For better outcomes, incorporate self-efficacy tools into patient education
For better outcomes, incorporate self-efficacy tools into patient education
To build confidence, allow time for practice and address barriers to success
In a well-known children’s story, a little engine was able to conquer a mountain by repeating the words — "I think I can." He believed that he had the skills to manage the situation at hand. Like the little engine, patients who think they can do something are more likely to reach the goal than those who lack self-confidence — whether it’s adhering to a low-fat diet or changing a wound dressing.
"It has been shown that the more people believe they can do something, the more they will persist in it and the better outcomes they will have," says Terri Pellino, PhD, RN, clinical nurse research specialist at the University of Wisconsin Hospital and Clinics in Madison. Education, however, is not enough. In order for behavior change to occur, patients must not only understand the components of a heart healthy diet, for example, they must believe they can adhere to the diet, she says.
To build self-efficacy, educators need to change people’s beliefs about what they think they will be successful at regarding any specific change, says John Love, MSW, a mental health counselor at the New Mexico Veterans Affairs (VA) Health Care System in Albuquerque. During the education process it is important to examine people’s belief systems and then begin to establish goal-setting exercises designed to begin to create change in those belief systems rather than to meet the end goal.
"We as educators run into problems because we see the end result as being the important part; but with chronic illness or addictive behavior, we can say we are looking at the rest of the person’s life," says Love. Building self-efficacy starts by helping patients begin to change the beliefs they have about themselves and their ability to make the changes needed to improve their health status. In most cases, the changes are enormous and connected to many other issues.
Many issues impact behavior change, agrees Zeena Engelke, RN, MS, senior clinical nurse specialist at the University of Wisconsin Hospital and Clinics in Madison. A diabetic teenager may know how to perform a skill, such as blood glucose monitoring, but chooses not to follow through at school in front of friends. Social environment, family environment, and religious or cultural beliefs could all impact adherence. Therefore, those issues must be uncovered and addressed during the education process.
Make self-efficacy part of education
To design patient education programs with self-efficacy in mind, it is important to include four educational techniques, says Kate Lorig, RN, DrPH, director of the Stanford Patient Education Research Center in Palo Alto, CA. These include:
• Skills mastery.
People must have an opportunity to do the behavior, such as exercise, and then report on the outcome. Problems are addressed, and the person continues to strive to achieve the goal until he or she is successful.
• Modeling.
People are more confident to make changes if they see others like themselves accomplishing the task. That’s why educational materials need to show people of different ages, ethnic groups, and genders doing the task. It’s also why class participants should conduct problem solving in a class setting before the instructor offers solutions.
• Reinterpretation of symptoms.
Self-efficacy is enhanced if people are taught to reinterpret the meaning of their symptoms. For example, if people think that fatigue is caused by a disease, the only thing they will do to address it is rest. However, if they learn that fatigue can be caused by negative moods such as depression, poor nutrition, lack of exercise, or as a side effect of medication, they have more options in addressing the problem.
• Social persuasion.
To build self-efficacy, patients can be urged to create short-term realistic goals. In Lorig’s disease self-management classes, participants make commitments to make a small change each week. For support, class members check in with one another during the week to see how their colleagues are doing.
"Self-efficacy is something you systematically build, and often you must teach in very different ways than traditional patient education is taught," says Lorig. Every minute of every class the four educational techniques must be systematically applied. For example, in the disease self-management classes designed at Stanford, each time a symptom is introduced the instructor discusses the causes and how each can be addressed.
Each person makes an action plan for the following week and then reports on it at the next class. When a problem is discussed, class members are always asked to offer suggestions for solutions.
Self-efficacy takes time. "In the smoking cessation program that I run, I want patients to understand that change is a process, not an event," says Love. Failure provides an opportunity to identify areas where more skills are needed.
For example, an unexpected incident, such as a son or daughter being expelled from school, might cause the patient to chain smoke three cigarettes. That incident could be used to help the patient identify tools they will need to get through similar stressful situations the next time they occur. "If the incident is an event, the patient failed. If it is a process, it is a learning experience that is part of a larger picture," explains Love.
"People get into an all-or-nothing mode," agrees Joan Greathouse, MEd, president of Joan Greathouse Consulting Co. in Seattle. Yet, the best way to reach a goal is one tiny step at a time and that builds self-confidence. To illustrate this point, she often tells a story about a radio station promotion she followed several years ago in which several people were determined to eat a car. Impossible? They accomplished their goal by grinding the car into fine pieces and eating it one tiny bit at a time.
Because it takes time to build self-efficacy, you can’t start teaching at the eleventh hour and expect people to feel confident about a task, says Engelke. Patient teaching should be across the continuum of care beginning upon admission and continuing through discharge and beyond if the patient needs a home health
nurse to help him or her carry out the self-care skills until they can be performed safely.
To build self-efficacy on the inpatient setting, give patients the chance to try out the skills they may be required to do in their homes. "Any opportunity you can give patients and families to get more involved in the learning, you increase the likelihood of them being able to complete that skill in their home environment," says Engelke.
To uncover barriers that may prevent patients from performing the skill at home, ask them how the technique will work for them at home, she advises. That question will prompt them to visualize the experience at home. Also describe a few scenarios of things that might happen so the patient can practice trouble shooting. Time and opportunity for practice need to be a part of the education process, says Engelke.
When people lack self-efficacy, they are less likely to comply. Therefore, it is a good idea to measure it during patient education sessions, says Pellino. For example, to determine if the pre-op education has been effective, educators at the University of Wisconsin Hospital and Clinics ask patients how prepared they feel for coping with their surgery or if they think they will be able to keep their pain under control. "It’s important to determine how comfortable people feel about doing the behavior," she says. Also important is to make sure they know how to perform the skill correctly.
Another way to measure self-efficacy is to ask how confident they are in performing the task on
a scale of one to 10. "If they say anything less than a seven, it gives us a pretty good indication that they will probably have problems," says Lorig. However, if the patient has a low self-efficacy rating, the educator can ask what kinds of problems the patient anticipates and begin to solve them.
Building self-efficacy into patient education programs will increase the likelihood of achieving such outcomes as better health status and less health care utilization. "If you look at how health care is outcome-driven today, you can’t help but integrate self-efficacy into your teaching program," says Engelke.
Sources
For more information on building self-efficacy into patient education programs, contact:
• Zeena Engelke, RN, MS, Senior Clinical Nurse Specialist, University of Wisconsin Hospital and Clinics, 3330 University Ave., Suite 300, Madison, WI 53705. Telephone: (608) 263-8734. Fax: (608) 265-5444. E-mail: [email protected].
• Joan Greathouse, MEd, President, Joan Greathouse Consulting Co., 3853 Williams Ave. W., Seattle, WA 98199-1540. Telephone: (206) 284-3996. Fax: (206) 284-6362. E-mail: [email protected].
• Kate Lorig, RN, DrPH, Director, Stanford Patient Education Research Center, 1000 Welch Road, Suite 204, Palo Alto, CA 94304. Telephone: (650) 723-7935.
• John Love, MSW, Mental Health Counselor, Behavioral Medicine, New Mexico VA Health Care System, 1501 San Pedro Drive S.E., Albuquerque, NM 87108. Telephone: (505) 265-1711, ext. 4336. Fax: (505) 256-2819.
• Terri Pellino, PhD, RN, Clinical Nurse Research Specialist, University of Wisconsin Hospital and Clinics, 600 Highland Ave., H4-885, Madison, WI 53792. Telephone: (608) 263-9213. Fax: (608) 263-9830. E-mail: [email protected].
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