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Self-Efficacy, part 2

Connie Davis
Monday, May 7th, 2012

Connie Davis MN, ARNP is a geriatric nurse practitioner, health care consultant and William Ziff Fellow at the Center for Advancing Health. This blog was originally posted on Connie’s website where she blogs about improving the patient experience. You can read Connie’s blogs and subscribe to her RSS feed here and follow her on twitter at @ConnieLDavis.

Self-efficacy keeps coming up everywhere I go. I have the honour of working with the California Institute for Mental Health on the Small County Care Integration collaborative. The teams are working on integrating behavioral health and primary care. The clients they work with have serious mental illness and are often also facing physical illness, sometimes partially due to the medications they take for their mental illness. The teams are measuring the self-confidence of their clients using the question Dr. John Wasson and his team developed: “How confident are you that you can control and manage most of your health problems?” Responses: Not very confident, somewhat confident, very confident. (This question is copyright FNX Corporation USA and the Trustees for Dartmouth College.)

Dr Wasson has actually suggested that what the world needs is a “Campaign for Confidence.” I agree with him. What would happen if we stopped focusing on clinical outcomes and specific behaviors and helped people feel more confident? I’m looking forward to finding out.

What could we do to improve confidence? First of all, remember that we need to be focusing on the problems the person has, not what health care professionals think they should focus on. Corbin and Strauss, in their qualitative study of people with chronic conditions, Unending Work and Care: Managing Chronic Illness at Home (1988), provide the guidance we need. People with chronic conditions face three tasks:
1) To manage the illness (to take medications, do treatments, monitor the condition, work with the health care team, etc.)
2) To adapt life roles (how to manage daily life and demands of life in light of the illness)
3) To manage emotions (most often anger, fear, frustration, and depression)

Whenever I am in an interaction, I know these three ideas can help shape the encounter. How is the person doing with these three tasks? What can I do to help? Are they confident in these three tasks?

The next thing to do is to build confidence through mastery. This is one of the techniques known to increase efficacy. Learning new skills is important. Making action plans based on self-determined goals and achieving them is another. There are many ways to do this. The Five A’s grew out of successful smoking cessation interventions and can be useful. The way that I have found most useful recently is Brief Action Planning. Dr Steve Cole initiated the idea, and several of us have worked together to refine it. The Action Planning process of the peer-lead Chronic Disease Self-management Program is another excellent example.

The basics are the same:
1) Take a goal, which is usually something that is accomplished over months, like “become for physically fit so I can play ball with my grandson” and break it down into smaller steps that can be achieved in a week or two, like “walk around the park three times this week on Monday, Wednesday and Friday after breakfast.”
2) A good check on the plan is to complete a confidence scale of 0-10, 0 indicating no confidence to complete the plan and 10 is totally sure. A confidence higher than 7 indicates increased likelihood of success, and if the confidence level is lower, the plan is revised until confidence is high, remembering that success increases confidence.
3) The check-in on the plan is important, too, either with the person who helped make the plan or a self-check in.
4) When plans go awry, problem solving is used. The basic steps are identifying the REAL problem, brainstorming ideas and picking one to try, really try for a week or two, to see if it helps. If the first idea doesn’t help, try another, or get ideas from another. If that doesn’t help, sometimes now isn’t a good time to work on this issue and something else might help.

Self-efficacy is a many faceted concept. Hopefully these ideas provide some guidance on what to do to build it.

Read Connie Davis’ Self-EFFICACY, Part 1 here.

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Self-Efficacy, Part 1

Connie Davis
Thursday, April 12th, 2012

Connie Davis MN, ARNP is a geriatric nurse practitioner, health care consultant and William Ziff Fellow at the Center for Advancing Health. This blog was originally posted on Connie’s website where she blogs about improving the patient experience. You can read Connie’s blogs and subscribe to her RSS feed here and follow her on twitter at @ConnieLDavis.

Self-efficacy is a very important concept in health care.  It is nearly the same thing as self-confidence, or a belief that you can do something, like monitor mood, change eating habits and start being more physically active.  It turns out that self-efficacy is linked to hospital utilization (low confidence = increased ER visits and days in hospital), to blood sugar control (low confidence = worse blood sugar control) and to changes in behavior.

I was first introduced to self-efficacy when I was preparing to be the nurse practitioner interventionist in a randomized, controlled trial of an intervention to reduce disability in older, community dwelling adults.  I read the work of Kate Lorig, RN, DrPH, who was developing self-management education programs to help people develop confidence to live with their chronic conditions.  I later met Kate and became a T-trainer for one of the many evidence-based programs she and her colleagues at the Stanford Patient Education Research Center have developed.  I learned that my job wasn’t to fill patient’s heads with facts (because information alone is unlikely to change behavior) but was instead to help them build confidence that change was possible by taking small steps toward patient-determined goals.

This new knowledge and approach was a career-changer.  No longer frustrated, puzzled or alarmed by what I saw patients doing, I understood the ups and downs of everyone’s journey and what part I could play in helping people improve their situations in a way that made sense to them.  I was introduced to Motivational Interviewing by Karen Artz, who taught me to be “The guide on the side, not the sage on the stage.”  I learned with my social worker colleague, Susy Favaro, who taught me many things, including how to say, “I wonder what would happen if…”  Susy and I worked together on the disability prevention study, and watched as the phone calls, face-to-face meetings, peer mentoring, and availability of exercise programs, social contact and self-management education slowly helped the intervention group improve their lives.

Dr Lorig and her colleagues have built their programs on some key ideas, including that self-management education is about problems that patient identify, not what health care professionals think they should know.  The programs feature techniques known to improve self-efficacy, such as modeling (seeing someone do a behavior, preferable someone like you), social persuasion (most effective from peers), reinterpreting symptoms (maybe the fatigue isn’t solely from the illness but is also from de-conditioning), and skills mastery (actually learning and having success with new approaches.)  These four techniques could be built into every program that interacts with patients, yet I am surprised how few health care professionals learn about them and about self-efficacy.  Just imagine if every cardiac rehabilitation, every health class for junior high students and every physical therapy program built these ideas into their work.

I’ll write more in my next post about other tips on increasing self-efficacy.

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Patient Engagement: Experts Talk about Challenges

Connie Davis
Monday, September 19th, 2011

This interview is the second in a series of brief chats between CFAH president and founder, Jessie Gruman and experts—our CFAH William Ziff Fellows—who have devoted their careers to understanding and encouraging people’s engagement in their health and health care.

Connie L. Davis, a geriatric nurse practitioner and health care consultant in British Columbia, advocates “a stepped approach to supporting patients’ active participation in self management.” 

Ms. Davis works to improve the partnerships between patients and health care professionals, concentrating on rural, remote and underserved populations. She is also a CFAH William Ziff Fellow.

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Gruman: Where is the low-hanging fruit in patient engagement – a change that is both possible to make without spending millions of dollars and that would make a real difference?

Davis: Really taking health literacy into account has great potential.  This means clinicians make use of teach-back methods and all materials are produced using clear language.  Addressing health literacy is excellent leverage because there is so much to be done and many of those things are pretty simple to do, so addressing them can have a significant effect.

Gruman: You have said “one size doesn’t fit all” when it comes to helping people better care for themselves.  How can care be organized to take into account the diversity of needs and preferences?

Davis: We’ve been pretty successful using a stepped care approach in primary care to encourage people to care for themselves.

Two principles guide all interventions: Cultural humility and Health literacy.

Within that framework, it’s important to provide self-management support fundamentals to everyone.  This means focusing on goal-setting and problem-solving for everyone, for example.  If these aren’t helpful for an individual, we make available more intensive approaches, like a care manager and group visits.  And for those who are still struggling, we use more expert methods, such as dialectical behavior therapy and addiction treatment.

Gruman: What changes have you seen in the past couple years that make you optimistic about patient engagement?

Davis: The rise of patient groups has been amazing.   When I came to British Columbia in 2005, there really weren’t any visible patient groups. Now there are many.  For example, a senior group in BC (called COSCO: Council of Senior Citizen Organizations) realized that there really wasn’t good senior-relevant health information available to them.  So they worked with professionals to develop 17 different presentations that they now deliver to senior groups all over the province.

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Additional Interviews with our Ziff Fellows on the challenges of patient engagement:

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The Hidden Secrets of Evidence

Connie Davis
Friday, July 15th, 2011

Connie Davis MN, ARNP is a geriatric nurse practitioner, health care consultant and William Ziff Fellow at the Center for Advancing Health. This blog was originally posted on Connie’s website where she blogs about improving the patient experience. To read other blogs by Connie and to subscribe to her RSS feed, click here.

I have a fear.  My fear is that the public has an unrealistic view of medicine and the science behind it. This is partially due to practitioner behavior (I count myself in this group) and the media.  Are we cultivating a society that won’t believe anything we say or conversely think everything they read is true and everything is possible? And how have we contributed to this mess?

Many health care professionals forget that the original intent of evidence-based medicine was to use medical science, in conjunction with practitioner judgment and patient values to make treatment decisions.  Too often a tool of evidence-based medicine (a clinical guideline) has become a blunt instrument, indiscriminately applied.  I know I have a bias because I practice geriatrics, where patients become more and more unique the older they get.  As John Sloan says, caring for the frail elderly is an “evidence-free zone.”  Thankfully, more and more organizations (the VA is a prime example) are realizing that one size does not fit all and a self-correction is currently happening (see this article by Eddy et al), and professional associations that often create guidelines are backing off their earlier targets. 

One of the most troubling aspects of evidence-based medicine is can we trust the evidence?  Now, I can cite the evidence like the most seasoned academic, and I know it should all be taken with the proverbial grain of salt.  What Archie Cochrane, the father of evidence-based medicine popularized is that we need to understand:

  1. Can it work (efficacy, often determined by a clinical trial or study)
  2. Does it work (effectiveness, in the real world with real people outside of a research setting)
  3. Is it worth it? (remembering that resources are finite)

Let’s look at each in turn. 

For #1, can it work, Dr John Ioannidis and his research group have cast a light on how limited our evidence really is, pointing out that a quarter of highly cited studies are never repeated; 16% when replicated, have weaker effects than the original research; and 16% of replications contradict earlier evidence.  This means we have reason to doubt over half of all published findings. 

The second, does it work, is also challenging.  Most medications are tested in a select group of people who do not have kidney or liver problems, don’t have many other illnesses other than the one in question and have a lot of support to take the medication and are followed regularly by those conducting the research.  I know this first hand, I worked on clinical drug trials for a couple of years.  This is far different than the real world of practice, where people are complicated, staff don’t see you back in a few days to see if you are having any side effects, and about half of people don’t fill prescriptions.

And the third question, is it worth it, has recently been addressed by Jarvinen and colleagues in an article about preventive medications.  They remind us how much the picture changes when we move from efficacy studies (1) to effectiveness (2) to cost-effectiveness (3). One of their calculations reveals that by administering medications to prevent osteoporosis to 1.86 million people over the age of 50 would result in 343 fewer fractures.  If their calculations hold up, this is an incredibly sobering message for preventive medication.

So where do we go from here?  I propose that clinicians:

  1. always couch evidence as “our current understanding” to remind patients that medical science is always evolving and that it may not apply to them as an individual,
  2. include patient values and their clinical judgment when considering the evidence (i.e. “evidence informed medicine”),
  3. consider the big picture of societal cost,
  4. work to find ways to explain risks and benefits of preventive medication (and include potential harms in shared decision making for all medications

I’ll be glad if we can keep all of these thoughts in the day light. The evidence is part of the picture, and we do the public a disservice when we present emerging findings as fact and fail to think about all the possibilities for individuals and society.   I’m also not sure if the public is ready to hear that medicine really is not ALL science.

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