Discussion:
In your response posts, discuss whether the strategies identified by your peers would be effective for your patient or in the clinical microsystem you are using as a basis for your final project. Explain your reasoning, and discuss changes that you believe would be required for the strategies to be effective.
Response 1:
There are numerous strategies that a leader should implement in the clinical microsystem in order to enhance self-efficacy and self-management of chronic care patients. "For clinical microsystems to effectively support complex patients with complex chronic illness, interdisciplinary team members must design care systems with explicit planning of multiple interacting inputs." (Nelson, Batalden, Godfrey, and Lazar, 2011). One such system developed by Wagner, is the Chronic Care Model. Within this model the clinical microsystem plays an important role regarding self-management support for a patient with a chronic illness. "The clinical microsystem's role is therefore to actively support self-efficacy through individual counseling and education, through professional or peer-led group programs, and through access to other appropriate self-management resources." (Nelson, Batalden, Godfrey, and Lazar, 2011).
One of the ways the Chronic Care Model can improve outcomes for a patient is by developing an informed and activated patient. With an activated patient there are four main components: knowledge, motivation, skills and confidence. These components are critical in order to enhance a patient's self-efficacy. Since patients with chronic illnesses spend more time away from the clinical microsystem, they manage their care independently at their home. So it is important for clinical leaders to effectively educate their patients. This helps patients become "experts" with their illness and with proper education it allows patients to "more fully align personal health priorities with actual health behaviors." (Nelson, Batalden, Godfrey, and Lazar, 2011). Patients with chronic illnesses must perform a variety of tasks, from monitoring blood pressure or even adjusting medication doses. Proper use of these "skills" comes from having the right knowledge and information passed down to them from the clinical microsystem. This in turn helps motivate the patient, making them want to treat their condition. And after a patient can successfully treat themselves at home, it ultimately builds their confidence. If a clinical leader can improve a patient's self-efficacy it will directly improve the outcome for the patient. "Self-efficacy has been linked to healthier behaviors and is an essential attribute of people living successfully with chronic illness." (Nelson, Batalden, Godfrey, and Lazar, 2011)
Nelson, E. C., Batalan, P. B., Godfrey, M. M., & Lazar, J. S. (2011). Value by Design: Developing clinical microsystems to achieve organizational excellence (1st ed.). San Francisco, CA: Jossey-Bass.
Response 2:
"According to Baundura's theory, self-efficacy refers to the confidence in one's abilities to do self-care desirably." (Mansouri, Ghadami, Najafi & Yektatalab, 2017, page 257) Patient's must be encouraged to participate in their care, as healthcare is advancing quickly and the patient may be required to handle more at home, such as medication administration and titration (e.g. insulin or blood pressure meds) or use infusion pumps for medications (e.g. antibiotics).
I am thinking about researching heart failure and the patient with this chronic disease for the final paper. Many of our patients in the cardiac ICU on are Milrinone, which is a medication to help the heart squeeze more efficiently. Milrinone can be administered at home, via an infusion pump, which is managed by the patient and family primarily. Patients will receive in home nursing services, as well as ongoing education by the visiting nurse and representatives from the IV pump company. This information must be taught at the patient's level, so that they will be able to manage their care at home. Everyone learns differently, so education must be tailored to individually. When the chronically ill patient is admitted into the hospital with heart failure, they often know more about their own illness and course than any provider does. The patient will know what meds they take and when, what symptoms they have or have not been feeling, and when things started to "change". Patient and family input is vital in making sure that the patient's care plan is what the patient wants and deserves. Case management and social work, along with other services such as nutrition, chaplain and nursing, can make sure that the patient's prospective care plan is something that the patient agrees to and can handle, both physically and emotionally.
"Heart failure self-care is a 2-stage process. First, self-care maintenance captures the day-to-day treatment adherence and monitoring behaviors. Then self-care management includes recognition of a change in homeostasis and response mobilization. The self-care process is influenced by self-efficacy. Heart failure patients derive event-free survival benefits from above average self-care and decreased hospitalization rates and improved quality of life from adequate self-care suggesting that the cost of heart failure may be mitigated by improving self-care." (Buck, Dickson, Fida, Riegel, D'Agostino, Alvaro & Vellone, 2015, page 1715)
"Therefore, using a self-management program to achieve better outcomes and reduce the costs of patient care is useful and effective and con help control the symptoms and complications of the disease." (Mansouri, Ghadami, Najafi & Yektatalab, 2017, page 257)
References
Buck, H. G., Dickson, V. V., Fida, R., Riegel, B., D'Agostino, F., Alvaro, R., & Vellone, E. (2015). Predictors of hospitalization and quality of life in heart failure: A model of comorbidity, self-efficacy and self-care. International
Journal Of Nursing Studies, 521714-1722. doi:10.1016/j.ijnurstu.2015.06.018)
Mansouri, P., Ghadami, M., Najafi, S. S., & Yektatalab, S. (2017). The effect of Self-
Management Training on Self-Efficacy of Cirrhotic Patients Referring to Transplantation Center of Nemazee Hospital: A Randomized Controlled Clinical Trial. International Journal Of Community Based Nursing & Midwifery, 5(3), 256-263.
Response 3:
When treating a patient with a chronic disease the healthcare team must also treat the autonomy of the individual. The patient is the driving force of the treatment. It is the patient who will ultimately make the decisions to adapt his/her lifestyle to meet the demands of the disease. As a partner with a patient the team must educate and advocate for the needs of the individual so the treatment plan meets their goals and lifestyle or it will become a burden and lead to noncompliance.
Self-efficacy refers to a person's perception of their capabilities within specific situations and activities while promoting learning and function. Bandura (1977) proposed that a person's judgment of their self-efficacy influenced action choice, environment, and coping behaviors. By increasing one's confidence, one enhances their understanding of their abilities allowing them to become active and modify activities based on their capabilities. Nurses can use self-efficacy scales to help manage a chronic illness by assessing the confidence in daily activities, emotions, managing medications, social interaction, and symptom changes.
The 5As cycle: Assess, Advice, Agree, Assist, Arrange was design to help collaborate care between the patient and healthcare team in order to obtain improved outcomes and maintain health. The team assesses for behaviors, knowledge and advices/educates the individual on the risks and challenges both agree on a plan and goals. Once this done the team assists the individual so the plan meets their lifestyle by providing support then an arrangement is made to follow up to reevaluate the failures and promote the successes.
Bandura, A. (1977). Social learning theory. Englewood Cliff, MJ:Prentice-Hall.
Brady TJ, Murphy L, O'Colmain BJ, Beauchesne D, Daniels B, Greenberg M, et al. A Meta-Analysis of Health Status, Health Behaviors, and
Health Care Utilization Outcomes of the Chronic Disease Self-Management Program. Prev Chronic Dis 2013;10:120112. DOI:
Nelson, E. C., Batalden, P. B., Godfrey, M. M., & Lazar, J. S. (2011). Value by design: Developing clinical microsystems to achieve organizational excellence. San Francisco: Jossey-Bass.