What’s your “House What’s your “House Recipe”?Recipe”?

Part IIPart II

Refining a Skin Refining a Skin Management SystemManagement System

Mount CarmelMount Carmel

April 30, 2008April 30, 2008

Mount Carmel in ReviewMount Carmel in Review

Licensed for Licensed for Medicare and Medicare and MedicaidMedicaid

Accommodates Accommodates long-term, sub-long-term, sub-acute and acute and traumatic brain traumatic brain injury residents.injury residents.

473 Beds473 Beds 10 units 10 units 94% to 95% 94% to 95%

capacitycapacity

Take in complex Take in complex woundswounds

High percentage of High percentage of Medicaid and Medicaid and Managed Care Managed Care residentsresidents

Long history of Long history of advanced wound advanced wound care managementcare management

Our “Recipe for Our “Recipe for Success”Success”

How do we take our Skin How do we take our Skin Management System to Management System to

the next level?the next level?

Dementia vs. High Dementia vs. High Cognitive Function?Cognitive Function?

We need to manage our We need to manage our “Noncompliant” “Noncompliant”

residentsresidents

Dementia CharacteristicsDementia Characteristics

Staff anticipate resident’s needsStaff anticipate resident’s needs Facility develops resident’s plan of Facility develops resident’s plan of

care based on experience and care based on experience and evidence-based outcomesevidence-based outcomes

Staff is obligated to “do the right Staff is obligated to “do the right thing”thing”– EthicallyEthically– RegulatoryRegulatory– Standards of practiceStandards of practice

Dementia CharacteristicsDementia Characteristics

Do not know how to position selfDo not know how to position self Are incapable of making informed, Are incapable of making informed,

rationale decisionsrationale decisions Declared incompetent or Declared incompetent or

incapacitatedincapacitated Loss of cognitive functioning Loss of cognitive functioning AlwaysAlways Loss of physical functioning Loss of physical functioning

SometimesSometimes

These were These were NOTNOT the the residents that posed residents that posed

the greatest challenge.the greatest challenge.

High Cognitive Functioning High Cognitive Functioning

Need to have a say Need to have a say in their own carein their own care

PhysicallyPhysically dependent, dependent, NOT NOT emotionally or emotionally or cognitively cognitively dependentdependent

Have their Have their own own agendaagenda

High Cognitive Functioning High Cognitive Functioning

Alert, oriented X 3Alert, oriented X 3 Trying to maintain Trying to maintain

what level of what level of Control or Control or Independence they Independence they havehave

High Cognitive Functioning High Cognitive Functioning Residents-AbilitiesResidents-Abilities

1.1. Have the ability Have the ability to make to make knowledgeable knowledgeable decisionsdecisions

2.2. Have the ability Have the ability to weigh to weigh alternativesalternatives

3.3. Have the ability Have the ability to manage riskto manage risk

Which Social or Which Social or Behavioral Model do Behavioral Model do

we use??we use??

Theory of Planned Theory of Planned Behavior/Reasoned ActionBehavior/Reasoned Action

Game Theory Game Theory

Social Cognitive TheorySocial Cognitive Theory

Locus of ControlLocus of Control

External Locus of External Locus of ControlControl

Individual believes that Individual believes that his/her behavior is his/her behavior is guided by fate, luck, or guided by fate, luck, or other external other external circumstancescircumstances

Internal Locus of Internal Locus of ControlControl

Individual believes that Individual believes that his/her behavior is his/her behavior is guided by his/her guided by his/her personal decisions and personal decisions and efforts. efforts.

And now for the And now for the fancy stuff!fancy stuff!

The secret ingredient

Health Belief Model (HBM)Health Belief Model (HBM)

Widely used conceptual frameworks Widely used conceptual frameworks for understanding health behaviorfor understanding health behavior

Developed in the early 1950’sDeveloped in the early 1950’s Greatest success for almost half a Greatest success for almost half a

century has been:century has been:– Promote condom usePromote condom use– Promote seatbelt usePromote seatbelt use– Medical complianceMedical compliance– TB Health screeningTB Health screening

Health Belief Model-GuidelinesHealth Belief Model-Guidelines

Based on the understanding Based on the understanding that a person will take a health-that a person will take a health-related action if that personrelated action if that person::

1.1. Feels that a Feels that a negative conditionnegative condition can be can be avoidedavoided..

2.2. Has a Has a positive expectationpositive expectation that by that by taking a recommended action he/she taking a recommended action he/she will will avoid a negative health conditionavoid a negative health condition..

3.3. Believes that he/she can Believes that he/she can successfullysuccessfully take a recommended health action.take a recommended health action.

Health Belief Model-FrameworkHealth Belief Model-Framework

Is a Is a frameworkframework for motivating people for motivating people to take positive health actions that to take positive health actions that uses the desire to uses the desire to avoid a negative avoid a negative health consequencehealth consequence as the prime as the prime motivation.motivation.– The perceived threat of a heart attack The perceived threat of a heart attack

can be used to motivate a person with can be used to motivate a person with high blood pressure into exercising more high blood pressure into exercising more oftenoften

Health Belief Model-Key elementHealth Belief Model-Key element

Note that avoiding a negative health Note that avoiding a negative health consequence is a key element of the consequence is a key element of the HBM.HBM.– For example, a person might increase For example, a person might increase

exercise to look good and feel better.exercise to look good and feel better.– This example does not fit the model This example does not fit the model

because the person is not motivated by because the person is not motivated by a negative health outcome, even though a negative health outcome, even though the health action of getting more the health action of getting more exercise is the same as for the person exercise is the same as for the person who wants to avoid a heart attack.who wants to avoid a heart attack.

Health Belief Model-Key conceptsHealth Belief Model-Key conceptsConcept Definition Definition Application Application

Perceived Susceptibility

One's opinion of chances of getting a condition

Define population's at risk, risk levels; personalize risk based on a person's features or behavior; heighten perceived susceptibility too low.

Perceived Severity One's opinion of how serious a condition and its consequences are

Specify consequences of the risk and the condition

Perceived Benefits One's belief in the efficacy of the advised action to reduce risk or seriousness of impact

Define action to take; how, where, when; clarify the positive effects to be expected.

Perceived Barriers One's opinion of the tangible and psychological costs of the advised action

Identify and reduce barriers through reassurance, incentives, assistance.

Cues to Action Strategies to activate "readiness"

Provide how-to information, promote awareness, reminders.

Self-Efficacy Strategies to activate "readiness"

Provide training, guidance in performing action.

Concept Definition Definition Application Application

Perceived Susceptibility

J.E. believes he can get a pressure wound.

He is at risk because of paraplegic, (2) previous stage IV wounds, a desire to stay up in chair for >16 hours at a time and a desire to lay on one side of the bed for extended periods of time

Perceived Severity J.E. knows the consequences of getting a wound and is very serious about avoiding future wounds.

J.E. knows the consequences of not relieving pressure to his extremities is a probable pressure wound.

Perceived Benefits J.E. believes that taking naps and repositioning in bed will protect him from developing a new wound.

J.E. will not be up for more than 6 hours at a time. and not lay on one side for more than 1 ½ hours at a time. Effectiveness will be measured by no new wounds.

Perceived Barriers

J.E. knows that he likes to be up for extended periods of time because it allows him more independence and more of a social life. He agrees to arrange his activities around a repositioning schedule.

J.E. identifies that he is embarrassed that he has to lay down in the middle of the day when he wants to be where other people are. Nursing staff work around his schedule and get him up/down for his specified activities

Cues to Action J.E. is given frequent praise and encouragement for sticking to a repositioning schedule. When he gets frustrated he talks to a counselor or is reminded by staff of past wound hx.

J.E. was provided with verbal and written information. He was given time to talk about his experiences with wounds, he is an active part of his care planning. Staff keeps track of wound-free status.

Self-Efficacy J.E. is confidant that the nursing staff will get him up/lay him down for his specified activities. He feels like he has responsibility for his own actions with positive consequences. (no wound)

J.E is given frequent counseling and positive reinforcement for adhering to a repositioning schedule. He talks about frustrations and works through them with the staff.

Concept Definition Definition Application Application

Perceived Susceptibility

G.N. believes she will get a pressure ulcer.

G.N. is at risk for an ulcer due to lack of mobility, does not like to turn side to side in bed, obesity, desire to stay up in chair to smoke.

Perceived Severity G.N. knows the consequences of getting a wound and is very serious about avoiding future wounds.

G.N.’s previous occupation was a wound care nurse. She is very aware of the consequences of not routinely relieving pressure and the impact it may have on her health and quality of life.

Perceived Benefits G.N. believes that reducing pressure and frequent repositioning in bed will protect her from developing a new wound.

G.N. will take frequent rest periods only being up in chair for less than 2 hours at a time. She believes that by doing this she will improve her wound status

Perceived Barriers

G.N. likes to be up in her chair and to be able to smoke and socialize with her friends. She agrees that she will come back to her room and lay down in bed more frequently during the day time.

G.N. likes to be with her friends to socialize and chain smoke. Staff agrees to contract with her to allow specific time frames so staff will be available to get her up when desired.

Cues to Action G.N. is given frequent praise and encouragement for sticking to a schedule. She is reminded of her knowledge base (nursing). She will have her friends come to her room to visit more frequently. She agrees to discuss concerns and frustrations with the nurse manager as needed.

G.N. was provided with verbal information. She was given time to talk about her experiences with wounds, both personal and professional. She is an active part of her care planning. Staff keeps track of wound status and updates her weekly during wound rounds.

Self-Efficacy G.N. is confidant that the nursing staff will work to schedule times to get up/lay down. She is aware of her smoking needs, will be able to regulate this plan effectively. She takes responsibility for own actions and feels that she is able to have positive wound healing.

G.N. continues to receive positive reinforcement with weekly improved wound status. She is able to get ongoing education from the wound staff. She receives positive emotional support from family and staff.

Staff Buy-in Cocoa or Coconuts?Staff Buy-in Cocoa or Coconuts? How does staff turn negative How does staff turn negative

behavior into positive outcomes?behavior into positive outcomes?

How does facility get staff to buy-in?How does facility get staff to buy-in?

How does the staff and resident build How does the staff and resident build trust?trust?

Reward to Staff Reward to Staff (mmm-Cookies)(mmm-Cookies)

Individualized plans of careIndividualized plans of care

Staff to encourage the resident to make Staff to encourage the resident to make informed decisions leading to:informed decisions leading to:– Better relationshipsBetter relationships– More trust and mutual respectMore trust and mutual respect– Less demands on staffLess demands on staff– Positive, less stressful, more rewarding working Positive, less stressful, more rewarding working

environmentenvironment

Health Belief Model-In ReviewHealth Belief Model-In Review

Based on the understanding Based on the understanding that a person will take a health-that a person will take a health-related action if that personrelated action if that person::

1.1. Feels that a Feels that a negative conditionnegative condition can be can be avoidedavoided..

2.2. Has a Has a positive expectationpositive expectation that by that by taking a recommended action he/she taking a recommended action he/she will will avoid a negative health conditionavoid a negative health condition..

3.3. Believes that he/she can Believes that he/she can successfullysuccessfully take a recommended health action.take a recommended health action.

Questions??Questions??Michelle Putz, RN, MBA, BSN, WCCMichelle Putz, RN, MBA, BSN, WCC

Director of NursingDirector of NursingOffice: (414) 325-4246Office: (414) 325-4246

Email: Email: Michelle.Putz@bhshealth.orgMichelle.Putz@bhshealth.org

Laure Zulkowski, RN, BSNLaure Zulkowski, RN, BSNAssistant Director of NursingAssistant Director of Nursing

Office: (414) 325-4053Office: (414) 325-4053