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Address Patient-Centered Concerns


RNAO's Interpretation of Evidence: 


Level of Evidence B,C: RNAO’s Assessment and Management of Venous Leg Ulcers 123
Level of Evidence Ia, Ib, III: RNAO’s Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients 

a. Assess Psychosocial Needs / Pain and Quality of Life (QOL)

“For patients with open surgical wounds, comfort is paramount to support the activities of home and work life while supporting the patient psychosocially”4

  • Communicate with patients, their caregivers and significant others to identify patient-centered goals to determine realistic expectations for healing or non-healing outcomes.
  • Assess pain and in collaboration with patient and caregivers, create a pain relief plan5
  • Assess quality of life (QOL)
    • Toolkit Item #10a and #10b for assessment forms
  • Screen for mental health concerns i.e. depression 
    • Toolkit Item #11a for assessment form
  • Encourage and provide ongoing support for smoking cessation if applicable
    • Toolkit Item #7a for Smoking, Chronic Wound Healing, and Implications for Evidence-Based Practice – McDaniel and Browning
    • Toolkit Item #7b for Checklist to readiness to quit smoking
    • Toolkit Item #7c for Applying 5 A’s to smoking cessation
    • Toolkit Item #7d for WHY test
    • Toolkit Item #7e for smoking cessation medication comparison chart
    • Toolkit Item #7f for Strategies to avoid relapse.6

b. Socioeconomic Determinates of Health (Canadian Nurses Association Social Determinants of Health and Nursing: A Summary of Issues)

  • Provide education to patients, caregivers and significant others for care and the management of a surgical wound
  • Assess for the presence or absence of social support system for treatment of surgical wounds.
Health is a resource for everyday life and is influenced by the determinants of health: income, social status, support networks, education, employment and working conditions, health services, healthy child development, physical environment, gender, culture, genetics, and personal health practices.7 Unemployment, lack of sick benefits, job insecurity, low income, and homelessness can deter healing and cause more stress.  For example, money is needed to purchase adequate food that is vital for wound healing. Patient may need a referral for a social worker to assist with finances.

The following questions could assist in assessing your patient’s financial concerns:

  1. Do you have benefits from any other sources to cover cost of compression stockings, medical drugs, parking fees, food allowance (e.g. work place or private Insurance, Veterans Affairs Canada, Aboriginal Affairs, Workers Safety and Insurance Board (WSIB), Trillium Drug Plan, Ontario Disability Support Program (ODSP))
  2. Are you the sole bread-winner in your family?
  3. How often have you used the food bank or soup kitchen this month?
  4. Do you have sick-time benefits or unemployment insurance?
  5. Would you like a referral to Meals on Wheels or information on food bank/soup kitchen?

Social Supports

There is evidence to suggest that strong supportive networks improve health and healing. Patients who have limited social support are more at risk for depression, greater risk for complications, decreased well-being, poor mental health and physical health. Furthermore, patients who are disabled, migrants from other countries, ethnic minorities and refugees are vulnerable to racism, discrimination and hostility that may harm their health. Patients who have stigmatizing conditions such as mental health, addictions (street drug use, methadone patients and cigarette smokers), and diseases such as HIV/AIDS suffer from higher rates of poverty and limited supports.
 
The following questions could assist in assessing your patient’s support system:
  1. Do you have someone to help you? Friend, family, neighbour, and/or church member?
  2. Do you feel down or depressed?
  3. Have you ever had thoughts of harming yourself?
  4. Do you have transportation to receive medical follow-up and to obtain groceries?
  5. Do you have someone to help you with your personal care such as showering?
  6. Do you have someone to get your groceries, housekeeping and other necessities?
  7. Are you afraid of your partner or family member?   
  8. Would you like a referral to a social worker or case worker?

c. Self-Management

  • Assess level of patient's self-management skills
The focus of self-management is to allow the patient to self-identify concerns and to address concerns collaboratively with nurses and health professionals. Fostering and promoting independence is strongly encouraged but the patient and caregiver will need to be assessed by health professional for cognitive and physical ability.

Review for independence or need for ongoing assistance with the following:
  • Barriers to participate (poor eyesight, physical limitations, transportation, socioeconomic, social environment, cognitive ability, other co-morbidities)
  • Decreased sensory perception
  • Review importance and potential barriers to smoking cessation at every visit
  • Adequate hygiene skin exposed to moisture, perspiration
  • Home Environment
  • Wound care
  • Nutrition
  • Equipment (IV, NPWT etc)
  • Post op medical device application and removal (compression, binders etc.)
  • Social/medical/family/employment obligations
Ensure that coping strategies have been implemented into care
  • Patient’s concerns and fears
  • Promoting independence to avoid practitioner/caregiver dependency
  • Signs of anxiety or other mental health issues (eg. delusions, hallucinations, paranoid behaviour)
  • Depression screen using Geriatric Depression Scale assessment form –GDS15
  • Suicide assessment if applicable
  • ETOH and illicit/recreational drug use
  • Check for availability for financial funding (e.g. private insurance, ADP, veterans medical benefits, Ontario Disability Support Program (ODSP), Non-Insured Health Benefits (NIHB) and Southern Ontario Aboriginal Diabetes Initiative (SOADI) for First Nations people and Inuit)

The Self-management Initiative, through the Ontario Ministry of Health and Long-Term Care (MOHLTC), is an integrated, comprehensive strategy aimed at preventing and improving management of chronic conditions in Ontario. The goal of this cost-free program is to provide education and skills training workshops to both health care providers and patients with chronic conditions. For more information, please call 1-866-337-3318 or www.wwselfmanagement.ca.
 

These activities are not necessarily linear with each step following the other sequentially. The goal of the 5 A’s , in the context of self-management support, is to develop a personalized, collaborative action plan that includes specific behavioural goals and a specific plan for overcoming barriers and reaching those goals. The 5 A’s are elements that are interrelated and are designed to be used in combination to achieve the best results especially when working with patients in complex health and life situations.

Figure 2 Adapted from:
RNAO Clinical Best Practice Guideline: Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients8

1. ASSESS

Beliefs, Behaviour, and Knowledge
  • Establish rapport with patients and families
  • Screen for depression on initial assessment, at regular intervals and advocate for follow-up treatment of depression
  • Establish a written agenda for appointments in collaboration with the patient and family, which may include:         
a) Reviewing clinical data          
b) Discussing patient’s experiences with self-management          
c) Medication administration          
d) Barriers/stressors          
e) Creating action plans          
f) Patient education including assessing learning style
  • Consistently assess patient’s readiness for change to help determine strategies to assist patient’s readiness for change to help determine strategies to assist patient with specific behaviours
  • Identify patient specific goals

2. ADVISE

Provide specific information about health risks and benefits of change
  • Combine effective behavioural, psychosocial strategies and self-management education processes as part of delivering self-management support    
  • Utilize the “ask-tell-ask” (also known as Elicit-Provide-Elicit) communication technique to ensure the patient receives the information required or requested  
  • Use the communication technique “Closing the Loop” (also known as “teach back”) to assess a patient’s understanding of information    
  • Assist patients in using information from self-monitoring techniques (e.g., glucose monitoring, home blood pressure monitoring) to manage their condition
  • Encourage patients to use monitoring methods (e.g., diaries, logs, personal health records) to monitor and track their health condition
  • Identify community resources for self-management (e.g., support groups)

3. AGREE

Collaboratively set goals based on patient’s interest and confidence in their ability to change the behaviour
  • Collaborate with patients to:           
a) Establish goals          
b) Develop action plans that enable achievement of SMART goals (see below)
c) Establish target dates for success of goals and reassessment
d) Monitor progress towards goals

4. ASSIST

Identify personal barriers, strategies, problem-solving techniques and social/environmental support
  • Use motivational interviewing with patients to allow them to fully participate in identifying their desired behavioural changes
  • Teach and assist patients to use problem-solving techniques
  • Be aware of community self-management programs in a variety of settings, and link patients to these programs through the provision of accurate information and relevant resources 

5. ARRANGE

Specify plan for follow-up (e.g., visits, phone calls, mailed reminders)
  • Arrange regular and sustained follow-up for patients based on the patient’s preference and availability (e.g., telephone, email, regular appointments). Nurses and patients discuss and agree on the data/information that will be reviewed at each appointment and share with other interdisciplinary team members involved
  • Use a variety of innovative, creative and flexible modalities with patients when providing self-management support such as:           
a) Electronic support systems          
b) Printed materials          
c) Telephone contact          
d) Face-to-face interaction          
e) New and emerging modalities          
  • Tailor the delivery of self-management support strategies to the patients’ culture, social and economic context across settings
  • Facilitate a collaborative practice team approach for effective self-management support
  • Share with caregiver/family members/circle of care

Table 1: Stages of Change Model

Stage in Transtheoretical Model of Change Patient Stage
Pre-contemplation Not thinking about change ; May be resigned ; Feeling of no control ; Denial: does not believe it applies to self ; Believes consequences are not serious
Contemplation Weighing benefits and costs of behavior, proposed change
Preparation Experimenting with small changes
Action Taking a definitive action to change
Maintenance Maintaining new behavior over time
Relapse Experiencing normal part of process of change ; Usually feels demoralized

Table 1: RNAO Clinical Best Practice Guideline: Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients9

There are 3 self-management strategies that health professionals can use to promote self-management in patients with venous leg ulcers10

  1. Motivational Interviewing (assess patient-centered concerns)

    The following questions could assist in assessing your patient’s concerns:
    • What is your most important problem or concern? (It may not be related to the disease)
    • Do you have a history of depression? Are you depressed now?
    • What has worked in the past and what did not work?
    • Why do you want to change and how hard are you willing to work?
    • Are you willing to make the changes in your lifestyle to improve your health?
    • What might prevent you from working hard on this (e.g., barriers that are present)

    Choose the one area that you would like to work on:
    • Improve physical activity
    • Self-management of wound care
    • Practice leg exercises
    • Purchasing, wearing and caring for my prescribed garments/devices
    • Donning and doffing prescribed post-surgical garments/devices
    • Nutrition
    • Leg elevations
    • Skin care
    • Control weight
    • Stop smoking
    • Prevention of new ulcers
    • Managing co-morbidities
    • Alternative therapy modalities
    • Work modifications  
    • Increase social activities
    • Signs and symptoms of infection
    • Control pain
    How willing are you to set goals and make changes in lifestyle on a scale of 1-10?

    What is it that you find most difficult about living with a surgical wound and how can I help you?
     
  2. Goal Setting
    • Provide specific health information and health risks requested from patient and family.
    • Collaboratively develop with patient and multidisciplinary team a Personal Action Plan
    • Set SMART Goals (Specific, Measureable, Achievable, Relevant and Timely)
    • Try to make goals small enough to achieve success
             Personal Action Plan
    1. List specific goals in behavioural terms
    2. List barriers and strategies to address them
    3. Specify Follow-up Plan
    4. Share plan with practice team and client's social support
  3. Problem Solving
    • Assist with problem solving to help identify barriers and enlist family/social support
    • Ascertain financial barriers
    • Arrange for follow-up visits to review goals and discuss challenges
    • Encourage healthy coping such as yoga, music, counselling, friends, and family support

Identify and Treat the Cause: 4.1 Assessment of Surgical Site Infections
 

  1. Ontario, Registered Nurses Association of. Nursing Best Practice Guideline: Integrating Smoking Cessation into Daily Nursing Practice. 2007.
  2. Best Practice Recommendations for the Prevention and Management of Open Surgical Wounds. Orsted Heather L., Keast David H., Kuhnke Janet, Armstrong Pamela et al. 1, s.l. : Wound Care Canada, 2010, Vol. 8.
  3. Ontario, Registered Nurses Association of. Nursing Best Practice Guideline: Assessment and Management of Pain 3rd edition. 2013.
  4. Best Practice Recommendations for the Prevention and Management of Open Surgical Wounds. Orsted Heather L., Keast David H., Kuhnke Janet, Armstrong Pamela et al. 1, s.l. : Wound Care Canada, 2010, Vol. 8.
  5. Ontario, Registered Nurses Association of. Nursing Best Practice Guideline: Assessment and Management of Pain 3rd edition. 2013.
  6. Ontario, Registered Nurses Association of. Nursing Best Practice Guideline: Integrating Smoking Cessation into Daily Nursing Practice. 2007.
  7. Association, Canadian Nurses. Social Determinants of Health and Nursing: A Summary of the Issues.
  8. Ontario, Registered Nurses Association of. Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients. 2010.
  9. Ontario, Registered Nurses Association of. Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients. 2010.
  10. Ontario, Registered Nurses Association of. Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients. 2010.

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