In this week’s blog, Anya De Iongh, an Occupational Therapist from NHS Ayrshire and Arran, United Kingdom reflects on the powerful role of coaching in encouraging shared decision making, empowerment and self-management and how health professionals can implement this in their practice.
I recently saw a patient who clearly demonstrated some change talk, and was ready to start to take the first steps towards making a significant lifestyle change to lose some weight. They were asking what services could help them, which was an interesting way for services to be framed as the solution, when many other community or self-directed options may also be beneficial. However, in this situation, we agreed a referral to the local weight management service was a sensible action to follow. I left the consultation with a ‘to do’ list (making the referral to this service), and the patient was left waiting for the next cog in the system to start turning. In the time it took for this next cog to turn, what would happen to that patient’s motivation to make this change? My guess was that it might slowly fade. What else could I have supported them to do in the meantime, while waiting for the referral?
The patient did need some input from a local service to help, so a referral was a sensible plan. And in some cases, either the logistics of the service (self-referrals are not always an option) or health literacy of the person means that it is necessary and appropriate for the healthcare professional to make that referral. Taking these steps however subtly shifts the loci of control further away from the patient. They have handed over the control about what happens next to us.
We talk about equal partnerships between professionals and patients in healthcare, but so often our desire to help (and the system we work within) mean that we end up with more actions than our patients. Perhaps it is no wonder that some people have the lower levels of activation we blame them for. In reality, it must feel like we leave them with little to ‘action’ themselves, or be ‘activated’ about.
While the systemic issues of health literacy and referral processes might feel like longer-term projects to change, we can support our patients to pull that loci of control back closer to them, by helping them identify steps they can take themselves in the meanwhile – short-term goals.
This is not about shirking our responsibility as healthcare professionals, but sharing it. Shared responsibility recognises the current challenges posed by modern illnesses, where medical and lifestyle management strategies are often needed in tandem (The Kings Fund, 2018) It is not passing the buck to patients, but about committing to doing what we need to do within an agreed plan and taking ‘healthy responsibility’ (Margiotta, 2022). That means supporting patients to identify what actions they can take from the conversation, helping them feel confident to follow-through with those actions (to further foster a sense of self-efficacy and confidence), while developing constructive boundaries to the scope of our practice. Often we talk about boundaries as a way of helping or protecting ourselves as healthcare professionals, but a lack of boundaries can harm patients just as much, if we end up ‘stealing’ their actions and therefore their sense of autonomy and self-efficacy. In terms of outcomes from our interactions with people, contributing to and building someone’s’ self-efficacy or health literacy for example should be seen as a valuable outcome, alongside the clinical and experiential measures. There is a wide range of strategies to achieve this outcome:
- small achievable goals, with a reasonable level of self-reported scaled confidence, and clear opportunities for goal follow-up to problem solve or recognise and build on the success;
- getting someone to find the specific resource online themselves, meaning they have to search and navigate a website, possibly finding out useful resources along the way, rather than just be given a direct link to the page in question (if their digital literacy skills and other factors support this);
- simply asking what someone has tried already, and what ideas they already have, to actively seek out and acknowledge the self-efficacy they already have; and
- think about how we document and record this, in our own medical notes, in a letter addressed to them and cc’ed to the other relevant professionals (AORMC, 2018) and shared records with a patient-owned personalised care & support plans
We talk about shared agenda setting and shared decision making, so shared action planning and goal setting is the right way to continue that person-centred empowering approach through to the end of the clinical consultation.
Anya de Iongh (@anyadei)
NHS Ayrshire & Arran
Academy of Royal Medical Colleges (2018) Please, write to me: writing outpatient clinic letters to patients – guidance. https://www.aomrc.org.uk/reports-guidance/please-write-to-me-writing-outpatient-clinic-letters-to-patients-guidance/
The King’s Fund (2018) Shared responsibility for health: the cultural change we need. https://www.kingsfund.org.uk/publications/shared-responsibility-health
Margiotta, B. (2022) Impact with Integrity: Repair the world without breaking yourself.