Enhancing the Medical Practice

Creative Approaches to Systems-Level Change in

Primary Care

Collaborative Family Healthcare Association 15th Annual ConferenceOctober 10-12, 2013 Broomfield, Colorado U.S.A.

Session #G4bSaturday, October 12, 2013

Shelley Hosterman, Ph.D.Tawnya Meadows, Ph.D.

Heather Babyar, Ph.D.Amanda Bleck, Ph.D.

Enhancing the Medical Practice

Shelley Hosterman, Ph.D.Tawnya Meadows, Ph.D.

Heather Babyar, Ph.D.Amanda Bleck, Ph.D.

Faculty DisclosurePlease include ONE of the following statements:

I/We have not had any relevant financial relationships during the past 12 months.

OR• I/We currently have or have had the following relevant

financial relationships (in any amount) during the past 12 months:

• (list them here)

Objectives

Behavior Passport System

Behavior Passport Program• PCPs & nurses expressed interest in approaches for

managing clinic behavior

Behavioral Observations:• Disruptive behavior interfering with flow• Frequent use of negative strategies to manage

behaviors (yelling, physical prompts)

• Desire to increase patient satisfaction & market clinic • PCPs wanted to teach general behavioral principles to

families| 6

Token Systems: Key Components

• Increases appropriate behavior & reduces incompatible, inappropriate behavior

• Earn stickers/points/tokens for desired behavior

• Stickers/points/tokens traded for rewards

• Research shows small/simple rewards are effective| 7

Token Systems• Well established, evidenced based intervention for

preventing/managing disruptive behavior

• Significant evidence to support effectiveness in home, school, inpatient, rehabilitation, & residential settings in a range of populations• Effective for severe behaviors (Christophersen et al., 1972;

Drabman et. Al, 1974; Kazdin, 1982)

• Strong evidence that parents & teachers can learn & implement procedure with integrity

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Behavior Passport : Development• Initial Development:

• Nurse input on sequence & piloted steps• Front desk input on support & logistics• Protocol with roles based on staff input• Created “jungle passport” based on clinic theme

• Follow up:• Print job, stickers, small prizes• Piloted program with several patients & gathered

feedback from nurses/PCPs/parents• Ensured most children would meet set goal • Revisit in staff meetings & revise as needed | 9

Stakeholder Comments: Parents

“I like it a lot. In fact, I was here last week with my 3-year-old, and I think it helped her a lot more because that’s the age where they act up a lot. So, it really did help her to behave more. It was a good reminder that you need to behave to get that sticker at the end.”

“It was good, easy to follow through, and I wouldn’t change a thing about it”

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Stakeholder Comments: Front Desk

Check in: “It’s a great idea. The parents think it’s great. I have positive feedback from parents and kids, especially the kids when they find out they are getting a prize at the end of the visit. I think, yes, it has helped children to be less disruptive.”

Team lead: “The patients love them. The parents think it’s the greatest thing. It helps them behave, especially when they have a long wait at the appointment.”

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Stakeholder Comments: Check Out

“I really do think it’s a good thing and it gives them something to look forward to. The parents like it too, and if we are animated about it, the parent gets excited about it too. It depends on how we talk about it, if we are animated, they get excited. Honestly, I think it’s a good thing.”

“I think its a good thing…the kids I have seen, I think it has helped some of them. It’s especially helpful to have something to work with when you’re going through trying to schedule appointments. You can remind them that they won’t get a sticker unless they cooperate. I think they should keep it, but not add anything else.”

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Stakeholder Comments: Nurses

“I thought they were good. It helps kids because if you are giving them something, they will do good. If they are bad you can say, “Oh, you want to earn a sticker to get a prize at the end so you need to behave.” It works very well. I had one patient yesterday who the mom said that he never usually behaves at the doctor’s office, but yesterday he had his passport and was doing really well. The mom said he never behaves well, but he was earning his stickers. I think it helped him.”

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Acceptability Surveys

Subscale Mean Range

Acceptability 4.53 Agree to strongly

Effect 3.98 Slightly to agree

Time 4.36 Agree to strongly

Total 4.33 Agree to strongly

0 (strong disagree) to 5 (strongly agree)3 = Slightly agree, 4 = Agree, 5 = Strongly Agree

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Behavior Intervention Rating Scale (Elliot & Treuting, 1991)

•Measures perceptions of treatment acceptability and perceived effectiveness of intervention in classrooms

•Three factors: Acceptability, Effectiveness & Time of Effect

Case Example: PCP• 5 year old male• Would always cry when he came to the office afraid of

any new thing we would do – weighing , blood pressure , temp, and of course the dreaded “exam”

• With the passport, he would not only cooperate BUT WOULD ask his mother what was “next,” so he could get a sticker and earn the prize in the basket.   

• This is a particularly good with the anxious patient• His experience and mine were quite a bit better after

using the passport.Dr. G.

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CBT Strategiesfor Administrationof Injections

Experience of injections• Negative history with shots needle fears, pre-

procedure anxiety, avoidance behaviors, non-adherence to vaccine schedules

• Up to 25% of adults have a fear of needles• 10% of population avoids vaccines/procedures

• Accumulated positive experiences reduce fear, support adherence, and maintain trust in providers

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Tool #1: Adult comments & modelingKey mechanisms:• Social referencing: When placed in unfamiliar

situations, children look for emotional cues the faces of other people & use these cues to determine how they should feel

• Modeling: Children learn by imitating adults

53% of the variance in child distress accounted for by maternal behavior (Schechter, 2007)

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Hurtful Comments & Modeling• Distress promoting comments: Focus child’s attention on

their own distress or threatening aspects of procedure

• Parents should avoid the following behaviors, which are associated with increased pain & distress in children:• Reassurance (“it’s okay”, comforting physically)• Empathy (I know it hurts, I would be scared too)• Apologies (I am so sorry we have to do this)• Physical restraint – Strong association with fearful bx• All indicate a frightening experience

Blount et al., 2009; McMurtry, 2010.; Schechter, et al, 2007; Taddio, 2010| 19

Hurtful Comments & ModelingAdult displays of distress: • Parental facial expression, tone, & verbal content• Crying, cringing, turning away, pacing, jittering• Children respond to signs of anxiety in parents

Talking about past negative experiences with shots: “Mommy hates shots too” or “Oh, I bet you hope you don’t get a shot today, your sister hates shots.”Giving control: “You tell us when you’re ready.”Criticism: “Don’t be a baby.”Punishment: “If you don’t get this shot, no pool today.”

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Helpful Comments & Modeling• Parent modeling coping strategies

• Role plays of coping well

• Watching a peer cope positively while learning more about procedure & role play

• Video taped modeling(Chambers et al., 2009)

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Tool #2: Attention & DistractionAttention: Main mechanism through which pain reaches awareness.

Distraction: Redirect attention elsewhere• Significant influence: Predict 40% of variance in coping of

preschool kids• Training parents & nurses in distraction increased coping &

reduced distress• Behavior of trained parents influences nurse behavior• Peak effectiveness age 7. No gender/age differences

Blount et al., 2009; Ridley-Johnson; Taddio, 2010

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Distraction Options• Nonprocedural talk

(preferred topics, verbal games, lists)

• Age appropriate toy play

• Humor• Interactive story,

cartoon, robot• Kaleidoscopes• Bubble-blowing

• Music• Electronic games• Movies• Party blowers• Virtual reality goggles

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DistractionDistraction work better if stimuli activity is: • Highly engaging, easily performed• Requires observable response• Matched to demands of medical task • More engaging distraction lower painParents can learn to effectively distract with support• Use of distractor + ignoring distress + parent praise

• Specific praise for engaging in distraction strategy• Enthusiasm & active engagement with child• Praise positive coping afterwards & promoting adaptive cognitions about

experience (I knew you could do it! That went really quickly! )

Parents implemented well & distress significantly reduced(Pringle et al., 2001)| 24

Tool #3: Coping Behaviors for Kids• Teaching parents/nurses coping-promoting

behaviors often produces sufficient improvement• If problems persist add child techniques

• Breathing exercises (Level B)• Reduce self-reported pain &

observer/nurse rated distress• Slow, deep breathing• Use: Party blower, bubbles, pinwheels

(Chambers et al., 2009)| 25

Coping Behaviors for Kids • Progressive Muscle Relaxation (PMR)

• Emotive imagery: Imagine favorite place with all senses

• Positive self talk: “I can do this,” “I can stay calm,” I can be brave like Spider Man”

• Child directed distraction (Level B evidence)• Reduces self-reported pain• Interactive movies best outcome

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Tool #4: Coaching & PreparationProviding simple information & coaching• More information less distress & better adjustment• Specific, procedural (what will do), sensory (what will

experience feel)• Timing matters (depends on age & temperament)

Coping strategies as part of the “game plan”• Practice of coping strategies at home can help• Review within steps of procedure

Ridley-Johnson, 2010; Schechter, 2007

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Combined interventions worked the best!Self-reported pain

Distress by observer

Distress by nurse

Self-report of distress

Breathing exercises X X XSuggestion

Child directed distraction X

Parent directed distraction X

Nurse directed distraction X X X

Parent coaching XCombined intervention X X X

• Chambers et al, 2009: Review of RCT & Quasi-RCTs on reduction of pain & distress during routine immunizations in children (ages 0 to 18)

• X: Indicates statistically significant reduction| 28

Questions & Comments

Thank you for your time and attention.

Contact information:Shelley Hosterman sjhosterman@geisinger.eduTawnya Meadows tjmeadows@geisinger.edu

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