Practitioners who are confident with specific skills around self-management support and behaviour change can make the most of appointments and consultations to support people with long-term conditions to self-manage. We have used the term ‘practitioner’ to cover anyone who is working with someone with a long term condition to help them better manage their own health and work towards outcomes that are important to them.
Research shows that more active support focused on confidence and behaviour works best to improve outcomes. The main techniques that practitioners can use to help achieve this are: agenda setting, goal setting and goal follow up. Together with empathetic and reflective listening skills and open exploratory questions, these enable conversations between individual and practitioner to focus on understanding the person’s perspective and creating the essential background for planning, decision-making and actions.
Romilla Jones, a diabetes specialist nurse, says ‘It’s refreshing to use self-management skills in the conversation… Overall the self-management support approach has made quite a difference to my job: it’s given me more tools to work with and more ways to talk to patients.’
The approach of agenda setting signals from the beginning that the person with a long-term condition is an active partner in their own care and that both parties will take a partnership approach. It can be done within the context of a single appointment or over a course of treatment.
The person is given the opportunity to share what is important to them, their priorities and what they are hoping will be achieved. The person and their practitioner each share what they want to talk about, and then they negotiate what would be the best us of their time together. Diabetes specialist nurse, Romilla Jones, says “I start by asking why they’ve come to the appointment – it re-frames the consultation as being about addressing their concerns…”
When done well, agenda setting means the appointments make the most of everyone’s time, with the person able to raise the things important to them and the practitioner able to talk about what they need to as well. It can also help avoid the occasions when someone only mentions as they are leaving the room at the end of an appointment, the key important issue to them, when there is little time or opportunity to address it.
Lesley Chrysanthou, who lives with diabetes, says of her experience ‘I no longer feel at the mercy of the health service and when I do see a health professional it’s a much more equal relationship”
Goal setting and action planning
In this stage of the appointment or consultation, the practitioner supports the person to identify the goal they want to work towards – such as joining a hobby group, being able to manage activities with grandchildren or cope better around the house – and to break this down into small achievable actions. Dr Shanti Vijayaraghavan says ‘People are living with their diabetes every day, and I only see a snapshot, so unless I understand what’s important to them and work with them to develop a shared plan, they won’t follow it and it’s futile.’
The important components of setting goals are summarised by the SMART method – specific, measurable, achievable, realistic and time-bound – and the evaluation of the goal (covered in our section on goal follow up below).
Overall, the goal should be the choice of the individual and not dictated by the practitioner. Trevor Critchley, who lives with diabetes said, “I talk through targets and goals which feel realistic and desirable to me. I feel I am being listened to and we work together to find solutions to my problems.”
Over time, achieving small incremental goals can help people’s confidence to self-manage grow. However, setting a goal that someone doesn’t feel confident they can achieve can deter them from acting and can exacerbate their general low confidence about managing their condition and their activation level. It is therefore important to explore how confident they feel, and if needs be, why and how to improve that confidence with a modified goal. This is why checking an individual’s confidence about achieving the goal is so essential.
Goal follow up
In subsequent appointments, goal follow up is essential to enable on-going behaviour changes. If the person has achieved their goal, goal follow up is an opportunity to acknowledge and affirm their achievement and start talking about the next goal. This might be maintaining the current goal or increasing it (an extra length or two of the swimming pool this week for example), or the next step if a goal is part of a bigger aim (such as finding out the times of a swimming pool, then asking a friend to join them). If the person hasn’t been successful with their goal, it is important for the practitioner to review with them what happened within good time, to avoid the person dwelling on the sense of ‘failure’ they may be experiencing.
Practitioners can use a range of ways to follow-up with people about their goals, and help them identify community resources that can support them to achieve their goals.
Simple problem solving approaches can help with goal follow up. This might involve checking that the goal is still important to them, and helping them think through alternative ways of achieving it. The diagram below shows one approach to problem solving that practitioners can use.