Supporting Self
Management
ECCF 6th Feb 2013
Cheryl Harvey and Audrey Taylor (NES)
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• What do you
know for sure
about self
management?
• What do you
wonder?
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• A conversation
tool
• To consider
different
perspectives
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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.
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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
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‘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
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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
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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
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Yes, but…
Well, it all sounds
good in theory but
wont work in my
service because…
There are so many
things - what really
makes the
difference?
Has a place
for certain
people but not
everyone…
Is SM all
talk?
Haven’t we
always done
this?
How should
clinical practice
change?
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Helping people
help themselves
The Heath Foundation - May 2011
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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…add your own
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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.)
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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
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Key message (so far)
The literature shows that proactive,
behaviourally focused selfmanagement support designed to
increase self-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
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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
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Continuum of strategies to support SM
Health Foundation 2011
Focus on self
efficacy
Telephone
coaching
Care plans
Patient held
records
Information
provision
Online courses
Motivational
interviewing
Goal setting
Active group education
Group
education
Written information
Behaviour
change
Self
monitoring
Electronic information
Focus on technical
skills
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• 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
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www.selfmanagementsupport.health.org.uk
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• A conversation
tool
• To consider
different
perspectives
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• Facilitated
approach….not didactic
• Exploring ideas rather
than giving predetermined solutions
• Harnessing your current
skills and experiences as
health practitioners
• Mirroring self
management
conversations
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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.
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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….’
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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.
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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?
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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.
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Risk – part of normal life
• 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.
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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
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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?
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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
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Self Efficacy Matters
•
Stronger sense of selfefficacy:
•
Lowered or reduced
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
•
•
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
•
•
•
•
•
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Supporting a persons self efficacy
• 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.
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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
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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’.
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Strengths / Assets
• 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.
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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.
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• How can you work with
people's strengths,
resourcefulness,
capabilities (i.e. their
Assets)?
• One ‘top tip’ to share with
others
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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
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“As far as Edward Bear knew, it was the only way of
coming downstairs, although he sometimes felt there
was another way, if only he could stop bumping for a
moment and think about it”
(AA Milne)
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