Wk.

4- The client- Self-Care, Self-management in

Chronic Illness.
Motivational Interviewing(MI) and Modeling, Role
Modeling(MRM)
Chronic disease self-management(CDSM): A
hybrid concept analysis (Miller et al, 2015)
 Self-management programs have improved
some health outcomes such as health status,
QoL & adherence – but changes are short lived
 CDSM is a ‘fluid, iterative process during which
patients incorporate multidimensional strategies
that meet their self-identified needs to cope with
Ch. diseases within the context of daily living’
( Miller. 158)

Self-care in clients with chronic Illness

  Self-care is required for successful management
and control of Chronic Disease. Ch Disease is
the leading cause of disability and death in the
USA( Miller)
 An important concept in in health maintenance,
disease prevention & health promotion.
 Self- care is essential to health in clients with
Ch. conditions living in LTC, retirement, rehab
facilities and during transition from one setting to
the next.

Self-Management in Chronic Conditions

 Self-management defines the tasks that
“individuals must undertake to live well with one
or more chronic conditions” . .
 It may be interchanged with self-care to describe
behaviors that help to maintain physiological
ability” (Kramer-Kile et al, 2014).
 Self-management is a dynamic process in which
client’s manage their chronic illness.

Self-Management
Self-management is a series of negotiated actions
framed by need and that can be both conscious and
thought through or Subconscious and intuitive.
Thus, patients do not solely reply upon medical
expert involvement in order to be able to adequately
self-manage their condition.
(Morden, Jinks, & Ong, 2012, p. 87)

Self-care as a Multidimensional Concept

 Self-care is considered as multiple activities
that prolong active life and prevented functional
decline.
 Reducing risks to illnesses, managing illnesses
and coping with functional limits (Beattie et al,
2003)
- Includes Self-care, professional care, social
network care (Lubben et al, 2003).

Chronic disease self-management(CDSM)

Clients utilize many resources to manage their
chronic disease conditions
- Internal individual characterises- Knowledge,
self-efficacy; self-regulation.

Chronic disease self-management(CDSM)-

Concept Analysis
CDSM consists of the following key concepts:-
- Antecedents-

- Complexity-

- Consequences-
Chronic disease self-management(CDSM)-
Strategies
 Clients use multidimensional strategies to manage
their CDSM .
 Strategies include
o The intrapersonal-

o The interpersonal-

o Environmental systems-
Outcomes of Self-Management Programs
1.Condition Outcomes –
- (morbidity, mortality, physiological markers,
functional status)

2.Individual Outcomes
- (client perceptions: health status, QofL, well
being, connectedness to others, -
transcendence)

3.Family Outcomes
- (i.e. depression in caregivers, family functioning,
caregiver burden)

4.Environmental outcomes
- (i.e. cost reductions, admission rates etc.)
Frameworks -Assessment & Intaervention that
support Self-care in the client:
Consists of
1.Patterson etal -Shifting perspectives
2.Sappington & Miller- Modeling, Role –
modeling theory.
3. Droppa - Motivation Interviewing technique-

The Shifting Perspectives Model-Paterson etal

Living with chronic illness is an on-going, continually
shifting process in which clients experience - - ‘a complex
dialectic between themselves and their world’ ( Miller pg.
23)

Ever changing perspective of the disease enables client's

people to make sense of their experience.

Shift in perspective from the traditional approach of pt. as

client to one of client as partner in care.
Model considers the unique needs, health status of the
individual in a given time frame.
The Shifting Perspectives Model-Paterson etal
Model depicts Ch. illness as an ongoing continually
shifting process.
Model consider both the illness and wellness of the
individual.
Illness is in the Foreground-Focus on sickness,
loss and burden of the chronic illness ;
- Learning about the illness, considerations for
treatment, Disease becomes the persons
identity.
Wellness in the foreground- Self is the identity and
not the disease
- Individual in control, not the disease
- Shift occurs in the individuals' thinking allowing
the person to focus beyond the disease.

2. The Shifting Perspectives Model (Thorne,

2001)
Sappington et al-MRM (Modeling & Role-
Modelling).
The theory of Modeling and Role Modeling(MRM)
enables nurses to care for and nurture each client with an
awareness of and respect for the individual's uniqueness.
MRM Integrates the various ways of knowing in nursing
Science- data collection and analysis
Art-the nurse’s understanding of the client’s perspective of
the world.
By using MRM , the nurse assist the client to attain,
maintain or promote health through purposeful
interventions.

MRM (Modeling & Role-Modelling).

Assessment- Modeling –The nurse seeks to know
and understand the client’s personal model of her\
his world and learns to appreciates its value and
significance.
The client is the expert in her\his lived experienced
of the illness and knows how she\he needs to be
helped. Ex –clients with Obesity.

Sappington et al-Modeling and Role

Modeling(MRM)
5 aims of the Intervention
- Build trust between the client and nurse;
- Promote hope and positive self-esteem
- facilitate client control;
- build on client's strengths,
- negotiate health-directed goals based on client's
model of the world.
MRM includes
- Self-care- knowledge,
- Resources-Internal- physical abilities, genetics, traits,
Growth & Development, cognitive abilities, need
satisfaction;
o External- social support, physical environment,
living arrangements, services.
- Action-

Sappington et al-MRM (Modeling & Role-

Modelling).
 The nurse assesses the adaptive potential in the
client
 There are 3 categories of adaptive potential
- Equilibrium maladaptive-
- Arousal – stress state
- Impoverishment-

Sappington et al-MRM (Modeling & Role-

Modelling).
 Role of Nurse: Facilitator. Understands the clients
unique view of the world.

 RN uses role-modeling interventions that fit with

the client model ;
- promote client’s sense of control over the
environment (internal & external).
- the nurse combines factual knowledge(client's
developmental phase) with understanding of the
client view of the world..

MRM (Modeling & Role-Modelling).

Intervention-
 - Role-Modeling – nurse plans and implements
interventions that are unique for the client;
- Facilitates the client in attaining, maintaining or
promoting health.
- Includes the analysis and nursing interventions
based on the client’s unique needs.
- Nurse engages the client in creative problem-
solving and shared decision making.

Sappington et al-Modeling and Role

Modeling(MRM)
 Essential components of Modeling-role-modeling
o Planning and implementing care- for each client’s
unique needs.
o The nurse does not judge\label\or become
impatient with the client.
o Nurse tries to understand the client from the
client’s view of their illness.
o Nurse builds on the client’s strength to promote
healing
o Promotes the client autonomy-
- Decisional autonomy-
- Executive autonomy-

Sappington et al-Modeling and Role Modeling

Disadvantages of Modeling, role modeling theory

Nurse-

- providing professional support vs providing

personal friendship- Boundaries and boundaries
violation.
- the nurse inability to use the art and science of
the discipline seamlessly- Benner Novice to
expert.

Client-

- their understanding and decision- making

ability.

Motivational Interviewing Supports Patient

Centered-Care (Droppa, 2014)

 Motivational Interviewing (MI) is a

communication approach used by health care
 providers to guide\facilitate change in clients
behavior.
 Focus on empowering client to make decision
regarding their health.

Motivational Interviewing Supports Patient

Centered-Care (Droppa, 2014)

Principles- building partnerships;

o Respecting the client’s autonomy,

compassion;
 o integration of client’s ideas and needs into
the care plan to
o promote self-efficacy;
o Sensitivity to client needs; empathy.

Rollnick and Miller(1995) redefined MI as

o “a collaborative person-centered directive form

of guiding to elicit and strengthen motivation to
change” (pg. 40).
o Ex- clients with Ch. illness and life-style
changes- Hypertension, diabetes, client with
addiction issues.

Intervention- Motivational Interviewing(MI)

o MI- Is Client-centered directional interviewing

methods intended to enhance inherent
motivation of clients towards specific goals.
o The intent is to guide the client to resolve
ambivalence about a specific matter.-Ex
 adherence to medication regimen, diet
modification, smoking cessation etc.
o It occurs through evoking the person’s
willingness, reasons, and desires to change a
behavior.
o It occurs in a relational context, guided by
empathy and acceptance.
o It is primarily concerned with helping clients to
make a decisions to adopt change and improve
their well-being.

Motivational Interviewing Supports Patient

Centered-Care (Droppa, 2014)

o Encouraging patients to set and achieve goals

for health maintenance and disease
management
 o Engaging patients in active (non-
pharmacological) management of chronic pain
o Improving patient’s medication adherence
o Promotion engagement in other evidence-based
behavior changes approaches

Motivational Interviewing Supports Patient

Centered-Care
• MI Communication strategies includes-
• Use of open-ended questions
• Reflective statement
• Summary statements- Ex- I hear that
• Affirmations statements

Motivational Interviewing
Another M1 Technique- DARN
- D-Desire to change
A-Ability to change
R- reason for change
 N- need for change)
Core principles- Expressed empathy, Rolling
resistance( recognize resistance and go with the
flow in the moment)
supporting self-efficacy;

Strategies to support self-management

1. Self-care agency is the capability to care for
oneself and emphasizes physical abilities( p 293) .
2. Self care model( MRM) nursing theory-Self care
health is holistic and not merely the absence of
physical or mental illness.

Factors Affecting Self-Management

• Personal/Lifestyle Characteristics
• Health Status
• Resources
• Environmental Characteristics
• Health Care System
Motivational Interviewing (MI) cont.
• Elements of Motivational Interviewing
a.Relational factor, and
b.Evoking and strengthening a particular
kind of language in the client called
‘change talk.’ Interviewers respond to this
language preferentially hence,
encouraging it in the client.
• Assumptions of Motivational Interviewing
1.Clients have an inherent drive towards health,
2.Client is the expert of their illness experience,
3.Client’s autonomy and client choice are
indispensable and preconditions for success.

Motivational Interviewing(MI)cont.
• Relationship Components in Motivational
Interviewing
• Relationship characterized by acceptance,
empathic understanding, and reflective
 listening skills, and evocative approaches
rather than fact-finding.
• Helping the client unfold the language that is
going to drive him\ her to change.
• HCP does not convey judgment or confront
the client.

• The spirit of Motivational Interviewing include

• Collaboration between provider and client
• supporting the client’s autonomy,
• Nurse uses empathy, acceptance and
compassion