Supporting Self-Management

NURS 3001
Week 4
Learning Focus Today

CONCEPTS
CONTEXT: COPD APPLYING BEHAVIOUR CHANGE
SELF-CARE
THEORIES
SELF- MANAGEMENT
ASSESSING READINESS
BEHAVIOURAL DETERMINANTS
USE IN PRACTICE
SHARED DECISION MAKING
 Definitions
What is self-care vs self-management?

Self-care – Broad view of supporting health through health promoting practices.

Health activities related to what individuals, families and communities do for themselves to
promote, maintain health, or address illness. Comprehensive of promotive, preventive, curative,
and rehabilitative care
Self-management – Chronic illness specific
Managing chronic illness day-to-day. This includes caring for emotional and physical health needs,
as well as managing the changes that occur as a result of their disease process, and over the
course their illness.
Self-Care and Chronic Illness
Concept Analysis: Tulu et al. (2021)
Self Management
Self-management is both a process and an outcome

Processes: engaging in education, receiving support,

Outcome: when people with long-term conditions achieve the skills

and knowledge to manage the medical, emotional, and role aspects of
their illness.
Self-Management
5 Core Processes
Problem
The individual, family and carers, and health Solving
professionals share information, understand the
individual's goals and create an action plan that
guides care at home and in the clinical setting. Taking Decision-
action making
Principles of self-management that help
collaboration are:
• define the issues
• set goals and problem solve
• provide active, sustained follow-up.
Partnerships
Resource
with
utilization
providers
Individual and Family Self-Management theory
Self-Management and Family Management Framework
 Framing Behaviour Change

• Behaviour change practices are influenced by an assumption that the behaviours impacting how health
and well-being are shaped, are modifiable and can be adapted.
• Although modifiable health behaviours are recognized as a major influence in the management of chronic
conditions, there are several barriers to effective behaviour change.
• Insufficient of support
• Healthcare silos and poor communication
• Individual health competencies
• Functional abilities
• Socio-environmental factors
• …..and more
• To meet the real needs of persons living with chronic diseases, healthcare professionals need education
fostering the development of behaviour change competencies, often rooted in behavioural science.

(Henriques & de Sousa Loura, 2023)

 Behavioral Determinants
Chronic diseases involve a complex interplay between genetic,
physiological, environmental and behaviour determinants. The health-
related decisions that people make will impact on their health outcomes.

Behaviour determinants are factors that influence the behaviour, either

in a positive or in a negative way à facilitators of and/or barriers to
achieving the health behaviour or not.
attending appointments,
↳

getting recommended screenings

-

Example Theory: COM- B Model (Michie et al., 2011)

This model groups determinants into three major categories:
• Capability - physical and psychological
• Motivation - reflexive and automatic
• Opportunity - social and physical

(Henriques & de Sousa Loura, 2023; Rafael Henriques et al. 2023)

 Theories and tools support the
Behaviour pathway of change and help us
Change Theories work with behavioural
determinants to.

• Identify what changes are needed

• Assess barriers and facilitators to those changes
• Develop specific actions
• Use effective motivating technique Integration Cognition

• Evaluate the change

 Shared Decision Making
Takes place in a trusting
relationship where there is a
partnership between the
provider and the patient.
(Truglio-Londrigan & Slyer,
2018)
Components: a process,
Facilitated by a collaborative
sharing best available
bi-directional mutual
evidence, support to
exchange of information and
consider options, informed
discussion involving
preference (Elwyn et al.,
negotiation (Truglio-
2012), joint arrival at health
Londrigan & Slyer, 2018)
care choice.

Shared decision making is a process that aims to have the health care professional and the patient jointly arrive at a health
care choice that is based on the best available research evidence, clinical expertise, and the values of the informed patient.
 Chronic Obstructive Pulmonary Disease (COPD)
• It is estimated that 1.6 million Canadians' live with COPD,
and believed that as many live with it but aren’t
diagnosed (Ontario Lung Association, 2022)
• COPD is the fifth leading cause of death in Canada. In
2016/17, COPD exacerbations were responsible for nearly
For Your 90 000 admissions to Canadian hospitals — more than any
other disease — with an average stay of 7 day (Flegel &
Stanbrook, 2018)
Reference – • Cigarette smoking is the most common risk factor causing
about 80-90% of cases (OLA, 2022)
• Generally, a slow progressing and debilitating disease
characterized by persistent airflow limitation associated
with an abnormal inflammatory response of the lungs
(British Columbia, 2017)
• Assessment of COPD based on patient’s level of
symptoms, risk for exacerbations, severity of spirometry
abnormality and the presence of comorbid conditions
(Gulanick & Myers, 2022)
 COPD Management

Therapeutic Goals Priority Areas for Lifestyle Common Comorbidities

Management

• To alleviate breathlessness and other • Cardiovascular diseases

respiratory symptoms that affect daily • Smoking cessation
• Lung cancer
activities • Physical Activity
• To prevent and reduce the frequency • Respiratory Services • Sleep apnea
and severity of acute exacerbations • Diet Considerations • Osteoporosis
• To minimize disease progression and • Air Quality • Diabetes
reduce the risk of morbidity/mortality
• Oxygen Therapy • Gastroesophageal reflux
• To optimally manage comorbidities to
reduce exacerbations and COPD • Immunization • Anxiety and Depression
symptoms related to comorbidities • Advanced Care Planning

(Agusti, 2023; British Columbia, 2017)

 • Use shared decision-making, accounting for patient
preferences and capabilities

COPD: • Include a chronic disease and self-management

approach facilitated by health professionals
Developing the • can significantly improve health status and
reduce hospital admissions for exacerbations
patient’s therapeutic by 40%
goals and management • Use non-pharmacological and pharmacological
plan interventions based on the individual patient’s
level of severity
• Simplify the medication regime in the context of
other conditions and treatments
• Review the treatment approach regularly

(British Columbia, 2017)

Examples of Health Behaviours/
Self-Management in Chronic Diseases

Health behaviours are not

only about preventing illness.
They are also essential in self-
management once the
disease has begun.

Tertiary prevention
Up Next: Applying Behaviour Change

Theories: Assessing Readiness: Use in Practice:

Social Cognitive Theory Transtheoretical model Motivational Interviewing
Health Belief Model (Stages of Change) 5 A’s Model
Health Belief Model
Main Proposition: Proposes that the likelihood of
an individual taking recommended health actions
is based on
• the perceived severity of the illness
• the individual’s estimate of the likelihood that
a specific action will reduce the threat, and
• perceived barriers to following
recommendations

Self-efficacy
(Lubkin, 2019)
Social Cognitive Theory
Main Proposition: Proposes that
behavioral, environmental, and personal
factors interact to determine each other –
this is called triadic reciprocity.

Self- efficacy is considered instrumental.

(Henriques & de Sousa Loura, 2023)

(Main, 2023)
Transtheoretical Model
Main Premise: Proses that individuals move through six stages to
making intentional change. This model focuses on the decision-
making processes of the individual.
 Adherence is the term used on the global
Adherence stage of health care delivery for how well the
patient manages the treatment plan

What factors influence nonadherence?

Avoid Use Instead Rationale

Person-Centered

(Afonso Miguel Cavaco et al. 2023).

 What are potential
practical limitations to
behaviour change
models and theories?
“
Motivational
Interviewing
Motivational Planning Engaging

Interviewing Evoking Focusing

Assumptions:
• Clients have an inherent drive toward health and wholeness
• The client is the expert about how to change their
circumstances
• The client’s experience of choosing and investing in their
intended change is critical to success
(Moyer, 2014)
 Processes of MI

• Understanding of the patient's point of view as a

Engaging way to develop a working alliance with them.

• The process of developing one or more clear

Focusing goals for change.

• Calling forth the patient’s own motivation for,

Evoking and ideas about, change.
Want to learn more? Here is a detailed guide to
motivational interviewing:
• The collaborative development of the next steps https://www.drugsandalcohol.ie/17873/1/Motivati
Planning that the individual is willing to take onal_Interviewing_brief_guide.pdf
(Chang, 2017)
What to DO and NOT DO in Motivational Interviewing
 “
• “MI is not a technique for tricking
people into doing what they do not want
to do. Rather, it is a skillful clinical style
for eliciting from patients their own good
motivations for making behaviour
changes in the interest of their health. It
involves guiding more than directing,
dancing rather than wrestling, listening
Motivational
at least as much as telling. The overall Interviewing
“spirit” has been described as
collaborative, evocative, and honouring
of patient autonomy (Rollnick et al.,
2008, p.6).”

• - Lubkin, p 47
“

(Tseng, et al., 2022)

5A Model of Health Adjustment and
Behaviour Change
A framework for supporting self-
management used to develop a
personalized, collaborative action
plan that includes specific
behavioural goals and a specific plan
for overcoming barriers and reaching
those goals.

• Assess
• Advise Personalized
• Agree Action Plan
• Assist
• Arrange
Example:
Quitting
Smoking
World Health Organization
(2014)

(GOLD, 2020)
 Coaching as a technique to enhance self-
Nursing Practice and management and family management

Self-Management
Medication and treatment self-management

Assessment
Nursing care coordination, technology, and
Supporting Change medication self-management
Organization

Resources and supports

Interprofessional Collaboration
Looking ahead to Week 5

Lecture time:
No seminars
Mid-term test
What should you expect
in the midterm exam?

• Use of Scantron – bring a pencil

• Questions:
• Multiple Choice (24) - 1 mark each
• True/False Questions (5) - 1 mark each
• Scenario-based question (3) – 1 mark each
• Matching: 2 sets of 4 questions (8) – 1 mark each

• Total of 40 marks and is worth 20% of the final grade.

• Time for completion: 90 minutes
Content of Questions
Covers the first four weeks including
lectures, seminars, and main
readings.

• Key concepts and sub concepts

• Knowledge and recall
• Application
• Use of nursing knowledge including
• Decision making
Practice Example:
Multiple Choice
Claire is a patient with cervical cancer who presents
to the chemotherapy clinic. In a discussion with the
nurse, Claire states: "Last month, each time I came
here for my chemo, the other nurse refused to care
for me. I feel that she's blaming me for my cervical
cancer." This is an example of:

a.Diminished self-worth
b.Experienced Stigma
c.Character Blemish
d.Internalized Oppression
Practice Example:
Which phrases are incorporated in the definition of
chronic illness (select all that apply).

a. experience of symptoms
b. how a disease is perceived and understood by
individuals and families
c. the pathophysiology of a condition
d. a permanent illness that involves the total human
environment
e. a, b, and d
f. all of the above
Practice Example: Matching
7. The inability to determine, accurately anticipate Response options.
health outcomes or determining meaning Indicate the best answer
associated with a chronic illness.______________ for each definition.

8. Characterized as the ability to navigate a. resiliency

challenging situations and bounce back from
adversity. ________________
b. dignity
9. The value that belongs to every human by c. uncertainty
virtue of being human; which can be informed by
interactions with others. ____________________
d. adaptation
10. Involves specific phases related to a health
event. Reflects the process of moving towards e. Illness trajectory
stability and includes renewing ability to function
with, or adapting to ongoing health changes.
_______________________ f. quality of life
Resources
• Agustí, A., Sisó-Almirall, A., Roman, M., & Vogelmeier, C. F. (2023). Gold 2023: Highlights for primary care. NPJ Primary Care
Respiratory Medicine, 33(1), 28–28. https://doi.org/10.1038/s41533-023-00349-4
• Chang, E. Living with Chronic Illness and Disability. Available from: Pageburstls, (3rd Edition). Elsevier Health Sciences (US), 2017.
• Dobber, J., Latour, C., Snaterse, M., van Meijel, B., Ter Riet, G., Scholte op Reimer, W., & Peters, R. (2019). Developing nurses’ skills
in motivational interviewing to promote a healthy lifestyle in patients with coronary artery disease. European Journal of
Cardiovascular Nursing, 18(1), 28-37.
• Elwyn, G., Frosch, D., Thomson, R., Joseph-Williams, N., Lloyd, A., Kinnersley, P., Cording, E., Tomson, D., Dodd, C., Rollnick, S.,
Edwards, A., & Barry, M. (2012). Shared Decision Making: A Model for Clinical Practice. Journal of General Internal Medicine :
JGIM, 27(10), 1361–1367. https://doi.org/10.1007/s11606-012-2077-6
• Global Initiative for Chronic Obstructive Lung Disease. (2020). Pocket guide to COPD diagnosis, management, and prevention. A
guide for health care professionals. https://goldcopd.org/gold-reports/
• Grady, P. A., & Gough, L. L. (2014). Self-management: a comprehensive approach to management of chronic conditions. American
journal of public health, 104(8), e25-e31
• Félix, I.B., Guerreiro, M.P. (2023). Implementing Behaviour Change Strategies. In: M.P. Guerreiro, I.B.,Félix, & M. Marques (eds) A
Practical Guide on Behaviour Change Support for Self-Managing Chronic Disease. Springer International Publishing.
https://doi.org/10.1007/978-3-031-20010-6_4 pg 58-79
• Flegel, K., & Stanbrook, M. (2018). To keep patients with COPD out of hospital, look beyond the lungs. Canadian Medication
Association Journal, 190 (48) E1402-E1403; DOI: 10.1503/cmaj.181462
• Henriques M. A., & de Sousa Loura, D., Concepts and Theories in Behaviour Change to Support Chronic Disease Self-Management. .
In: M.P. Guerreiro, I.B.,Félix, & M. Marques (eds) A Practical Guide on Behaviour Change Support for Self-Managing Chronic
Disease. Springer International Publishing. https://doi.org/10.1007/978-3-031-20010-6_4. pg. 11- 21
• Johnson, A., & Chang, E. (2017). Living with Chronic Illness and Disability. (3rd Ed.). Elsevier Health Sciences
• Lai, P.-C., Wu, S.-F. V., Alizargar, J., Pranata, S., Tsai, J.-M., & Hsieh, N.-C. (2021). Factors influencing self-efficacy and self-
management among patients with pre-end-stage renal disease (Pre-ESRD). Healthcare, 9(3), 1-
12.https://doi.org/10.3390/healthcare9030266
Resources
• Main P. (2023). Social cognitive theory. Structural Learning. https://www.structural-learning.com/post/social-cognitive-theories
• Michie, S., van Stralen, M. M., & West, R. (2011). The behaviour change wheel: a new method for characterising and designing
behaviour change interventions. Implement. Sci., 6(42), 1–11. https://doi.org/10.1186/1748-5908-6-42
• Rafael Henriques, H., Camolas, J., Pimenta, N., & Mendes, A. Identifying and Assessing Self-Management Behaviours. (2023). In:
M.P. Guerreiro, I.B.,Félix,, & M. Marques (eds) A Practical Guide on Behaviour Change Support for Self-Managing Chronic Disease.
Springer International Publishing. https://doi.org/10.1007/978-3-031-20010-6_4. pg 23 -58.
• RNAO (2010). Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients. https://rnao.ca/sites/rnao-
ca/files/Strategies_to_Support_Self-Management_in_Chronic_Conditions_-_Collaboration_with_Clients.pdf
• RNAO (2017). Integrating tobacco interventions into daily practice. 3rd Ed. https://rnao.ca/sites/rnao-
ca/files/bpg/FINAL_TOBACCO_INTERVENTION_WEB.pdf
• Ryan, P. A., & Sawin, K. J. (2014). Individual and Family Self-Management Theory [Revised Figure]. Retrieved
from https://uwm.edu/nursing/wp-content/uploads/sites/538/2021/05/IFSMT_manuscript_no_copyright_07_31_2019-002.jpg
• Truglio-Londrigan, M., & Slyer, J. T. (2018). Shared Decision-Making for Nursing Practice: An Integrative Review. The open nursing
journal, 12, 1–14. https://doi.org/10.2174/1874434601812010001
• Tseng, M. F., Huang, C. C., Tsai, S. C., Tsay, M. D., Chang, Y. K., Juan, C. L., Hsu, F. C., & Wong, R. H. (2022). Promotion of Smoking
Cessation Using the Transtheoretical Model: Short-Term and Long-Term Effectiveness for Workers in Coastal Central
Taiwan. Tobacco use insights, 15, 1179173X221104410. https://doi.org/10.1177/1179173X221104410
• Toukhsati, S., Jaarsma, T., Babu, A., Driscoll, A., & Hare, D. (2019). Self-care interventions that reduce hospital readmissions in
patients with heart failure; Towards the identification of change agents. Clinical Medicine Insights: Cardiology, 13,
https://doi.org/10.1177/1179546819856855