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Self-management Education

Case Study 1: Samir's 5-step Framework

Samir is a 54 year old man who has lived with type 2 diabetes for 10 years. He and his wife Aneela moved to Canada from Pakistan 15 years ago, and they have two children who have moved away from home; one to attend university in Vancouver and the other to return to Pakistan to be married and start a family. Samir and Aneela own a home and a convenience store in Edmonton. The store is open 7 days a week, and they do have help from family members at the store.

This is the self-management story of Samir, as he talks with his diabetes team member about his struggles with a healthy lifestyle. The following pages will take you through some of the steps of the Self-management Education 5-Step Framework with Samir.

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Assess Educate Collaborate Set Goals Follow Up

Self-management Education - ASSESS Part 1

Samir has come into the office to get his annual flu shot. You take this opportunity to inquire about his diabetes self-management, and discuss with him the importance of self-monitoring, adhering to physical activity and dietary regimens, plus taking medications regularly. He thinks he is doing fine as is. What should your next step be?

Question 1: “Self-management? Who cares? Not me.” Which answer is correct?

A.	Give him one small goal to start with.
B.	Send him to see a dietitian to discuss this further with him.
C.	Ask him if you can re-address this at another visit.
D.	Wait for him to bring it up with you at another visit.

Reveal Answer

Self-management Education - ASSESS Part 2

At the next visit, having obtained his permission at his previous appointment, you enquire about Samir’s activity, which consists of some light lifting, some shelf re-stocking and sweeping the store of the floor; otherwise he is sitting or standing at the cash register. Although he doesn’t break a sweat, he thinks that this is a reasonable level of physical activity and does not think that he needs to change this:

Question 2: Your patient doesn’t identify a problem. Which answer is correct?

A.	Suggest some additional activities that you think he should try.
B.	Acknowledge his feelings, and move on to something else.
C.	Explain the dangers and consequences of limited physical activity and ask him to reconsider.
D.	Respect his choice and ask if you can revisit the possibility of working on physical activity at a future encounter.

Reveal Answer

Self-management Education – ASSESS Part 3

You bring up smoking and Samir is agreeable to talking about this. His confidence is high, but he mentions a number of roadblocks (barriers) to implementing his smoking cessation plan. As you propose solutions, he discounts them as soon as you raise them. For example, he knows that he gets irritable if he doesn’t smoke; he’s worried that this is bad for business. And how will he deal with stress if there are lot customers? Also, he’s worried that he will gain weight. You:

A.	Reflect about his struggles with the solutions and ask if this is an action plan he really wants, and ask if he wants to try a different plan.
B.	Reflect about his struggles and suggest an action plan that you think would work better.
C.	Ask him to decide what it is he really wants to do.
D.	Leave the barriers unresolved and hope they work themselves out when he tries to act on the plan.

Reveal Answer

Self-management Education - EDUCATE

In further follow-up visits, Samir updates his Action Plan to include “choosing healthier food choices every day.” In your discussion about his action plan he mentions he would like some information on how to accomplish this goal. What might be an effective way to respond?

A.	“Great! I will make you a list of all the strategies you can use to accomplish these goals.”
B.	“You said you wanted to choose healthier foods, here are some great print materials on meal planning.”
C.	“You mentioned that you are open to some information to help accomplish your goals. In my experience there are a few things that seem to work well for people, would it be alright if I shared some of these with you, and you could decide which might work best for you?”
D.	“I am glad to hear it, choosing healthier food choices can help control your blood sugars and blood pressure.”

Reveal Answer

Self-management Education – COLLABORATE Part 1

Samir has begun the process of communicating his goal setting with you. He provides you with his action plan which includes healthy eating strategies as well as a measurable exercise goal. But when you get to assessing his confidence, he rates his confidence at 4 out of 10. What might you consider next?

A.	Commend Samir for setting up his action plan and tell him to move forward.
B.	Acknowledge his work and explore potential new barriers using open communication skills.
C.	Congratulate Samir but you suggest his action plan needs further fine tuning with your input.
D.	Provide further education materials on exercise planning and healthy eating.

Reveal Answer

Self-management Education – COLLABORATE Part 2

Samir has mentioned potential barriers and opportunities regarding setting goals for walking and, decreasing his smoking, while working long days at his store. His wife walks at lunch, and has encouraged him to quit smoking as well. A team approach may also involve family support to help Samir reach his goal. What may be the best approach to include Samir’s wife to support his goals?

A.	Contact Samir’s wife and review how you think she can support his goals, following permission from him to do so.
B.	Assess with Samir whether this is an appropriate time to encourage family support in achieving his goals.
C.	Set up a tentative walking schedule for Samir using his wife’s current walking program.
D.	Provide a theraband band / exercise pamphlet to Samir and his wife to use on rainy days together.

Reveal Answer

Self-management Education - GOAL SETTING

In subsequent visits, you have helped Samir identify a possible barrier: his fear about increasing activity. He explains that because of all the pills he takes and chest pain he had years ago, he wonders if it’s too late to get healthier. Although he now recognizes the importance of increasing physical activity, he feels he is at a 6 on a scale of 1 to 10 for confidence, because he fears that he may not be able to stay active if the store gets busy and he can’t take a break. You help Samir set a goal for increasing activity in his daily living by using the 5 characteristics of S.M.A.R.T goal setting.

Question 4: Which of the following are the CORRECT response(s)? (there may be more than one)

A.	“I agree with your doctor. You should exercise a total of 150 minutes each week, on at least 3 separate occasions”
B.	“Starting tomorrow, I will try to walk one lap around store every morning, at lunch, and before I leave the store at the end of the day. I will do this until I come back for my follow up visit.”
C.	“I encourage and support your goal – let’s keep track of this goal and set a follow up appointment”
D.	“Well, I agree that your concern about chest pain and low blood sugar is reason enough to leave physical activity alone for a while.”

Reveal Answer

Self-management Education – FOLLOW-UP

You are meeting with Samir for follow up. He mentions that his action plan has not gone as well as he would have liked. His nephew had to reduce his hours at the store and, he has been busier in the store than before. He describes how he is eating “some” meals at work when he has time and has only managed to find time to walk on his only day off when he is not working. One consequence of him working so much is that he finds he does not have time to smoke as much at work. How do you deal with these developments?

A.	Give him more solutions to help him achieve his original action plan. Maybe another person could be hired and he could consider reducing the hours of the store.
B.	Congratulate him on his accomplishments. Work with Samir to create a new action plan and adjust his goals as necessary.
C.	Reinforce how important it is for him to reach the goals in his original action plan; 1 month may not be long enough to achieve the goals he decided upon.
D.	Samir is still not ready to change and he needs to be reminded of what the long-term consequences of his actions on his overall health.

Reveal Answer

Reveal All Answers

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Give him one small goal to start with.	Incorrect. If Samir does not think that the goal that you set with him is important, then setting goals will not be an effective strategy at changing his behaviour.
Send him to see a dietitian to discuss this further with him.	Incorrect. If Samir does not recognize the relevance of self-management to manage his diabetes, he will not be receptive to seeing the dietitian, and unlikely to follow his/her advice.
Ask him if you can re-address this at another visit.	CORRECT. This respects Samir’s autonomy, yet allows you the opportunity to revisit this issue.
Wait for him to bring it up with you at another visit.	Incorrect. Self-management education should be actively promoted (or revisited) at each opportunity.

Reflect about his struggles with the solutions and ask if this is an action plan he really wants, and ask if he wants to try a different plan.	CORRECT. This is the BEST answer. While answer B may work, you are better off giving him permission to abandon the plan and have him generate a new one. If you jump to suggesting a new one for him, he may feel pressured to say "yes".
Reflect about his struggles and suggest an action plan that you think would work better.	Incorrect. This is not the best answer. While it is important for Samir to identify his own goal, this does not open the door for collaboration. Collaboration is needed to help educate and support him to identify the barriers and develop strategies to overcome them.
Ask him to decide what it is he really wants to do.	Incorrect. This is not the best answer. While it is important for Samir to identify his own goal, this does not open the door for collaboration. Collaboration is needed to help educate and support him to identify the barriers and develop strategies to overcome them.
Leave the barriers unresolved and hope they work themselves out when he tries to act on the plan.	Incorrect. While it is important to acknowledge the barriers he tells you about, simply moving away from the discussion to does not leave the door open for more collaborative discussion and planning for him to set other goals and succeed with his self-management.

Commend Samir for setting up his action plan and tell him to move forward.	Incorrect. This may not be best choice. Although it provides positive reinforcement, it does not allow any delving or sorting with what may be a new obstacle or barrier to move forward with his proposed action plan.
Acknowledge his work and explore potential new barriers using open communication skills.	CORRECT. This is the best answer. Open lines of effective communication are necessary to build a foundation of trust, and equal partnership. Working together to realize shared goals should be present in each encounter. Opening the communication door, even a crack, allows the individual an outlet, while at the same time helping remove any negative thoughts from their shoulders. Listening is an art form.
Congratulate Samir but you suggest his action plan needs further fine tuning with your input.	Incorrect. This is not the best answer. This answer tends to dissolve the full collaborative process because one party has 'taken over'.
Provide further education materials on exercise planning and healthy eating.	Incorrect. This is not the best answer. Seizing education opportunities at any interval is important, though you need to be savvy with timing. More effort exploring potential barriers should be a priority before choosing the educational strategy and delivery method.

“I agree with your doctor. You should exercise a total of 150 minutes each week, on at least 3 separate occasions”	Incorrect. This statement sets the goal for the patient, and doesn't allow the patient to identify his own goal and also, it does not communicate accurate information.
“Starting tomorrow, I will try to walk one lap around store every morning, at lunch, and before I leave the store at the end of the day. I will do this until I come back for my follow up visit.”	CORRECT. This is the best answer because Samir set his own goal, which is specific, measurable, achievable, realistic and timely. Answer C is also correct.
“I encourage and support your goal – let’s keep track of this goal and set a follow up appointment”	CORRECT. Support, encouragement and asking Samir write down his goal can help promote reaching that goal. By filling in the Me, My Health and My Diabetes Team > Targets Goals and Results tool and placing it an obvious place, such as a location in Samir’s store that he can see regularly, he has created a reminder that can help promote his desired behaviour change. By setting a follow-up appointment with Samir, and being available to talk with him, you can help support, assess and adjust his goal to increase physical activity. See Target, Goals and Results. Answer B is also correct.
“Well, I agree that your concern about chest pain and low blood sugar is reason enough to leave physical activity alone for a while.”	Incorrect. This response reinforces the patient’s inaccurate knowledge / assumptions and supports his rationale for not building physical activity into his daily routine.