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XPO Around the Globe

Message Action Plan

November 5, 2017 | Rick Warren

“Pray in the Spirit at all times with all kinds of prayers, asking for everything you need. To do this you must always be ready and never give up. And always pray for all God's people.” Ephesians 6:18 (NCV)

BY DEVELOPING 2 HABITS

“Pray on every occasion, as the Spirit leads.” Ephesians 6:18 (TEV)

“Never stop praying! (Pray all the time!)” 1 Thessalonians 5:17 (GW)

“Seven times a day I praise you!” Psalm 119:164 (NIV)

Action Plan: Try starting every day this week by reading a chapter from Psalms. Pray through that chapter, turning the authors’ words into your prayers.

A DAILY SCHEDULE BUILT ON THE LORD’S PRAYER

Jesus said, “. . .Your Father knows what you need before you ask him. So then, this is how you should pray: 'Our Father in heaven’ . . .” Matthew 6:8-9

“Every good gift and every perfect present comes from your Father of light in heaven . . .” James 1:17

Action Plan: Download the Gratitude list and write down things that you are thankful for for each letter of the alphabet.

“Hallowed be your name . . .” Matthew 6:9b

“Every day I will bless your name, and praise it forever and ever!” Psalm 145:2

GOD SAYS “I AM . . .”

Abba YourLoving Father!

El Deah Your God Who Knows Everything!

Jehovah Rapha Your God who Heals you!

El Shaddai God Almighty – with all the Power you need!

“Those who know your name trust in you, for you, Lord, have never abandoned those who truly seek you.” Psalm 9:10

Action Plan: Email Rick at SCHUTZ Womens Macarena Wedge Sandal Toasted view online G31PKgNk
to receive the list of names of God. Write each one on a 3x5 card and each morning, read 1 card and think about the promise in God’s name.

“May your kingdom come, and may your will be done, on earth as it is in heaven.” Matthew 6:10

“If you seek first God’s kingdom and his righteousness, all the other things will be given to you as well.” Matthew 6:33

“Give us today our daily bread.” Matthew 6:11

I ask for anything I need.

Jesus: “You can ask for anything in my name” John.14:13 (NLT)

“I’d be sinning against the Lord if I failed to pray for you.” 1 Samuel 12:23

“Jesus has the power of God, by which he gives us everything we need to live, and to serve God. We have these things because we know him.” 2 Peter 1:3 (NCV)

Action Plan: Somewhere in your house, create a prayer request list that is visible every day. Write down prayer requests for yourself and others and then write out how those prayers are answered

“Forgive us our sins as we forgive those who sin against us.” Matthew 6:12

“I confessed my sins to you and didn’t try to hide them . . . Then you forgave me and now all my guilt is gone!” Psalm 32:5

“And lead us not into temptation but deliver us from the evil one.” Matthew 6:13

DISCUSSION

Principal findings

The results of this study show that the OPTION scale provides a method of scoring the extent to which clinicians involve patients in the decision making process at the consultation level. Based on the psychometric characteristics reported, we were satisfied that the scale could be used to provide a score for the competence framework we had defined as “shared decision making”. Although there is little overall variance between practitioners, there is considerable variability practitioners, as shown by the differing quartile ranges around their mean scores (fig 2). Some clinicians have a narrower range of scores than others. This may indicate that these clinicians are able to modify their involvement levels across different consultations and to adapt it to the preferred roles of patients in these interactions. This is, however, a conjecture that needs further investigation.

The content validity of the instrument was based on formulating the items from the existing literature, using the results of a series of studies designed to understand how patient involvement can best be achieved in professional practice, followed by subsequent development using an iterative design and assessment cycle. The results with the instrument in this sample of consultations indicate that low levels of involvement in shared decision making are achieved by GPs and that paternalism is the typical “modus operandi” in routine consultations. These practitioners volunteered to take part in a research study on communication skills, and represent those with a high level of confidence in their skills who were aware that we were recording their consultations. Results from other practitioners are likely to be at least on a par or, most likely, lower.

The results indicate that the OPTION instrument achieves acceptable levels of measurement reliability for use in research settings. By focusing on a specific dimension this scale seems to have acceptable levels of reliability compared with similar measures. Stetson Elastic Detail Ankle Boots Black Plum outlet factory outlet visit for sale new styles sale online QdAuCu
Construct validity was supported by a correlation between involvement scores and patient age and the existence of clinical equipoise in the consultation (although the sample was limited); both hypotheses are supported by previous findings. The lack of correlation between involvement scores and sex of the practitioner or success at the MRCGP was not unexpected, given the weak evidence for these hypotheses.

Strengths and weaknesses of the study

The strength of this study lies in the method of instrument development and a rigorous application of scale development procedures. Some weaknesses were however noted during the study. Most consultations in general practice contain more than one problem solving issue and it is impractical to apply the OPTION instrument to every single presenting problem. Raters are therefore required to agree an problem. Guidance is given for this issue in a revised manual. In summary, the problem is chosen for which the prime attention is given during the consultation or for which the clinician achieves the greatest involvement score, as the aim is to score demonstrated not to calculate involvement across all possible decisions. Secondly, parent and child consultations required additional guidelines (advising that the interaction between the clinician and the adult was assessed), and the raters had to judge which was the main patient participant where teenagers were being consulted. It was not possible to estimate concurrent validity (correlation of the measure with some other scale of the concept or trait to be assessed) as there was neither a “gold standard” nor a comparable instrument available. Correlation with patient opinions about their preferred and achieved involvement levels will be reported in further studies from trials conducted in parallel with this validation study.

Psychometric assessment also revealed areas where further instrument refinement is necessary. Item 1 may need to be conceptualised as a “gateway” item in which the assessment of involvement in decision making cannot continue if no agreed problem can be identified. Although item 5 has a relatively high kappa score, the response rate was skewed and the factor loading is low. The item is retained, however, as it asks about a feature (use of risk communications tools) that is known not to occur in current service settings. As interventions to change this situation are being introduced, however, the results are likely to change with time as decision aids are introduced into clinical settings. lowest price for sale Soviet Soviet Callista Hi Casual Mid Cut Lace Up Sneaker Black clearance online ebay outlet collections tumblr cheap online lIxlurz
Item 9 questions whether clinicians “provide opportunities for the patient to ask questions” but it has low kappa scores and a factor loading score below 0.2. This item needs modification and further testing to overcome the variation in scoring judgement. There is also a need to consider changing the scale from one that measures magnitude rather than attitude.

Implications for research and formative skill development

OPTION scores for these routine consultations taken from general practice in a UK setting are low. For some items almost no responses were registered—for example, there was 99.7% disagreement with item 5 which asked if the clinician “checks the patient’s preferred information format”. Further research work in this area will involve presenting information in different formats and it is known that, when practitioners develop the skills of involving patients, there is a tendency for a pendulum effect. Retaining these items and others that reveal skewed or “floor” scores should enhance the ability of the instrument to register change.

The OPTION scale can therefore be used to determine the extent to which clinicians involve patients in clinical decisions. It should be noted that the results show that some practitioners have a wider scatter of scores than others. This result is congruent with the theoretical stance that practitioners should be flexible in their consulting style and adapt to the nature of the problem and the patient preference for participation in clinical decisions, although we cannot be certain that this has occurred. It is noteworthy, however, that these OPTION scores are low and it is anticipated that higher scores will be evident after periods of skill development. The instrument should be used to determine scores at a group level (mean scores) or at consultation levels and not to provide a definitive OPTION score that is taken to be characteristic of that practitioner’s ability, unless attention is given to case mix, sample size, and confidence interval estimation. The responsiveness of the instrument to change (increased levels of patient involvement in decision making after skill development) will be validated in further evaluations. It should be emphasised that this tool is designed as an evaluation of a consultation process. It does not measure patient’s preferred role, their contribution to the consultation interaction (also important), or their perceived levels of involvement or satisfaction. Without this measure of communication we believe that a vital piece of the presumed linkage between patient involvement and improved outcomes in health care is missing.

Implications for practice

In the face of the widespread acceptance that patient centredness is a fundamental goal in clinical practice, and that sharing decisions is one of the key components of this approach, the result of this study confirms that the practice of GPs, as represented by this sample (who are an “above average” sample in terms of MRCGP membership and willingness to participate in this type of research), lies far away from espoused models in books and communication skills courses and, indeed, the wishes of certain patients. Do data from service contexts challenge these espoused models? Are the ideals of patient centredness and involvement in decision making completely unrealistic for day to day service contexts? Given that clinicians are consistently positive about the principles of patient centredness and patient participation in decision making processes, perhaps the issue of skill development is only a small obstacle and the structural constraints, particularly the lack of time and readily accessible and relevant information about the harms and benefits of healthcare interventions, are the true limiting factors. These practitioners volunteered to have their consultations studied but, even so, the results reveal a very limited degree of patient participation. This study, among many others, provides additional evidence for the assertion that successful patient participation demands more time than is currently allocated. Perhaps these results also lend support to others for the need to harness technologies such as decision aids FAAERD Cactus Repeated Mens Breathable Mesh Walking Sneakers Air Cushion Sports Shoes Breathable Athletic Running Shoes discount fake online sale online buy cheap official nbVF8Rrl
so that consultations have firmer foundations for partnerships.

Key messages

The OPTION scale provides a method of scoring the extent to which clinicians involve patients in the decision making process at the consultation level.

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