A Critical Evaluation of Three Different Methods for Treating Generalised Anxiety Disorder

Anxiety is a normal feeling associated with the body sending an alarm for potential danger (Burton, Western, & Kowalski, 2019). A person with an anxiety disorder is subject to frequent feelings of anxiety inhibiting their life (Burton et al., 2019). Bandelow, and Michaelis (2015, as cited in Burton et al., 2019) estimated that 33.7% of people will be subject to an anxiety disorder in their lifetime. Generalised Anxiety disorder (GAD) is shaped by constant anxiety with irrational concerns about general life situations (Stapinksi, Abbott, & Rapee, 2010, as cited in Burton et al., 2019). GAD can have consequential impairment such as Low occupational level (Massion, Warshaw, & Keller, 1993 as cited in Crits-Christoph et al., 2011), increased suicidal risk (Boden, Fergusson, & Horwood, 2007 as cited in Crits-Christoph et al., 2011) and low emotional health (Robins & Regier, 1991 as cited in Crits-Christoph et al., 2011). This essay will critical evaluate three different types of treatments for GAD, which are Cognitive Behavioural Therapy (CBT), Psychodynamic therapy, and herbal medicine (specifically the use of chamomile extract).  It will discuss the benefits and disadvantages of all three treatments, and that CBT is the preferred treatment over psychodynamic therapy, and chamomile extract.

Herbal medication, such as chamomile extract, can be an effective alternative to conventional drugs in the treatment for GAD (Keefe, Mao, Soeller, Li, & Amsterdam, 2016). Studies on chamomile extract have shown positive results like producing anxiolytic activity, and a reduction in the severity, in GAD (Keefe et al., 2016). The production of anxiolytic activity, with chamomile, affects hormone and neurotransmitters, such as dopamine and y-aminobutyric acid (Keefe et al., 2016).  Keefe et al. (2016) conduct an open-label study on the short-term effects of chamomile therapy to treat GAD. Keefe et al. hypothesised that Chamomile extract would reduce adverse effects and the severity of GAD. The study consisted of 180 patients with 179 taking at least one dose, 500mg to 1500mg daily, of chamomile extract over the course of eight weeks (Keefe et al., 2016). Over half (58.1%) of the participants of the study experienced a meaningful response (Keefe et al., 2016). A small percentage of people (11.7%) experienced side-effects that were considered mild (Keefe et al., 2016). Drowsiness was the most commonly occurring side-effect (7.2%) and 3.9% experienced a lingering herbal taste (Keefe et al., 2016). These side effects are mild compared to Vilazodone, a conventional drug, where common side effects were nausea 27.6% and diarrhea 26.1% (Zareifopoulos & Dylia, 2017).

Chamomile extract has limitations, that should be considered before use in the treatment if GAD, including limited research and mild side effects (Keefe et al., 2016). It is difficult to confirm the benefits of chamomile extract, as there has been few human clinical trials (Keefe et al., 2016). Keefe et al. (2016) discuss the need for more research in Chamomile to treat GAD, including blind testing and longer studies, noting it is a limitation. Chamomile extract has yielded promising results, but further long-term studies are needed to confirm its benefits on GAD (Keefe et al., 2016). This herbal medication still needs to be considered for people as an alternative to traditional medication, only once it has been further tested for people suffering from GAD. As such it cannot be used in a safe and effective way to treat GAD until further studies are conducted.

Psychodynamic therapy focuses on the understanding of processing impeding emotions and difficult relationship patterns (Crits-Christoph, 2002; Blagys & Hilsenroth, 2000 as cited in Lilliengren, Johansson, Town, Kisely, and Abbass, 2017). Short-term psychodynamic psychotherapy (STPP) (Salzer, Winkelbach, Leweke, Leibing, & Leichsenring, 2011), and intensive short-term dynamic psychotherapy (ISTDP) are effective types of psychodynamic therapy (Lilliengren, Johansson, Town, Kisely, & Abbass, 2017). Lilliengren et al. (2017) conducted a study on ISTDP for GAD and hypothesised the benefits in psychiatric symptoms, interpersonal problems and a reduction in the cost of healthcare. ISTDP was delivered in two varying formats (Lilliengren et al., 2017). The first format was graded for patients with low anxiety tolerance and the second was a standard format for patients with emotional detachment (Lilliengren et al., 2017). A session typically lasted 50 minutes and patients received an average of 8.3 sessions (Lilliengren et al., 2017). Over half of the patients (60.9%) completed at least one self-assessment to report their results (Lilliengren et al., 2017). These sessions reduced psychiatric and interpersonal symptoms in patients (Lilliengren et al., 2017). Studies into STPP have had lasting positive effects after 12 months in the treatment of GAD (Salzer et al., 2011). In Salzer et al. (2011) study initially 28 people were treated with up to 30 sessions of STPP and 17 were used in a follow up of the results after 12 months (Salzer et al., 2011). The study showed positive results as GAD symptoms were significantly improved and maintained (Salzer et al., 2011).

STPP and ISDTP has limitations when compared to CBT, high drop-out rates, and limited research (Salzer et al., 2011; Lilliengren et al., 2017). Lilliengren et al. (2017) had one third of the patients stopped treatment after one session. With limited sessions the results need to be viewed with caution, as ISTDP may not be the reason for the patient’s improvement (Lilliengren et al., 2017). ISTDP produced positive outcomes, but the study is not adequate, due to high drop-out rates and the average amount of sessions required not used by patients. Salzer et al. (2011) compared STPP and CBT at 12 months after the initial treatment. Salzer et al. noted that both treatments had consistent significant improvement of symptoms after 12 months, but CBT showed superior results in trait anxiety and worry. This study’s sample size is too small to be able to determine the superior treatment of the two and further studies into long term success is needed (Salzer et al., 2011). Even though STPP and ISTDP have shown positive results (Lilliengren et al., 2017; Salzer et al., 2011), CBT has shown some better preliminary results (Salzer et al., 2011).

CBT uses various cognitive and behavioural techniques which focus on changing maladaptive behaviours on unwarranted anxiety in GAD (Hofmann, 2008; Smits, Julian, Rosenfield, & Powers, 2012, as cited in Carpenter et al., 2018). CBT is effective in treating GAD and had positive outcomes in several studies (Cuijpers et al., 2014; Carpenter et al., 2018; Salzer et al., 2011; Crits-Christoph et al., 2011). Salzer et al. (2011) study showed positive results for CBT, and in trait anxiety and worry, CBT demonstrated some better preliminary results to STPP. Cuijpers et al. (2014) compared 41 randomized trials on psychotherapy of which 35 included CBT as a therapy. Out of these 35 studies it was shown that CBT is an effective treatment against GAD (Cuijpers et al., 2014). The CBT in Crits-Christoph et al. (2011) study consisted of various techniques from the Borkovec and Costello (1993) and Borkovec, Newman, Pincus and Lytle (2002) studies (as cited in Crits-Christoph et al, 2011). CBT has shown some positive results and may have longer lasting results than other care (Cuijpers et al., 2014). Carpenter et al. (2018), compared 41 studies of CBT to a pill placebo for patients with anxiety related disorders in a meta-analysis. Two studies of the 41 were specifically related to GAD, with 57 patients, which showed that CBT is moderately effective for treatment of GAD compared to the placebo (Carpenter et al., 2018).

CBT has had similar results to medication trials (Crits-Christoph et al., 2011). and without the need for patient interaction, medication can be more successful. Crits-Christoph et al. (2011) research involved a study of CBT combined with medication. The CBT in Crits-Christoph et al. study consisted of various techniques from the Borkovec and Costello (1993) and Borkovec, Newman, Pincus and Lytle (2002) studies (as cited in Crits-Christoph et al, 2011). Twelve weeks of CBT was offered to patients, as all patients were initially offered a medication trial, the enthusiasm for CBT was low, and two-thirds declined the treatment offered (Crits-Christoph et al. 2011). These reasons may have affected the results as CBT and medication combined with CBT had the same results as medication alone (Crits-Christoph et al., 2011). CBT needs further follow-up studies for treatment in GAD but has shown positive results.

GAD is defined by excessive worry over normal life situations and can lead to disruption in a person’s normal daily activities. Chamomile is a herbal treatment that has shown some improvement for GAD sufferers. Chamomile has had little research and while side effects are low and mild, they still exist. Therefore, Chamomile cannot be used in a safe and effective way to treat GAD. STPP and ISDTP both have shown positive results and STPP research has had similar results to CBT. As ISDTP and SSTP have not had the same level of studies, and follow-up studies conducted, it cannot be determined to be as effective as CBT. CBT having the highest quantity of studies, most successful research, and without side-effects can be effective in treatment of GAD. All treatment for GAD is personal and as such CBT may not work for all people suffering, as it requires patient involvement. Therefore, for the most beneficial outcome, GAD should be treated with the patient’s personal opinion in mind, offering CBT as a first option.

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This essay will be used as a tool to critique and improve my leadership and management skills as this is essential to the changes that are needed in the NHS improvement plan. In this process I have identified my leadership strengths as well as my development needs. I have used self assessment and feedback from colleagues in the form of my managers, peers and direct reports. I have also reflected upon my vision and style of management and further identified areas that can be enhanced into making me a more versatile leader as this is important to the NHS modernisation programme (DH 2000). With this information I have formulated an action plan that is SMART (Specific, Measureable, Action Oriented, Realistic and Time bound) (NHS Leadership Qualities Framework 2002).

Leadership is essential and central to the current NHS modernisation programme. In fact the department of health quotes

“anyone working in the NHS regardless of their position, grade, qualification or place of work, may be a leader or agent of change and improvement” (DH 2001).

In simple terms the department of health is looking towards its own staff to develop and deliver their NHS improvement plan and are looking for visionary staff at all levels of experience (DH 1999). The changes that I have had to lead and am currently leading have been driven by reducing waiting times for new case patients as well as implementing the “18 week Pathway” from referral to treatment (DH 2006). Other drivers for change and improvement have been the implementation of the “Choose and Book” system, whereby patients are invited to choose where they are referred and given the option of booking their appointments. The reason for these changes on a whole has been to provide a faster, more user friendly and convenient access to care for patients requiring treatment (DH 2005).

My professional title is Head of Orthoptic Services which is an allied health profession. I have to provide clinical leadership whilst ensuring a comprehensive and equitable service is provided that is responsive to changing needs, that is flexible to change and has to directly follow department of health guidelines and changes. My leadership role is to manage and develop the Orthoptic Services within the framework of national guidelines and ensure that

effective communication

across 3 hospital based departments, out-reach clinics, special schools and screening clinics is adhered to, to enable effect change. Within this role I am met with challenges that are set from management levels above me that I have to react to within my sphere of influence. These may include financial management, staffing levels, waiting targets and service developments in line with the NHS improvement plan (DH 2004). In providing these changes the challenges that I face are mainly down to financial constraints and staffing levels. Staffing levels are always an issue since our department lost a member of staff due to recruitment and retention, and as a method of cost savings the post was dissolved. Conflict is often an issue as change is at this time frequent and often initially met with resistance and negativity; I myself can initially have these reactions and project them.

My personal vision of leadership is to be a transformational leader. This type of leader has the skills to share their vision, motivate their team and gain commitment, which will as a result inspire performance (Bennis, 2003, p 31-46). I am keen to motivate my staff by giving them objectives that I feel are appropriate and within their capabilities; this gives them a varied, inspiring work life and will broaden and increase their interests. This has been highlighted in my LQF feedback which I will discuss in greater detail later. I feel this is also how the department of health envisions how leadership will carry forward their NHS improvement plan (DH 2001). However, this is sometimes not always possible and in more challenging times I can become more of a transactional leader. I feel sometimes when I have to pass on objectives that people are resistant to, then “reward and punishment” which is characteristic of transactional leadership comes into force. One example of this was when a member of staff’s competencies was called into question due to consistently producing clinically inadequate test results.

My leadership philosophy is to be a leader who has inspirational qualities and to be credible. This should involve being approachable, hard working, trustworthy, competent and supportive. If I am able to fulfil these criteria then I feel I will have credibility as a leader and or manager. This is what followers expect of a leader (Kouzes and Posner, 1997, p 19-31). The reason for this is because a confident and competent leader will have the ability and capabilities which will be obvious to their followers. They will be able to share their vision which will inspire the staff to follow in their footsteps.

To be a successful leader it is important to self assess and understand about self-knowledge. If one is able to identify their strengths and any areas for development, this will result in being able to set realistic parameters and be able to capitalise on their strengths, interests and capabilities (Bennis, 2003, p47-64).

I have therefore completed an assessment of myself by using the NHS Leadership Qualities Framework 360 Feedback assessment tool (LQF). I have also completed a shortened Myers Briggs Type Indicator (MBTI) to identify my personality type. The LQF is based upon research with over 3,328 participants and is evidence based grounded research with 150 NHS Chief Executives and Directors of all disciplines. This makes it a robust form of assessment (NHS Leadership Qualities Framework 2002).

. My criticism of the LQF would be that you have to carefully select who you feel is able to fill it out in a critical but positive way. I feel that if this is not done it has the ability to skew the percentage scales especially if there has only been small numbers of participants in each group. This creates statistically insignificant results. Finally some of my direct reports felt that the language and questions were quite technical and needed some form of political astuteness and management knowledge, therefore making it difficult to fill out completely accurately.

I have been able to identify key qualities from the LQF which not only fit in with my leadership philosophy but in my role as a leader. Some of these qualities I had no idea I possessed. I appear confident and am approachable, supportive, motivated, focused, determined and a good communicator. I also have the will to see service developments; this is key to the Department of Health’s modernisation and improvement plans (DH 2000). These qualities have been identified by my managers, peers and direct reports. Some of these qualities fit in with being a transformational leader which is clearly what is important to the department of health’s improvement plan. Interestingly some of my needs for development have been identified as not being self-confident, not dealing with disciplinary needs and identifying slipping standards, these development needs all point to a more transactional form of leadership or the more management orientated tasks.

This process (LQF) has forced me to be far more critical and reflective of myself. It has been uncomfortable at times as some of the feedback has been quite damning of my leadership style, however it is apparent that this is an anomaly in the process and not the general feeling from the rest of the participants. It has highlighted to me key strengths that I have aspired to possess, and it has clearly highlighted areas needed for development, some of which I feel I may have been subconsciously aware of. An example of my strengths directly ties in with the department of health’s NHS modernisation programme quote:

“Anyone working in the NHS regardless of their position, grade, qualification or place of work, may be a leader or agent of change and improvement” (DH 2001).

A number of direct reports state I delegate duties well which “allows people to expand their own role in the department. This creates new challenges for people which maintains motivation” (LQF page 44). Other comments relating to this go on to state “this makes people feel valued, able to branch into other areas of expertise and helps to retain staff”.

In this process I have been able to clearly identify key qualities and strengths; however, in order to become a more effective leader some development needs have been identified. In order to achieve this I have created action plans for three areas I would like to work on. Firstly to improve my time management skills, my next plan will be to develop the ability to confront colleagues in a self managed way and finally to increase my self confidence. (Appendix 1)

To enable myself to improve these development needs I have formulated action plans for each. I am going to attempt to use ideas and recommendations from professional consensus but also from the likes of Bennis, Kouzes and Posner, Tracy and Covey all advocators of personal development and leading experts in leadership.

My first action plans objective is to improve my time management skills. The rationale behind this is because poor organisation and time management creates a negative outlook for all groups of people I work with, my peers, direct reports and my managers. It has been stated in the LQF that it “sets undesirable standards to others”. Also objectives can be left too close to the deadline which then creates a rushed and poorly planned outcome which can directly affect the quality of the project. Ultimately the deadline can be missed if other tasks make me have to digress from the original task. Furthermore people have identified that I need to improve my long term planning and “see the bigger picture”, however, this is difficult if I am constantly dealing with the day to day urgent tasks or “Fire-fighting” as quoted by a peer. Having reflected upon my style of leadership and identifying a quality I possess, approachability, I also feel this can hinder effectiveness. I currently operate an “open door policy” and try to be approachable. This causes frequent interruptions and digressions which puts pressure on myself and creates difficulty reaching deadlines.

The strategies I am going to explore are based around Stephen Covey and Brian Tracy’s methods of improving personal effectiveness. Before I set about this I feel I will have to reduce the potential unnecessary interruptions and digressions. Firstly I still want to remain an approachable leader with an open door policy, this, my staff felt was a strength, however, I feel that if I restrict access I will have more uninterrupted time which will make me able to work for longer periods of time and thus reach goals and objectives far more effectively. My first step is to simply close my door between certain hours and ensure that people are aware that if the door is closed I am not available, but I will make staff know that I am available between the hours of 08.00 – 09.00 (dependent on start time), 12.00 – 13.30 and 16.00-17.00.

The next step will be to improve clarity; this is the most important concept in personal effectiveness, if I have absolutely clear goals and objectives, this should improve my productivity and prevent me procrastinating (Tracy, 2004, p7). Ideally I will start to document what it is I want to achieve since this will enable me to visualise what it is I am aiming for. During this process I will set a realistic deadline to achieving my goals, this will give the objective urgency. I will plan ahead, again documenting what needs to be achieved. Finally, something I rarely do will be to take action on the plan immediately (Tracy, 2004, p7). The next step will involve building upon my clarity and identified goals and objectives and will involve planning ahead by working from a list. A short time making a plan of the day ahead will in the long run save time. Therefore I am going to list the tasks or objectives that need to be achieved monthly, weekly and daily, and as I have achieved an objective I will cross it off. Tracy (2004, p14) explains that monthly and weekly lists increases effectiveness and efficiency, and ultimately improves motivation and drive since you are able to visualise your achievements. It is this sense of accomplishment that generates forward motion. This strategy will be a very useful evaluation tool as it will enable me to assess my progress and achievements. This plan of action also fits in with the “Quadrant II” theory where I need to balance my working life between urgent and important issues (Covey, 2004, p150). There are four quadrants (I) important and urgent (II) Important and not urgent (III) not important but urgent and (IV) not important and not urgent. Currently if I reflect upon my practice and what has been highlighted in my LQF I am working in quadrant I. “Jerry spends most of his time “fire-fighting” at work – i.e. he is constantly dealing with the immediate problem rather than getting on top of things and looking ahead and planning better” (LQF, p47). This affects my drive for improvement which is key to the NHS Modernisation and Improvement plan (DH 2000). Covey (2004, p152) states that this leads to stress, burnout, crisis management and “fire-fighting” and therefore lead me to be far less effective and efficient. The idea is to work more in quadrant II where I am dealing with important but not urgent tasks, if I can achieve this then this will impact on having to deal with the urgent and important tasks that prevent me from planning ahead and driving for improvement. Furthermore if I can get into quadrant II, less and less tasks will be urgent and important. An example of a problem that exists at the moment as a result of poor time management and dealing with urgent and important issues all the time is patient discharge letters. I am unable to sit for any length of time and write them, they are therefore mounting up and compounding my inefficiency. If I were to list them on my weekly schedule, then I will be able to visualise the task needs doing. Therefore if I can eliminate the pile that exists, it will be easier to stay on top of the task, one letter at a time is easier and more effective than having to sit down and write ten. Therefore my evaluation tool will be to constantly review my task lists and assess my achievements and work on the objectives that are left outstanding.

The second action plans objective is to look at developing my ability to confront members of staff at all levels in a self managed way. The rationale behind this is because confrontation at work occurs at all levels, meaning that I have to manage confrontation with my peers and direct reports. Confrontation and conflict appeared frequently in my LQF assessment, with comments suggesting I “shy away from it”, “bury my head in the sand”, “let standards slip rather than deal with confrontation” and “do not deal with disciplinary issues to avoid confrontation”. These comments were particularly used by my peers and direct reports. All this fits in with the difficulty I have dealing with conflict management. Conflict is likely when the work place has staff of varying backgrounds (Outhwaite, 2003, p347-375), for example professionals versus semi professionals, which can then lead to perceived status differences making joint working far more difficult. One of my peer comments was to do with the perception that my staff controls me and that I have little control over them. Though I disagree with the majority of this statement, there does appear to be some obvious perceptions within my peers that this is in fact the case.

The strategy to improve on my ability to confront colleagues in a self managed way will concentrate on conflict resolution. My role as a leader is to identify, explore and resolve issues that may be causing conflict, this may be uncomfortable but can only be achieved with perseverance and some degree of risk (Outhwaite, 2003, p347-375).

Confronting my direct reports would be the logical first step, the reason for this is the feedback I received from my peers, suggesting they (direct reports) “control me”. My own direct reports suggested that I dislike confronting them when standards are slipping or when disciplinary issues need resolving (LQF, p 44-45). Return to work interviews after sickness are left or not done, these by no means are a disciplinary action, however if they are not done it gives the opinion that I “do not care”. In line with improving my time management skills, my intention is to immediately list the interview down on my schedule, so that I can visualise the need to do it. If clinical case note standards slip, then I should deal with them immediately also. There was a case when a colleague had written highly inappropriate comments in clinical records that were brought to my attention. I procrastinated far too long in dealing with this, so that when I did eventually confront the member of staff I was met with hostility “Why did you not speak to me months ago”. My staff members were aware of the issue and were uncomfortable that nothing had been done. If feel if I had exercised better assertiveness and had identified, explored and resolved the issue earlier then the outcome would have been more positive for me and my direct reports. I feel the longer issues are left, the more I worry and become less in control. When it comes to the confrontation, I am tense, uncomfortable and out of control. The quicker I can explore and resolve the issue the easier it will be to deal with and I will be moving towards a more self managed way of dealing with confrontation. Furthermore the quicker I act on these types of issues the more it will be a self managed style of leadership, as it will prevent me from being pushed into dealing with confrontation by my direct reports and peers.

Managing confrontation with my peers will employ a more open and honest form of communication (Covey 2004, p 202). Through my LQF and reflection I have identified that with my immediate peers there is differing professional backgrounds and probable peer resentment. It is clear that with both parties small issues and annoyances have been left to “fester”. This then leads to an escalation of bad feeling and antagonism between us all. With the differing professional backgrounds there has always been a differing level of expectation across the workforce. Covey (2004, p 201-202) examines dealing with the issues head on by arranging a series of meetings to mediate and resolve the existing issues and promote a more open and positive working relationship. By taking these steps myself to deal with the current situation, I will be self managing confrontation and will not be forced into having to deal with issues by outside pressures and necessity.

Evaluation of this action plan will again be in the form of scheduling and crossing off achievements, but also reflecting upon the experience.

“Rule: Continuous learning is the minimum requirement for success in any field” (Tracy 2004, p52).

If I can maintain a diary reflecting upon conflicts that have been resolved and concentrate on the problems and not the personalities then I will be moving towards a self managed way of dealing with confrontation. I will be forcing myself to learn from my experiences and be able to identify successful and less successful outcomes and identify why these exist or what it was that was different between each confrontation. I will reflect upon the use of some of my strengths identified in my LQF. Confidence but not arrogance, highly developed communication style and being able to listen, these are all important in dealing with conflict management (Outhwaite, 2003, p 374-375).

My final action plans objective will be to increase my self confidence. The rationale behind this is very personal. Already through my LQF assessment I have learnt that people mostly perceive me as confident and having motivational and inspiring qualities, however, my own personal confidence levels are very poor. Fear of change, conflict and failure is a barrier to my confidence. The LQF assessment showed a very low score for taking calculated risks, this does not surprise me since my direct reports and peers are very unforgiving when it comes to poor judgement and change, even if it was justified. One particular peer is very judgemental regarding failure and slipping standards. My time management skills are in need of further development and a sense of not achieving the balance between non urgent and important tasks (Quadrant II) and constantly dealing with immediate issues constantly chips away at ones confidence levels. Not being able to achieve positive outcomes in conflicts and confrontations needs to be addressed. The more I can succeed and develop the win/win habit the better my confidence will become. It is not about “winning” confrontations and moving forward my way, but more that agreements and solutions end with a mutually beneficial or satisfying outcome (Covey, 2004, p207).

My strategy to improving my self confidence will start by formulating organisational plans and task sheets. When I achieve an objective or project I will cross these of the list and highlight it as an “achieved small win” (Kouzes and Posner, 1997, p 242-265). This creates momentum and the sense of achievement as previously discussed. I will rate key results on a scale of one to ten and identify strengths and weaknesses, the weaknesses can be used to further develop. If I learn from these weakness and train further this will eliminate the feelings of inadequacy and the lack of confidence I have (Tracy 2004, p 51). Key results or completed projects can be discussed with colleagues and appraised by my manager (Tracy, 2004, p 35-40). All these achievements that I have previously never reflected upon will start to give me a sense of confidence and accomplishment I have never previously thought about. On reflection I have assessed my achievements more on a win/lose scenario, but the more I can work towards the win/win habit (Covey, 2004, p 205-234) and pass this on to my direct reports the more I am likely to succeed and become self confident. My direct reports tend to assess accomplishments using the win/lose way, and therefore anything that is achieved must have the outcome of “us” having “won the battle”, it is not surprising that this promotes the lack of confidence and a feeling of inadequacy I have.

Evaluation of this action plan will be to more frequently assess my achievements and accomplishments (Kouzes and Posner, 1997, p 242-265). This will involve assessing my task sheets and my organisational plan which will be done on a daily, weekly and monthly basis. This will help me visualise the tasks that have been completed. The rating of tasks and further training can be assessed by looking at the ratings and assessing if they are improving. This will enable me to build my self confidence. Conflicts and confrontations can be reflected upon and I will be able to better understand the concepts behind win/win. If I can self manage the confrontations and aim for win/win, not only will I be achieving mutually satisfactory benefits and outcomes, but this will be working towards building my self confidence as more and more tasks will be achievable. It will also improve the interdepartmental conflicts and possible peer resentment that has been evident since my LQF.

To conclude, it is obvious that all my action plans link into each other. As I become a more effective and efficient leader, then my peers will have less reason to resent my management style and pressure me into acting upon issues that are troubling them. This will then have the effect of lessening conflicts and confrontations. Furthermore, as I improve my time management skills and lessen the confrontations that occur, this will start impacting on my own self confidence. My own self confidence is directly affected by poorly self managed confrontations and an increasing number of tasks that are left undone or incomplete. It is obvious from my strengths that I have the ability to carry out these action plans and that my staff members are more than willing to take on tasks that are suitable for them as they state “this makes people feel valued, able to branch into other areas of expertise and helps to retain staff”.

The Department of Health is looking for visionary staff members that are able to implement and carry out their modernisation plan. As my leadership skills improve I will be more effective in leading change and envisioning improvements becoming the embodiment of the Department of Health’s modernisation and improvement plan.

The WHO states that “‘‘the aim of therapeutic education (TE) is to teach the patient the adequate know-how. The patient’s TE is a permanent process, which is part of medical care. It includes sensitization, information, learning and psychosocial support, which are all related to the pathology and its treatments. The education should allow the patient and his family to have a better collaboration with the health care professionals’’

Therefore, TE aids patients with chronic conditions to have better understanding of their disease and learn how to manage it. The main goal of TE is to improve the prognosis of the diseases and that can be achieved by reducing both morbidity and complications. Other objective of TE is regarding public health cost. TE offers patients with OA better self-management as a result it reduces medical care attention and because of lesser help from the medical care it reduces the direct and indirect cost. Further studies are needed regarding on the impact of TE in medical cost.

The Haute Autorite´ de sante´ (HAS) in France have outlined the overall and specific goals of TE. Improving the patients’ health and patients’ families’ way of living is the general goal of TE. Patients’ achievement and maintenance of self-care competency or the ability to cope with competency depending on background and experience are the specific goals of TE. TE programs should consider data from evidence-based medicine, as well as recommendations from evidence-based practice. The HAS focuses on the important role of the patients in the implementation of the education activity, the demand for a multidisciplinary team to lead the program, and the need to assess the quality and efficacy of these programs. Educational programs for OA include the ­­­­­­­­­diseases chronic nature, treatment involving pharmacological and non-pharmacological therapy, and lifestyle modification. The educational process must start at the first medical visit, from the diagnosis, and continue after surgical therapy, with rehabilitation being the best time to begin self-care program.

PKQ-OA a questionnaire specifically for OA patient knowledge has been used to assess patients knowledge regarding their condition. When the authors asses the questionnaire, they have found out that there is a wide range of knowledge levels among patients diagnosed with OA, the scores are ranging from 8 to 26 out of 30.Knowledge was not correlated with disease duration or patient’s age or sex; however, the number of years spent in formal education was correlated with high test scores. Most patients know the symptoms of their condition but many methods of joint protection and energy conservation have been reported. Wrong beliefs were identified and common ones are ‘‘OA is caused by cold damp weather’’ and ‘‘blood tests are useful in OA diagnosis’’. Poor knowledge about analgesic were dentified: < 1/3 of patients knew that analgesic should be taken when experiencing pain. Muscle tightening and strengthening exercise are helpful exercise for OA but 13% of patients assumed that housework is included in these exercises. Only 71% of patient knew that maintaining a recommended weight according to their height or taking note of their BMI (Body Mass Index) and age is a helpful way in slowing down the progressions of OA.

Avoidance of activity has been related to musculoskeletal disorders. Fear and anxiety may both contribute to the fear-avoidance model in musculoskeletal disorders. A patient’s interpretation of pain may lead to either of the two:

• An adaptive response, whereby the patient deals with the pain and is more likely to manage it and maintain daily activities that will help achieve functional recovery;
• A non-adaptive response that leads to maladaptive behaviors, including pain-related fear, avoidance, and hypervigilance.

Because of pain patients with musculoskeletal disorders tends to avoid activities for the fear of experiencing it. Now that the patient is avoiding or abstaining from physical activities, this will lead to further disability through unfavorable effects of physical inactivity and weakening of the musculoskeletal system.

TE should be included in the management of OA according to European League Against Rheumatism (EULAR), Osteoarthritis Research Society International (OARSI), and The French College of Physical Medicine and Rehabilitation (SOFMER). EULAR concern patient’s education, physical exercise, technical aids and diet, but do not supply sufficient information regarding non-pharmacological therapies. OARSI insist on the importance of educating patients with hip or knee OA and stating the areas that TE must be stress to patients. Explaining the goals of treatment and the importance of changing lifestyle, such as the importance of exercise, activity adaptations, weight loss and other measures to help the joint(s) are the areas involve in the education. SOFMER highlight the need for educational programs that is design to encourage daily practice of an exercise activity. With these recommendations sufficient details must be supplied for these measures to be implemented, especially patient’s education.

The recommendations created by US National Institute of Health regarding weight loss in OA are commonly used for obesity treatment in TE because no specific recommendation exists for TE regarding weight loss in OA.

According to the literature and international recommendation TE should be included in OA management. The main goal of the education is to change patient’s lifestyle especially regarding physical activity and weight loss. Education must be started from the early stage of OA, as well as the pre- and postoperative periods. Further studies are required to create a better effective educational program for OA, it is either unaided or with the help of other therapies, and measure its cost-effectiveness.

Reference:

Coudeyre, E., Sanchez, K., Rannou, F., Poiraudeau, S., Lefevre-Colau, M.-M. (2010) Impact of self-care programs for lower limb osteoarthritis and influence of patients’ beliefs. Annals of Physical and Rehabilitation Medicine 53, 434–450

Self-management aid interventions that can help patient with OA improve their quality of life. One way to offer self-management to patient with OA is through telephone-based OA management program. In this study conducted by Sperber et. al. the program offers 4 components: phone calls, educational material, setting goals and action plans. Among all the participants more than 80% agreed that each component was helpful and the average rating of overall helpfulness on a scale from 1 to 10 was 7.6. Participants of these program said that this intervention and each components is helpful in managing osteoarthritis.

Participants most frequently mentioned the health educator’s calls (44 of 140, 31%) as the most helpful component of the intervention. The health educators’ phone call aided patients to stay on task with the educational materials and goal setting. With the phone call patients have ease discussing their condition with someone who has knowledge and understand their condition. Also the calls provided them educational benefit by teaching and clarifying information.

Educational materials (written and audio) (20 of 140, 14%) provided patients with information regarding OA and ways how to manage OA better. Audio cassette and easy-to-read references are helpful and with these materials combined with the phone call it will be more helpful for patients with OA. Goalsetting (11 of 140, 8%), setting goal were helpful and and with the consistent phone calls participants takes active role in managing their condition. Participants also commonly said that exercise (42 of 140, 30%) and healthy eating and weight management (20 of 140, 14%) are helpful for managing their osteoarthritis symptoms because implementing these behaviors help them manage their pain levels. But one patient stated that the exercise increase his strength and improves ability to stand up but does not diminish pain.

This study has limitation but these results provide information on planning OA self-management support interventions. These program may target and benefit to some patients with OA.

Reference:

Sperber, N.R., Bosworth, H.B., Coffman, C.J., Juntilla, K.A., Lindquist, J.H., Oddone, E.Z., Walker, T.A., Weinberger, M., Allen, K.D. (2012) Participant evaluation of a telephone-based osteoarthritis self-management program, 2006-2009. Prev Chronic Dis;9:110119. DOI:

http://dx.doi.org/10.5888/pcd9.110119