Last week, I made a joint visit with a nurse to the home of a 58-year-old woman who is being seen for a diabetic foot wound. Before the visit, the nurse shared with me how frustrated she was with this woman: her blood sugars were poorly controlled, her wound healing was stalled, her diet continued to be high in carbohydrates, and her motivation to manage her illness was marginal. The only encouraging aspect of her behavior was that she seemed to be taking her medications fairly consistently.
During the visit, the nurse carefully checked the woman’s vital signs, and had the patient check her blood sugar. It was 256. The memory feature of her glucometer showed a blood sugar range of 231-346 over the previous 7 days. The nurse queried the woman about her medications and her diet. The woman demonstrated knowledge of her medication regimen and said she was taking them as prescribed. She said she was doing her best to adjust her diet, but her food choices remained high in carbohydrates. She appeared to be eating large amounts frequently.
The nurse set about to change the dressing on the patient’s foot wound. The wound did not show signs of infection, but the tissue was pale with scant serous drainage. Its size was slowly but steadily increasing. After taking measurements and cleansing the wound, the nurse applied a new dressing. She then sat down next to the patient and said, “I am really worried about you. Your wound won’t heal if your blood sugars are over 200. It will just keep getting bigger and then infected, and then you’ll have to go into the hospital and you could lose your leg. This is very serious and I don’t see that we are making progress. You have to get your blood sugars lower.”
The nurse then scheduled her next visit, and we left.
Using Coaching to Teach Coaching
When we returned to the office, I wanted to engage this nurse in thinking about alternative approaches to the patient’s care. Specifically, I wanted to motivate her to use adult teaching methods. I thought for a moment about having her read something about adult learning, or sharing a power point handout I had on adult teaching/learning. But I opted for a coaching approach.
I started our review session by asking her to describe a learning experience she had had that she had found really effective. She described a time when she had made a mistake and her manager had helped her correct it and learn from it. I asked her if she thought such an approach might work with this patient. The nurse was quiet. I sat with the silence, metaphorically biting my tongue. I really wanted to tell her how to do this but I knew that it would be so much better for her to discover her own answers to this question.
“I guess so,” she finally said. “What would that look like?” I asked. “Well, she’s making mistakes in what she eats. Well, maybe not a mistake, but she makes bad choices.” “How could you work with her to help her understand the connection between what she eats and her wound healing – like your manager worked with you when you made a mistake?” I asked to engage her in critical thinking and reflective practice.
And so the conversation went, until she came up with a plan to ask the patient if she’d like to keep a log of her blood sugars and then together they would try to identify blood sugar patterns and causes of hyperglycemia.
If I had done what was more comfortable and efficient for me – telling her what to do – I would have only been replicating her prescriptive approach to teaching that I’d witnessed during the joint visit. Using open-ended questions that engaged the nurse in solving the problem herself resulted in a better plan than I could have prescribed, and role modeled a collaborative, patient-centered approach to patient teaching.
CHAMP’s Newest Course: Helping Patients Adhere – fast pace medical clinic
CHAMP is launching “Helping Patients Adhere“, a terrific new course. This 1-unit course explains key reasons for non-adherence behavior and teaches evidence-based strategies that you can apply to help your patients optimize treatment.
The course is composed of 2 sections. The first looks at issues of adherence and an evidence-based “stages of change” model. The second section addresses the importance of health literacy to adherence, and illustrates teach-back and its importance to effective adherence.
If you’ve been frustrated about some of your patients’ lack of adherence to treatment or medications, the stage of change model is really useful. Instead of asking why don’t patients change, it’s so much more useful to know how DO patients change. The course clearly presents the stages of change and specific interventions for you to consider. There also are assignments that will help you incorporate the techniques presented into your clinical practice.
As you might know, I sometimes use my soon to be 85 year-old mother Joan as an example. Some decisions she’s had to make regarding treatment decisions really fit into this model, and I thought about her as I read about the stages of change.
Precontemplation is the first stage. Often this stage represents a lack of knowledge. The patient does not feel a need to change based on what he/she knows. My mother’s cardiologist wanted her to start warfarin therapy for atrial fibrillation. However, she had a negative perception of warfarin, based on an unfortunate experience my father had with the medication. She stayed in this stage until she was hospitalized with a TIA and suffered adverse consequences. She then had to contemplate the risk benefit of anticoagulation therapy, and eventually took action to go on warfarin. Lo and behold, she’s become a very adherent patient, and now is maintained on a stable dose of warfarin.
Since I’ve read the course I’ve applied some of the intervention strategies as my mother contemplates and prepares for a serious surgery for an aortic aneurysm. This course is a great value, and I’d love to hear how it’s changed your practice.