Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients

Recommendation 1.0: Nurses utilize the “5 A’s” behavioural change approach of assess, advise, agree, assist and arrange, to incorporate multiple self-management strategies when supporting clients with a chronic illness to assist in improved outcomes.

Assess

Recommendation 1.1.a: Nurses establish rapport with clients and families.

Recommendation 1.1.b: Nurses screen for depression on initial assessment, at regular intervals and advocate for follow-up treatment of depression.

Recommendation 1.1.c: Nurses establish a written agenda for appointments in collaboration with the client and family, which may include:

• Reviewing clinical data
• Discussing client’s experiences with self-management;
• Medication administration;
• Barriers/stressors;
• Creating action plans; and
• Client education

Recommendation 1.1.d: Nurses consistently assess client’s readiness for change to help determine strategies to assist client’s readiness for change to help determine strategies to assist client with specific behaviours.

Recommendation 1.1.e: Nurses encourage clients to use health risk appraisal instruments; model use of such tools, and discuss the results of the risk assessment with them at regular follow up.

Advise

Recommendation 1.2.a: Nurses combine effective behavioural, psychosocial strategies and self-management education processes as part of delivering self-management support.

Recommendation 1.2.b: Nurses utilize the “ask-tell-ask” (also known as "Elicit- Provide-Elicit”) communication technique to ensure the client receives the information required or requested.

Recommendation 1.2.c: Nurses use the communication technique “Closing the Loop” (also known as “teach back”) to assess a client’s understanding of information.

Recommendation 1.2.d: Nurses assist clients in using information from self-monitoring techniques (e.g., glucose monitoring, home blood pressure monitoring) to manage their condition.

Recommendation 1.2.e: Nurses encourage clients to use monitoring methods (e.g., diaries, logs, personal health records) to monitor and track their health condition.

Agree

Recommendation 1.3: Nurses collaborate with clients to:

• Establish goals;
• Develop action plans that enable achievement of goals; and
• Monitor progress towards goals.

Assist

Recommendation 1.4.a: Nurses who are appropriately trained use motivational interviewing with their clients to allow clients to fully participate in identifying their desired behavioural changes.

Recommendation 1.4.b: Nurses teach and assist clients to use problem-solving techniques.

Recommendation 1.4.c: Nurses are aware of community self-management programs in a variety of settings, and link clients to these programs through the provision of accurate information and relevant resources.

Arrange

Recommendation 1.5: Nurses arrange regular and sustained follow-up for clients based on the client’s preference and availability (e.g., telephone, email, regular appointments). Nurses and clients discuss and agree on the data/information that will be reviewed at each appointment.

Innovative delivery models

Recommendation 2.0: Nurses use a variety of innovative, creative, and flexible modalities with clients when providing self-management support such as:

• Electronic support system
• Printed materials
• Telephone contact
• Face-to-face interaction
• New and emerging modalities

Recommendation 2.1: Nurses tailor the delivery of self-management support strategies to clients’ culture, social and economic context across settings.

Recommendation 2.2: Nurses facilitate a collaborative practice team approach for effective self-management support.

Recommendation 3.0: Nursing academic programs integrate principles of self-management support education throughout their core curriculum and in continuing education.

Recommendation 3.1: Organizations provide self-management support education through a variety of ongoing professional development opportunities to support nurses in effectively developing skills in self-management support.

Recommendation 4.0: Organizations provide opportunities for nurses to take leadership roles in the provision of self-management support.

Recommendation 4.1: Organizations integrate self-management support values and principles related to fostering client-centered care and therapeutic relationships in the delivery of care. and services, through inclusion in strategic plans and organizational goals.

Recommendation 4.2: Decision makers (Chief Executive Officers, Directors, Managers, Stakeholders) within organizations ensure adequate funding is available for self-management support initiatives such as technology to provide education to clients and nurses.

Recommendation 4.3: Nursing best practice guidelines can be successfully implemented where there are adequate planning strategies, resources, organizational and administrative supports and appropriate facilitation of guideline uptake among clinicians. 

• An effective organizational plan for implementation includes: An assessment of organizational readiness and barriers to implementation, taking into account local circumstances. 
• Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process. 
• Ongoing opportunities for discussion and education to reinforce the importance of best practices. 
• Dedication of a qualified individual to provide the support needed for the education and implementation process.
• Ongoing opportunities for discussion and education to reinforce the importance of best practices. 
• Opportunities for reflection on personal and organizational experience in implementing guidelines.