bps sigopac bristol october 2016 - prof austyn snowden : understanding as intervention?
TRANSCRIPT
Understandingas
Intervention?
Professor Austyn SnowdenChair in Mental Health
Edinburgh Napier University
Overview• Person centred care is policy• Person centred care is difficult to define• Person centred care is possible• Person centred care is optimal?
The policy• ‘Shared decision-making must become the norm
…to better reflect the principle of ‘no decision about me without me’.’ (Department of Health, 2011: 39).
• ‘Foster a common culture shared by all in the service of putting the patient first.’ (Francis, 2013: 4)
• ‘Person-centred care is one of the 3 core tenets of care in NHS Scotland (NES, 2015)
The problem
• People are irrational (Amos Tversky)• 2 placebos are better than one (Fabio
Benedetti). But:• People’s actions are broadly coherent
with their own beliefs (Leon Festinger)
The concept: concordance
Snowden, A., & Marland, G. R. (2012). No decision about me without me: concordance operationalised. Journal of Clinical Nursing, 22, 1353–1360. http://doi.org/10.1111/j.1365-2702.2012.04337.x
The Study
Evaluating holistic needs assessment
in outpatient cancer care.
Background to the RCT
• Many cancer survivors have moderate to severe unmet needs, often as consequences of treatment.
• Changing the way cancer survivors are supported remains an ongoing priority.
• Much of this work has focused on better understanding and acting on people’s individual holistic needs.
Holistic Needs Assessment• Highlights the unmet needs of people affected
by cancer, by the people affected by cancer.• Enables healthcare professionals to focus on
those needs in a structured way.• Enables appropriate services to meet those
needs.• Aids the development of an individualised care
plan (National Cancer Action Team 2013).
Holistic Needs Assessment
1. Physical needs2. Psychological Needs3. Practical needs4. Family needs5. Emotional needs6. Spiritual needs
Origins: HNA ‘wheel’ plus distress thermometer
1. Physical needs2. Psychological Needs3. Practical needs4. Family needs5. Emotional needs6. Spiritual needs
HNA Process
Patient completes HNA
Signpost issues
Care plan
Clinician and patient joint discussion
Hypotheses
1. Use of HNA within clinical consultation will facilitate increased patient participation
2. Use of HNA within clinical consultation will facilitate increased levels of shared decision making
3. Use of HNA within clinical consultation will facilitate increased levels of self-efficacy
Measures
Person Centred
Care
Consultation Style
Patient Involvement
Self-efficacyConsultation Time
Self-management
and navigation through support services
Measures
Person Centred
Care
Consultation Style
Patient Involvement
Self-efficacyConsultation Time
Self-management
and navigation through support services
Method
• Randomised into HNA or Control• Post diagnosis- follow up after treatment
Recruitment (n=300)
• Audio record consultations• HNA group- Concerns checklist• Both groups- Lorig Self-efficacy scale + CollaboRATE
Process
• Who talking, how much, what and when:• Dialogue ratio(DR) + preponderance of initiative (PI)Analysis
Method
• Randomised into HNA or Control• Post diagnosis- follow up after treatment
Recruitment (n=300)
• Audio record consultations• HNA group- Concerns checklist• Both groups- Lorig self-efficacy scale + CollaboRATE
Process
• Who talking, how much, what and when• Dialogue ratio(DR) + preponderance of initiative (PI)Analysis
Patient Participation measuresDialogue Ratio:
Monologue Dialogue
Dyad
Preponderance of Initiative:Who initiates conversation?
Who is talking, and what about?
Patient Participation measures
Outcome measures• Lorig self efficacy scale• CollaboRATE
Hypotheses
1. Use of HNA within clinical consultation will facilitate increased patient participation
2. Use of HNA within clinical consultation will facilitate increased levels of shared decision making
3. Use of HNA within clinical consultation will facilitate increased levels of self-efficacy
-1 -0.8 -0.6 -0.4 -0.2 0 0.2 0.4 0.6 0.8 1
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Preponderance of Initiative
Dia
logu
e R
atio
Summary data
Pat
ient
Led
Patient led dialogue
Patient led monologue
Phy
sici
an L
ed
Physician led dialogue
Physician led monologue
DialogueMonologue
HNAHNA
HNAHNA
TAUTAUTAU
TAUTAU
TAUTAU
TAU
Lorig self efficacy correlation?
Sex Age Treatment Education Relationship status
Concerns
67 % Male
32 % Female
61 Chemo-rad 45% no qualifications
72% Married/co-
habiting
Sore/dry mouth
Score - 4
55 patients head and neck or colorectal cancer7 clinicians (CNS, Consultant, Surgeon)
Interim results
Measurements
N Minimum Maximum MeanStd. Deviation
HNA score 29 1 10 4.17 2.44
CollaboRATE 55 4 9 8.43 1.13
Lorig 55 3 10 7.86 1.69
Results
H1: Use of HNA within clinical consultation will facilitate increased patient participation • Average % of conversation initiated by
clinician higher in experimental group = 76% (e) vs 49% (c)
• Average % of discussion conducted as dialogue was higher in the experimental group = 31% (e) vs 19% (c)
H2: Use of HNA within clinical consultation will facilitate increased levels of shared decision making• No significant difference in CollaboRATE scores:
CollaboRATE8
8.1
8.2
8.3
8.4
8.5
8.6
8.7
ExperimentalControl
H3: Use of HNA within clinical consultation will facilitate increased levels of self-efficacy • The experimental group scored higher on Lorig (8.3 ± 1.5) than
the control group (7.4 ± 1.8), a statistically significant difference of 0.92 (95% CI, 1.8 to 0.02), t(53) = 2.074, p = .043.
Summary
• HNA changes the nature of the clinical consultation. • HNA group has greater proportion of conversation
started by clinician, but more of it is dialogue.• Is the HNA helping the clinician understand better?
Association between HNA and self-efficacy is very promising. It suggests the change is positive.
• Caveat: Distress is generally low and self-efficacy is high
• Need more data…
Mean number of problems discussed
Mean number of problems
8.28
6.95
Experimental Control
0
25
50
75
100 Physical Practical Family EmotionalSpiritual Lifestyle
Related findingsRelated research: patient flow through ICJ
Different professional, same tool, different needs?• 8.5% all needs identified by council workers
related to housing (n=1500)• When HNA done by nurse only 2% needs
related to housing (n=5000)• 86% needs physical with consultant
oncologist. 50% council worker• No-one ever has any spiritual needs…
maybe chaplain has to ask...?
Clinical application HNA + recording
Patient
• Greater awareness and expression of needs
• Shared decision making and person centred care
Clinician
• Professional reflection from audio recordings
• Better understanding of patient needs
• Better understanding of clinician role
Policy• Evidence for person
centred care?• Evidence for MDT
Principles revisited…• People don’t do what they’re told to, regardless of
how rational that may be.• Being listened to may help people help
themselves• Understanding the function, limits and
operationalisation of this may lead to more effective treatment consistent with the principles of person centred care AND interdisciplinary specialisation
• It may offer you the evidence you need…
Ie. HNA has a place in your QoF:• Is this service safe?• Is this service equitable, while also focused on
those most in need?• Is this service timely and responsive?• Is this service respectful, collaborative and
patient-centred?• Is this service offering effective interventions?• Is this service contributing to efficient
multidisciplinary care?
Snowden, A., Young, J., & Fleming, M. (2016). Protocol for a mixed methods longitudinal enquiry into the impact of a community based supportive service for people affected by cancer. BMC Cancer, 16(1), 720. http://doi.org/10.1186/s12885-016-2757-4
Snowden, A., Young, J., White, C., Murray, E., Richard, C., Lussier, M.-T., … Ross, E. (2015). Evaluating Holistic Needs Assessment in Outpatient Cancer Care: a Randomised Controlled Trial- the study protocol. BMJ Open, 5(e006840). http://doi.org/10.1136/bmjopen-2014-006840
Snowden A, Martin C, Mathers B, Donnell A. (2014). Concordance: a concept analysis. Journal of Advanced Nursing 10.1111jan.12147
Snowden A, White CA, Christie Z, Murray E, McGowan C, Scott R. (2012). Helping the Clinician Help Me. Towards Listening in Cancer Care. British Journal of Nursing 21:10, S18-26