‘Bridges methodology’: defining our values 10 years on

Our methodology describes how we work with healthcare teams, people and families through research and improvement projects and interprofessional training, to co-produce a Bridges self-management support package suited to the local context. This is in keeping with our mission as a social enterprise: to improve the lives of people living with acute and long-term conditions, by working with healthcare teams to define and deliver best practice in self-management support.
Here, we will articulate the values that underpin our work with people, families and healthcare teams to embed and sustain effective self-management support:

1. Self-management is perceived differently by patients, families and practitioners and across different health and social care settings

We believe that the purpose of self-management is to support people and families to manage life well with their long-term health condition(s). For effective self-management support to be enacted in clinical practice, practitioners need to adopt broad approaches to self-management support by focussing on what matters most to the person [2]. This can be achieved through flexible and collaborative ways of working that can run counter to some conventional professional training and practices.

2. Self-management support goes beyond personal agency

Self-management programmes have been criticised for a narrow focus on personal agency, where a person’s health behaviours are mediated purely through cognitive processes. This perpetuates the perception of self-management as the sole responsibility of the person and introduces inequity of access to self-management interventions. People with cognitive and communication impairments, complex health conditions, poor health literacy, complex social situations and low socioeconomic status can be excluded from self-management interventions but potentially have the most to gain. We challenge these assumptions about hard-to-reach groups and support practitioners to find solutions by creating a space in which rehabilitation and care can be jointly determined within the social and material needs of the person.

3. Self-management support can and should be started early in the acute setting

There is a common perception that self-management support is reserved for community providers and third sector organisations. Our work shows that self-management support can be integrated into the working practices of acute healthcare teams [3, 4] and engage people and families earlier in care and rehabilitation practices, which in turn can reduce length of stay, improve their hospital discharge experience and help them to prepare for a more successful transition into the community or onto other rehabilitation facilities.

4. Self-management support can be integrated into the daily working practices of practitioners

We believe that ‘every interaction counts’ and through our training programmes practitioners create the strategies and language to nurture self-management skills in the people and families they are working with. In this way self-management support can be delivered by healthcare practitioners of any profession and grade, even during the briefest of interactions.

5. Practitioners need to relinquish control and develop skills in partnership – working with people and families

To enhance their self-management support practitioners need to readdress the power balance between patient and practitioner. This should take the form of a collaborative and open relationship in which the skills and expertise of the patient are accessed. After attending our training, practitioners have reported changes in their behaviour including active listening, joint problem solving, joint decision making and moving away from their professional agenda to work with what matters most to the person.

6. Self-management support is most effective when whole teams are trained

We prefer to train whole teams to deconstruct assumptions about self-management support between practitioners, facilitate a shared understanding of effective self-management support and agree a local implementation and evaluation plan. Teams benefit from discussion about barriers and successes in an interprofessional learning environment and we support them to overcome any professional and organisational challenges to implementation and sustainability [5].

7. Teams who successfully integrate self-management support liberate team and goal setting processes

Anecdotally we have reflected on the notion that teams who have successfully integrated Bridges into their working practices appear to have flat hierarchical structures which seems to create a more open and supportive environment in which to explore different ways of working [1]. We have seen teams put support workers in charge of goal setting with patients, liberate themselves from lengthy assessment paperwork, incorporate self-management strategies into telephone triage and allow patients and family members to lead their own progress and goal setting meetings.

8. The coproduced Bridges books for patients and families provide a structure for self-management support in practice…

The content of these peer support tools is defined by the patient and family contributors, theoretically based and designed and tested to a high quality through research and development projects. They can provide a structure around which practitioners can provide self-management support in any clinical setting, that has been determined by patients and family members themselves.

9. …but there is more to self-management support than using the Bridges books

The effectiveness of the Bridges books is enhanced by the communication skills and partnership working of the practitioner. Our focus is on how practitioners and teams integrate key self-management strategies and a shared language into their daily practice with the books used as tools that can further enhance their self-management support.

10. We must tailor support to individuals and contexts: Bridges is a principled intervention

Bridges is a complex and principled intervention in that it is defined by a set of seven key principles, underpinned by a sound theoretical basis and enhanced by unique coproduced self-management tools for patients and families. We work together with practitioners to help them to work out what their self-management practices might look and sound like when working with different individuals within their specific work environments.

References:
[1] Jones F, Poestges H & Brimicombe L. (2016) Building bridges between healthcare professionals, patients and families: A coproduced and integrated approach to self-management support in stroke. Neurorehabilitation, 39(4), pp. 471-480
[2] Morgan H, Entwistle V, Cribb A, Christmas S, Owens J, Skea Z & Watt I (2016) We need to talk about purpose: A critical interpretive synthesis of health and social care professionals’ approaches to self-management support for people with long-term conditions. Health Expectations, doi: 10.1111/hex.12453
[3] Makela P, Gawned S, Jones F. (2014) Starting early: integration of self-management support into an acute stroke service. BMJ Qual Improv Report 2014;3: doi:10.1136/bmjquality.u202037.w1759
[4] Jones F & Brimicombe L (2014) Every interaction counts: The ‘Bridges’ approach to stroke self-management. International Journal of Therapy and Rehabilitaiton, 21(4), pp. 158-159
[5] Kulnik ST, Poestges H, Brimicombe L, Hammond J and Jones F. (2016) Implementing an interprofessional model of self-management support across a community workforce: a mixed methods evaluation study. Journal of Interprofessional care, Dec 6:1-10. [Epub ahead of print].