Underpinning Theory
Bridges has evolved from a rich evidence base and robust theoretical framework.
Bridges was one of the first self-management programmes for stroke. Since then, the approach has been continually refined, contextualised and evaluated across many other health conditions such as cancer and long Covid through our research projects, and practically implemented and evaluated through our training and sustainability support.
This evidence has helped us understand the most effective ways to support self-management for people living with different long-term conditions. It’s also informed how best to train, implement and sustain this approach with health and care practitioners across different care pathways, by focusing on core principles and real-life practical applications of these principles.
Here are some key principles and theories that inform the Bridges approach.
Social Cognitive Theory and Self-Efficacy
Self-management programmes underpinned by theory of change (why the activities should lead to a change in planned goals and outcomes) can help to understand the context, mechanisms and outcomes that help to facilitate success.
Bridges is underpinned by Albert Bandura’s Social Cognitive Theory and his key construct of self-efficacy, which helps to explain the relationship between a social environment, the person and their behaviour. Self-management programmes underpinned by self-efficacy principles can be more effective.
Self-efficacy has been used to explain behaviour in people across multiple areas such as health, sport, education and business, and inform the methods and interventions that can help facilitate changes in behaviour and improve individuals’ confidence, knowledge and skills.
When people’s self-efficacy is low, they can start to feel out of control, helpless, and hopeless. By using specific language and strategies, Bridges trained practitioners look for opportunities to build and strengthen self-efficacy, in other words in ‘an individual’s belief in their own capability’. As self-efficacy rises so do the feelings of being able to cope with setbacks and navigate problems increase and ultimately people can start to feel more in control.
As we’ve discovered in one of our recent studies in people with long Covid, working in this way, and supporting people to feel more confident, skilful and knowledgeable about managing day to day, is not a cure but can have a significant impact on self-efficacy, quality of life and emotional wellbeing.
Bandura died in 2012 aged 95. One of the proudest moments for Fiona (our founder) was receiving a handwritten note from him requesting a copy of her stroke self-efficacy scale.
Bridges continues to understand the relationship between the need of people with different conditions and the inputs and activities of healthcare practitioners to understand the behaviour of both groups. We now incorporate more learning about collective efficacy and social networks as well as Normalisation Process theory. All of this helps us understand how people can build their own personal community, and how healthcare practitioners, teams and services pathways can make Bridges business as usual.
Mastery and Modelling – or ‘feelings of success and learning from peers’
Bridges approach uses sources of self-efficacy such as goal mastery (feeling of personal success) and modelling (learning from others).These key principles started to shape the way in which we developed our books, core principles, language and ultimately the training delivered to healthcare practitioners.
These principles support practitioners to shift to become more of a coach in their practice. Instead of directing, controlling and determining the content of healthcare sessions, they focus on how the experiences or changes are perceived and felt by the individual. They ask, ‘how does that feel?’ first, when a small success is achieved, rather than congratulating (however well meaning).
Being curious and listening, they encourage the person to reflect on their own individual resources or the support around them. Over time, or sometimes in one session, the person can start to link their own performance and behaviour with their individual efforts and not only the clinical skills and expertise of their healthcare practitioner. Our research has shown this is not about dose but the quality of the interaction and the relationship, and that more sessions does not necessarily mean better.
Bridges advocates for developing a trusting and collaborative relationship from the first interaction, and we have shown this is possible in acute healthcare settings such as Major Trauma and Acute Brain Injury units. As a patient in a highly medicalised environment, we recognise there may not always be the space to explore ideas, hopes and fears. However, in Bridges practitioners, a personalised approach to supported self-management can start much earlier in a care pathway.
Co-Design and Participatory Research
As our work has evolved, we have integrated more participatory research methods, and we use co-design and co-production methods as much as we can in our intervention development and training delivery. Participatory research designs and methods involve direct collaboration with those affected by the issues being studied. This way of working prioritises the voices and insights of those directly impacted, designing interventions and support that they most want and need.
Bridges has many examples of how it has used co-design, including our books for people with many different long-term conditions, and intervention development for our recent LISTEN trial for people with long-Covid. We also co-author papers with people living with different conditions that are involved in our research.
Bridges has collaborated with City St George’s University to create an online educational resource hub which provides guides and research materials for participatory research. This hub includes films of researchers form City St George’s and Bridges talking about their co-design and participatory approaches to research.