Promoting Independence and Self Management

Almost half the population of Scotland have at least one long term condition (Scottish Health Survey 2014) and we know that the older people become, the more long term conditions they will develop.

It has been suggested that on average, the length of time someone with a long term condition spends with a healthcare professional is roughly 4 hours per year (NHS England 2006). For the rest of the time, they or their families are managing the condition and their circumstances at home.

For a more detailed background and more information check out the IFIC Scotland Webinar Integrated Care Matters, Series 4: Self Management and Co production https://vimeo.com/368784654

There are a number of techniques nurses can use to help people to self manage. By embedding these skills in our practice we can support people at every interaction to engage in the behaviours necessary to facilitate self management to the point where it becomes second nature.

These include:

1. Health promoting behaviours

2. Signposting to easy to read information and educational materials

3. Facilitate the person to set small achievable goals and plan actions to achieve these.

4. Peer Support

5. Provide a coaching role

6. Support unpaid carers and recognise the very important role they have.

As nurses we have a vital role to play in ensuring people have the right knowledge, skills and support when they need it. This will enable people to develop the skills and confidence to live as independently as possible and to live well despite their long term conditions. During the development of Scotland’s Self Management Strategy, the Health and Social Care Alliance (THE ALLIANCE), together with people living with long term conditions identified key stages when people said they needed more support to continue to self manage. The key stages are:

1. On diagnosis of a long term condition

2. Living for today

3. Progression

4. Transitions

5. End of Life

Please go and take a look at the Scotland’s Self Management Strategy entitled ‘Gaun Yersel’ which can be found at www.alliance-scotland.org.uk/wp-content/uploads/2017/11/ALLIANCE-SM-Gaun-Yersel-Strategy-2008.pdf

Most people will say they self manage to varying degrees. For some this may be in the form of managing complex medication regimens, for others this may involve using highly technical skills and equipment. As a result people need different levels of support at different times to help them to self-manage their own conditions.

There are some excellent resources on Self Management and Co Production available at: https://www.alliance-scotland.org.uk/self-management-and-co-production-hub/ Take a look and watch some of the very helpful videos.

In 2011, The Health Foundation published “Helping People help themselves” which looks at the evidence around self management.

The Key Points from this document are:

Evidence suggests that supporting self-management works. Supporting people to look after themselves can improve their motivation, the extent to which they eat well and exercise, as well as improving their symptoms and clinical outcomes.

Although many initiatives and different types of support are available, some are more useful than others. To encourage people to engage in self management activities the provision of information alone is unlikely to be enough to motivate behaviour change – more self-management approaches are necessary.

So, how do we know that people understand the health related information or instruction of techniques we provide to facilitate self management? There is an approach called Teach-Back. Its very simple and quick. After providing information about their condition or demonstrating a technique, all you have to do is ask the person to explain back in their own words what they have just heard or seen in order to demonstrate their understanding. If the person is unable to explain or describe the technique or information, then we should re-educate the person using different words until the person can show they understand. This is not a test for the patient, so asking the person to explain back what they have just heard should be done in a relaxed and friendly manner, avoiding technical jargon. Teach-Back has been shown to be a very useful technique to promote understanding and facilitate self management. It is a technique related to health literacy – for more about health literacy, look at the previous post on this blog site on Sensory Changes and Frailty.

For more information about teach-back go to http://teachbacktraining.org/home

Sensory Changes and Frailty

As we age, our sensory systems gradually start to decline. For more information about the ways in which our senses are affected by age the following article from MedlinePlus Medical Encyclopaedia, called Ageing Changes in the Senses is a useful summary which you can access HERE

To understand the scale of the problem consider firstly the number of older people who wear glasses or contacts who are over 55. It’s also worth noting that it is estimated that 945,000 people in Scotland are deaf or have hearing loss and that more than 500,000 people in Scotland have a form of tinnitus.

Sensory impairment has been shown to have psychological, psychosocial,
and functional effects that may lead to social isolation, anxiety, depression, paranoia, and decreased self-esteem.

Dual sensory loss (DSL), the presence of both hearing loss and vision loss is particularly prevalent among ageing populations across the world with studies showing that more than 20% of adults older than 70 years are affected with that percentage increasing with advancing age. The interaction between the variety of visual losses and the variation in types of hearing loss means that there is a wide variation in each individuals needs. This makes it difficult for community staff who have very little cross disciplinary training to meet every need they encounter even though they are meeting older people with multiple sensory impairments every day.

However DSL also affects the ability of older people to perform Instrumental Activities of Daily Living (IADL’s). So although problems with dressing and bathing may occur using a ‘phone or grocery shopping, preparing meals, managing housework and money are far more likely problems and will limit the ability of frail older people to remain at home. The likelihood of identifying and intervening when such problems exist is not helped by older adults themselves, who tend to overestimate their capabilities. Not only are AIDL’s affected, frail older people with sensory impairments also experience poorer overall mobility and the more severe the loss the more likely functional and cognitive decline will occur.

What Can You Do?

The Importance of Hearing Aids. One of the most important things you can do is encourage the use of hearing aids. Kochkin and Rogin (2000) in a study conducted for the US National Council on Aging showed that individuals with hearing impairment who did not use hearing aids participated in statistically significantly fewer social activities and reported statistically significantly more anxiety, depression, emotional instability, and paranoia than individuals who used hearing aids.

However there is a huge stigma surrounding hearing impairment that generally manifests as a reluctance to acquire hearing aids or to participate in any other types of aural rehabilitation.

Consider the Persons Manual Dexterity? With advancing age comes diminished manual dexterity. This has direct effects on several aspects of
hearing aid use and aural rehabilitation, with the most obvious being hearing aid insertion, manipulation of the hearing aid controls, and handling of the battery. There is a strong association between poor manual dexterity and poorer hearing aid outcomes, like less daily use, and lower satisfaction with hearing aids. A study by Parving and Philip (1991) reported that 40% of hearing aid users by the time they were 90 could not use the
volume control wheel, 36% could not change the hearing aid battery, and 34% could not clean the hearing aid ear mould.

Consider the Person’s Health Literacy. DSL is also known to limit a person’s ability to understand and recall the information provided and to successfully integrate self-care into their daily life. It has
been shown that generally older people have the lowest health literacy and
related adverse health outcomes than younger people. Therefore, communication needs to be optimized to accommodate the sensory needs of older individuals to the extent possible.

  • To ensure this the environment needs to be optimized.
  • You need to speak clearly and make efforts to clearly enunciate and to increase the time between spoken words, decreasing your rate of speech.
  • Provide clear written materials. Remember literacy level and pitch to a reading age around 12. Written material should be 14 points and have wide spaces between the lines. A sans serif font should be used and multiple columns on a page should be avoided.

A more extensive guide with videos on how to communicate with someone with hearing loss can be found HERE

Provide/Use Assistive Devices. Like hearing loops, magnifiers with lights, video magnifiers, tactile devices (like vibrating alarm clocks, door bells etc). Whatever you think might help the person. See: https://www.hearinglink.org/living/loops-equipment/ and https://shop.rnib.org.uk/

Provide Redundancy. When delivering information use multiple perceptual channels (visual, auditory, and tactile). This increases the person’s opportunity to all information provided. Supplement anything you say with written materials which can be verbally repeated by carers, relatives etc. If you use low or high technology always buy/use technology with built in redundancy. The reason for doing this is that the circumstances of the person the assistive technology/device will change. As a result, you never know when you might need more functions/capabilities to be switched on.

Use Patient Teach-back. A useful method for verifying that the information you want the person to understand is understood to get the person to repeat back in his or her own words what was said or demonstrate the procedure you are trying to get them to learn/understand indicated by the provider. This way you can check the communication is understood and correct any misunderstandings. See http://scottishhealthcouncil.org/patient__public_participation/participation_toolkit/teach-back.aspx#.Xhu9_sj7TIU

Further Information

See: Royal National Institute for the Blind Services page https://www.rnib.org.uk/services-we-offer-advice-professionals-health-professionals/services-patients

and Action on Hearing Loss’s Guidance for Nurses. https://www.actiononhearingloss.org.uk/how-we-help/health-and-social-care-professionals/guidance-for-nurses/