or reduced sense of self-efficacy: • Avoid challenging tasks • Believe that difficult tasks and situations are beyond their capabilities • Focus on personal failings and negative outomes • Lose confidence in personal abilities

33. Self efficacy is complex but we can support it through affirming, praising, congratulating, endorsing, supporting the person to refine techniques and gain mastery over self management behaviours and actions. Supporting a persons self efficacy

34. The magic ingredient! • where does your own sense of confidence and self efficacy come from? • how do we as healthcare professionals potentially (and unintentionally) undermine a person sense of self efficacy? • what do you currently do to support a person’s self confidence or self efficacy? “If I have the belief that I can do it, surely I shall acquire the capacity to do it even if I may not have it at the beginning” Mahatma Gandhi

35. Scene • Shows Anna 1 yr on feeling more confident and in control over her life, being supported by a worker whose approach is ‘different’, in that they value the skills and experience Anna has. Anna describes this approach as one where the worker listened, this was different from usual which she described as ‘lessoning rather than helping’.

36. Easy to identify deficits and problems, but focusing on problems and limitations can be disheartening. For some people who have been in contact with the health services over a period of time their sense of self (image and identity) can become dominated by the experience of illness and loss. Strengths / Assets

37. Assets • Personal things such as experience, life roles, faith or spirituality, determination and resilience • Other people and community, such as neighbours, family, friends, clubs, groups, sports and perhaps pets • Wider social things, such as access to internet, good housing, having a job to go to and accessible transport.

38. How can you work with people's strengths, resourcefulness, capabilities (i.e. their Assets)? • One ‘top tip’ to share with others

39. What next? Over to you … but here’s a starter for ten… • Consider what you could start doing/stop doing/ do in a different way as a result of what you’ve discussed • What do you need to do to enable you to do this • Any learning or information needs which have come up as a result of discussing Anna’s story

40. “As far as Edward Bear knew, it was the only way ofcoming downstairs, although he sometimes felt therewas another way, if only he could stop bumping for amoment and think about it” (AA Milne)