/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/cpg/,/clinical/cckm-tools/content/cpg/npg/,

/clinical/cckm-tools/content/cpg/npg/name-111779-en.cckm

20170118

page

100

UWHC,UWMF,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Clinical Practice Guidelines,Nursing Practice Guidelines

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

Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Nursing Practice Guidelines


Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 11/2016EArsenaultknudsen@uwhealth.org
1
Guideline Title: Strategies to Support Self-Management in Chronic Conditions: Collaboration
with Clients
Effective Date: November 2016
Approved By: Nursing Practice Guidelines Committee; Nursing Practice Council
I. Guideline Overview
This content is extracted from the adopted source document: Registered Nurses’ Association of
Ontario. (2010). Strategies to Support Self-Management in Chronic Conditions: Collaboration with
Clients. Toronto, Canada. Registered Nurses’ Association of Ontario. Please refer to the source
guideline for complete information.
Target Population:
[This guideline] … is intended for nurses who work in a variety of practice settings across the
continuum of care.
Nursing Practice Guideline Objectives
The purpose of this guideline is to provide evidence-based recommendations for Registered
Nurses … in self-management support. These recommendations identify strategies and
interventions that enhance an individual’s ability to manage their chronic health condition.
Guiding Principles
The guiding principles of this guideline on self-management supports follow the tenet that they
are client-led, nurse-facilitated processes (i.e., the client sets the agenda by driving
interactions and action plans). Furthermore, client and family participation is paramount. Care
strategies must be tailored toward the attitudes, beliefs, culture and preferences of client, and
a shift of power must occur from health care provider to client. This can be achieved through
the establishment of a therapeutic relationship and a focus on client-centred care.
Key Assumptions
The recommendations within this guideline are based on the following key assumptions:
1. While clients may need information and support to self-management about their health
state, they are ultimately in control of these important self-management decisions.
(Bodenheimer, Lorig, Holman, Grumbach, 2002).
2. The client’s need for support with decision making specific to their self-management is
variable and should be individually tailored.
3. Information and support for clients related to their self-management should promote care
consistent with scientific evidence and client preferences.
4. Collaborative relationships with clients and their families are critical to the success of self-
management support.
5. Self-management options depend on individual client’s circumstances, and availability of
resources.
6. This BPG is intended to promote the provision of evidenced based care of the highest
quality related to decision and self-management support for adults with chronic health
conditions.
7. Nurses are one of several health care provider groups that are involved in providing self-
management support.
University of Wisconsin Hospitals and Clinics
Nursing Practice Guideline At-a-Glance

Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 11/2016EArsenaultknudsen@uwhealth.org
2
II. Practice Recommendations
The RNAO has organized the recommendations with the following headings, please click on the
hyperlink to go directly to each section.
ξ Assess
ξ Advise
ξ Agree
ξ Assist
ξ Arrange
ξ Innovative delivery models
ξ Educational recommendations
ξ Organization and policy recommendations
RNAO
Recommendation
Number
RNAO Recommendation
(see full guideline for complete list of recommendations)
Type of
Evidence
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.
Ia
ASSESS
1.1.a Nurses establish rapport with clients and families. III
1.1.b Nurses screen for depression on initial assessment, at regular
intervals and advocate for follow-up treatment of depression. Ib
1.1.c
Nurses establish a written agenda for appointments in
collaboration with the client and family, which may include:
ξ Reviewing clinical data
ξ Discussing client’s experiences with self-management
ξ Medication administration
ξ Barriers/stressors
ξ Creating action plans
ξ Client education
IIb
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.
III
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.
Ib
ADVISE
1.2.a
Nurses combine effective behavioural, psychosocial strategies
and self-management education processes as part of delivering
self-management support.
Ia
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.
III
1.2.c
Nurses use the communication technique “Closing the Loop”
(also known as “teach back”) to assess a client’s understanding
of information.
III
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.
Ib

Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 11/2016EArsenaultknudsen@uwhealth.org
3
1.2.e
Nurses encourage clients to use monitoring methods (e.g.,
diaries, logs, personal health records) to monitor and track
their health condition.
III
AGREE
1.3
Nurses collaborate with clients to:
ξ Establish goals;
ξ Develop action plans that enable achievement of goals;
and
ξ Monitor progress towards goals.
Ia
ASSIST
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.
Ia
1.4.b Nurses teach and assist clients to use problem-solving
techniques. Ia
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.
Ib
ARRANGE
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.
Ia
INNOVATIVE DELIVERY MODELS
2.0
Nurses use a variety of innovative, creative, and flexible
modalities with clients when providing self-management
support such as:
a) Electronic support systems
b) Printed materials
c) Telephone contact
d) Face-to-face interaction
e) New and emerging modalities
IIb
2.1
Nurses tailor the delivery of self-management support
strategies to clients’ culture, social and economic context
across settings.
IIa
2.2 Nurses facilitate a collaborative practice team approach for
effective self-management support. Ib
EDUCATIONAL RECOMMENDATIONS
3.0
Nursing academic programs integrate principles of self-
management support education throughout their core
curriculum and in continuing education.
IV
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.
IV
ORGANIZATION AND POLICY RECOMMENDATIONS
4.0 Organizations provide opportunities for nurses to take
leadership roles in the provision of self-management support. IV

Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 11/2016EArsenaultknudsen@uwhealth.org
4
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.
IV
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.
IV
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:
ξ An assessment of organizational readiness and barriers
to implementation, taking into account local
circumstances.
ξ Involvement of all members (whether in a direct or
indirect supportive function) who will contribute to the
implementation process.
ξ Ongoing opportunities for discussion and education to
reinforce the importance of best practices.
ξ Dedication of a qualified individual to provide the
support needed for the education and implementation
process.
ξ Ongoing opportunities for discussion and education to
reinforce the importance of best practices.
ξ Opportunities for reflection on personal and
organizational experience in implementing guidelines.
IV
III. Pertinent Resources
A. Policies
ξ UWHC Departmental Policy 8.0, Patient and Family Centered Care
B. Patient Education Resources
ξ Health Facts for You #4377: Tips for Talking With Your Health Care Provider
ξ Health Facts for You #6585: What Is Stress and How Can I Relieve It?
ξ Health Facts for You #7523: Healthy Changes: Setting Goals & Making Plans
C. Clinical Tools
ξ Person and Family Centered Care Nursing Practice Guideline
ξ Facilitating Client Centred Learning Nursing Practice Guideline
ξ TRIP: Person-Centered Care and Communication
ξ Agency for Healthcare Research and Quality, Health Literacy Universal Precautions
Tool Kit (includes content on teach-back, self-management, empowerment, and
support systems)
ξ Institute for Healthcare Improvement, Partnering in Self-Management Support: A
Toolkit for Clinicians
ξ UW Health Transitions in Care Program
ξ Pediatric Complex Care Program
ξ Complex Case Management Program
IV. References
See full guideline document for list of references.

Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 11/2016EArsenaultknudsen@uwhealth.org
5
V. Rating Scheme For The Strength Of The Recommendations
Types of Evidence
Ia Evidence obtained from meta -analysis or systematic review of randomized controlled
trials.
Ib Evidence obtained from at least one randomized controlled trial.
IIa Evidence obtained from at least one well -designed controlled study without
randomization.
IIb Evidence obtained from at least one other type of well -designed quasi - experimental
study, without randomization.
III
Evidence obtained from well -designed, non-experimental descriptive studies, such as
comparative studies, correlation studies and case studies.
IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities