Thinking Laterally: A Case Study in Wound Care Patient Compliance
by Paula Erwin-Toth MSN, RN, CWOCN, CNS, FAAN
As summer gives way to fall, one of the first thoughts most of us have is back to school. Patients and caregivers often feel as though every day is the first day of school and they are being asked to take the final exam before they have learned anything. Learner readiness is the cornerstone of an effective teaching/learning process.
Adult learners build knowledge based on past experiences and through a variety of media that engage their senses. Most people have a preferred method of learning and it is up to us as health care professionals to ensure our education templates can be tailored to the needs of each patient and their caregivers.
With school back session, the onset of fall not only has us adjusting our clocks, but also getting ready for winter. People with health conditions often have difficulty even thinking about the next day let alone the next season. Reviewing short and long-term goals along with keeping a record of accomplishments, challenges and revision of goals is critical to keeping everyone engaged: patients, caregivers and health care providers alike.
Case Study: Getting Patients to be Accountable for Their Health
Let's walk through the case of Mr. May (not his real name). Mr. May was diagnosed with Type II diabetes mellitus five years ago. Mrs. May has performed her husband’s glucose monitoring, administration of insulin, diet management and arranging his follow up appointments. Mr. May continues smoking three packs of cigarettes a day and keeps a steady supply of chips, beer and sweets "squirreled away" all around the house, in his truck and in the garage – even in the next door neighbor's garage. Not surprisingly, Mr. May's blood glucose remains high, he is 70 pounds overweight and his emphysema has worsened. An ulcer on his great toe is what brought him to the wound clinic.
I imagine you have all had and will have a Mr. and Mrs. May in your practices. What is your approach? One of my favorite sayings is "In order to effectively teach you have to reach" – in this case reaching your patient and his wife. Mr. May was still in denial about his diabetes and emphysema; he had managed to disassociate himself from his diseases, treatments and prognosis. Mrs. May was the 'go to' caregiver in their family and was happy to manage all aspects of her husband's care. Oddly enough, the foot ulcer was a blessing in disguise. It gave us the opportunity to start over with Mr. and Mrs. May. Granted, the easiest thing to do would have been to teach Mrs. May how to perform wound care and ensure her husband complied with offloading and the overall treatment plan. That would have been easy, but ineffective for both the short-term and especially long-term management of Mr. May's health challenges.
Asking Questions to Engage Patients in Their Wound Care
As part of my patient assessment I wanted to know the background of Mr. May. What did he do before he retired? What were his hobbies? I asked him to walk me through a typical day. As it happened, Mr. May is a retired police detective and Mrs. May a retired nurse. They met when he was a "beat cop" and she was a nurse in the emergency department. Their relationship and family dynamics can be directly traced back to how they met and why they fell in love. Mr. May's job was to protect and provide for his family; Mrs. May's job was to make their home a safe haven and care for her family. This relationship worked for them for over 40 years but eventually allowed Mr. May to disassociate himself from his own health care needs. Rather than approach the Mays directly about the need for Mr. May to take responsibility for his own care, I took an "end around" (fall football metaphor) approach to reach Mr. May.
When I asked I asked him about his work he lit up like a light bulb. I steered the conversation to his thoughts about repeat offenders-criminals who were given multiple opportunities to turn their lives around but failed to do so. He acknowledged that many face many obstacles and how their family and friends can lead them into falling back into bad habits. He said, and I quote, "The criminals need to 'Man Up' and take responsibilities for their own lives. I mean both men and women when I say that."
At that point I used therapeutic silence and looked directly into his eyes. I said nothing and maintained eye contact until his color of his face turned an alarming shade of puce. Mrs. May gasped and for a moment I felt my life pass before my eyes. Then an amazing thing happened – Mr. May laughed. Not just a chuckle, a full blown belly laugh. He laughed and laughed and slapped his knees until he cried.
In that brief conversation I was able to reach the Mr. May on a level he understood. I was tapping into his wealth of experiences in order to help him help himself. He later said my silent stare hit him like a bolt of lightning and should I ever give up nursing, I had a promising future as a police detective. I worked with the Mays to help them find a new dynamic as he finally began to grapple with and take control of his health challenges. Those five extra minutes I spent chatting about what seemed like an unrelated topic made all difference in a passive patient versus one who became an active participant in his health care.
About The Author
Paula Erwin-Toth has over 30 years of experience in wound, ostomy and continence care. She is a well-known author, lecturer and patient advocate who is dedicated to improving the care of people with wounds, ostomies and incontinence in the US and abroad.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.