1. Whats your House Recipe? Part II Refining a Skin Management System Mount Carmel April 30, 2008

2. Mount Carmel in Review Licensed for Medicare and Medicaid Licensed for Medicare and Medicaid Accommodates long-term, sub- acute and traumatic brain injury residents. Accommodates long-term, sub- acute and traumatic brain injury residents. 473 Beds 473 Beds 10 units 10 units 94% to 95% capacity 94% to 95% capacity Take in complex wounds Take in complex wounds High percentage of Medicaid and Managed Care residents High percentage of Medicaid and Managed Care residents Long history of advanced wound care management Long history of advanced wound care management

3. Our Recipe for Success

4. How do we take our Skin Management System to the next level?

5. Dementia vs. High Cognitive Function? We need to manage our Noncompliant residents

6. Dementia Characteristics Staff anticipate residents needs Staff anticipate residents needs Facility develops residents plan of care based on experience and evidence-based outcomes Facility develops residents plan of care based on experience and evidence-based outcomes Staff is obligated to do the right thing Staff is obligated to do the right thing –Ethically –Regulatory –Standards of practice

7. Dementia Characteristics Do not know how to position self Do not know how to position self Are incapable of making informed, rationale decisions Are incapable of making informed, rationale decisions Declared incompetent or incapacitated Declared incompetent or incapacitated Loss of cognitive functioning Always Loss of cognitive functioning Always Loss of physical functioning Sometimes Loss of physical functioning Sometimes

8. These were NOT the residents that posed the greatest challenge.

9. High Cognitive Functioning Need to have a say in their own care Need to have a say in their own care Physically dependent, NOT emotionally or cognitively dependent Physically dependent, NOT emotionally or cognitively dependent Have their own agenda Have their own agenda

10. High Cognitive Functioning Alert, oriented X 3 Alert, oriented X 3 Trying to maintain what level of Control or Independence they have Trying to maintain what level of Control or Independence they have

11. High Cognitive Functioning Residents-Abilities 1. Have the ability to make knowledgeable decisions 2. Have the ability to weigh alternatives 3. Have the ability to manage risk

12. Which Social or Behavioral Model do we use??

13. Theory of Planned Behavior/Reasoned Action

14. Game Theory

15. Social Cognitive Theory

16. Locus of Control External Locus of Control Individual believes that his/her behavior is guided by fate, luck, or other external circumstances Internal Locus of Control Individual believes that his/her behavior is guided by his/her personal decisions and efforts.

17. And now for the fancy stuff! The secret ingredient

18. Health Belief Model (HBM) Widely used conceptual frameworks for understanding health behavior Widely used conceptual frameworks for understanding health behavior Developed in the early 1950s Developed in the early 1950s Greatest success for almost half a century has been: Greatest success for almost half a century has been: –Promote condom use –Promote seatbelt use –Medical compliance –TB Health screening

19. Health Belief Model-Guidelines Based on the understanding that a person will take a health- related action if that person: Based on the understanding that a person will take a health- related action if that person: 1.Feels that a negative condition can be avoided. 2.Has a positive expectation that by taking a recommended action he/she will avoid a negative health condition. 3.Believes that he/she can successfully take a recommended health action.

20. Health Belief Model-Framework Is a framework for motivating people to take positive health actions that uses the desire to avoid a negative health consequence as the prime motivation. –The perceived threat of a heart attack can be used to motivate a person with high blood pressure into exercising more often

21. Health Belief Model-Key element Note that avoiding a negative health consequence is a key element of the HBM. Note that avoiding a negative health consequence is a key element of the HBM. –For example, a person might increase exercise to look good and feel better. –This example does not fit the model because the person is not motivated by a negative health outcome, even though the health action of getting more exercise is the same as for the person who wants to avoid a heart attack.

22. Health Belief Model-Key concepts ConceptDefinitionApplication 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.

23. ConceptDefinitionApplication 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.

24. 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.

25. ConceptDefinitionApplication 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

26. 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.

27. Staff Buy-in Cocoa or Coconuts? How does staff turn negative behavior into positive outcomes? How does staff turn negative 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 trust? How does the staff and resident build trust?

28. Reward to Staff (mmm-Cookies) Individualized plans of care Individualized plans of care Staff to encourage the resident to make informed decisions leading to: Staff to encourage the resident to make informed decisions leading to: –Better relationships –More trust and mutual respect –Less demands on staff –Positive, less stressful, more rewarding working environment

29. Health Belief Model-In Review Based on the understanding that a person will take a health- related action if that person: Based on the understanding that a person will take a health- related action if that person: 1.Feels that a negative condition can be avoided. 2.Has a positive expectation that by taking a recommended action he/she will avoid a negative health condition. 3.Believes that he/she can successfully take a recommended health action.

30. Questions?? Michelle Putz, RN, MBA, BSN, WCC Director of Nursing Office: (414) 325-4246 Email: Michelle.Putz@bhshealth.org Michelle.Putz@bhshealth.org Laure Zulkowski, RN, BSN Assistant Director of Nursing Office: (414) 325-4053