Many of us occupational therapists feel we already work in a client-centered way and promote self management when working with our clients, including stroke clients. Often we may think we do this, but do we really know what self management means and do we understand the tools and theory that underlines it? Have we done particular training in self management in OT school or during our practice?

This article aims to explain what self management really is and the benefits of using this approach in stroke rehabilitation. It provides some easy to follow tips on how to promote the approach in practice and explore some of the obstacles to its implementation.

What Does Self-Management Mean?

The ultimate goal of self management is to encourage patients to own and control the rehabilitation process. It is defined as:

“The actions individuals and caregivers take for themselves, their children, their families and others to stay fit and maintain good physical and mental health; meet social and psychological needs; prevent illness or accidents; care for minor ailments and long term conditions; and maintain health and wellbeing after an acute illness or discharge from hospital” (UK Department of Health, 2005).

The Agency for Healthcare Research and Quality refers to self management as helping clients to make good choices and sustain healthy behaviors.

We know that long term conditions, such as stroke, are the leading cause of death and disability worldwide. Health and social care help when symptoms worsen but mostly people and their families are responsible for making decisions and influencing their own wellbeing. There is evidence demonstrating that often needs are unmet in the longer term post-stroke (McKevitt, 2011) and that stroke is a sudden event; therefore adjustment may be different than for other long term conditions.

What Does Self Management Entail During Stroke Rehab?

Supporting self-management involves educating people about their condition and care and motivating them to care for themselves better. It can be viewed in two ways. As a portfolio of techniques and tools that help clients choose healthy behaviors; and a fundamental transformation of the client–caregiver relationship into a collaborative partnership.

Self management facilitates behavior change and supports self efficacy (a person’s confidence about looking after themselves). It’s more than just information provision, it’s about active goal setting and using behavioral change interventions.

Social cognitive theory underlines the self management approach. The theory includes the concept of self efficacy which can influence motivation and health behaviors by determining the goals people set, how much effort they invest in achieving those goals and their resilience when faced with difficulties of failure. Self efficacy is supported to develop by encouraging mastery experiences, vicarious experiences/modelling, physiological/internal feedback and social persuasion/information from a credible source.

How Does Self Management Help Our Clients?

Literature shows that the idea of helping people to help themselves which involves proactive and behaviorally focused self-management support designed to increase self-efficacy, can have a positive impact on people’s clinical symptoms, their attitudes and behaviors, their quality of life and on patterns of people’s healthcare resource use.

American controlled clinical trials quoted on the agency for healthcare research and quality website indicate improved clinical outcomes for patients involved in self management programs compared with those involved in information only patient education. Another study shows increased self efficacy and more participatory decision making as outcome of self management approach being used.

What Are the Components of Self-Management?

These include:

• Involving people in decision making.
• Emphasizing problem solving rather than giving people direct answers.
• Promoting healthy lifestyles and educating people about their conditions.
• Developing care plans as a partnership between clients and professionals.
• Setting goals and following up on the extent to which these are achieved over time.
• Helping people to monitor their symptoms and know when to take appropriate action.
• Helping people to manage the social, emotional and physical impacts of their condition.
• Proactive follow up.
• Providing opportunities to share and learn from other service users.

What Can Occupational Therapists Do to Promote Self-Management in Stroke Clients?

Below are some strategies and tips that can be used by OT’s in everyday practice to promote self management:

• Spend time with clients understanding their priorities, what is important to them and their personal circumstances.
• Ask clients about their hopes and fears and use these to direct intervention and tap into their motivation.
• Support the client to set small targets that are in their own words.
• Help clients to focus on small things in the here and now that they can change. Ask “What is one small thing that is going to be different the next time I meet you?”
• Use success stories from the client’s past to help with tackling future challenges. -Support clients to monitor their own change versus therapist lead feedback on perceived changes.
• Help to build the client’s self efficacy by reflecting on feelings of personal success. -Educate clients about their condition.
• Support the client’s self discovery by helping them engage in activities where they learn about themselves, including what they can do and what is difficult. This helps provide opportunities for mastery experiences.
• Support clients to build on the person and family and friends skills, support and existing experiences.
  Help clients to use peer and social support networks to build confidence and insight via vicarious experiences.
• Help clients to take action by asking reflective questions such as “how did you manage previously when you managed to make a change/overcome a difficulty” or “What is one small step you can make that will help you feel you are moving forward?”

Self management is not just for patients post-hospital/chronic phase of a condition and is not just for motivated, high-functioning or health-literate people. It’s not focusing on SMART goals led by clinicals and is not an add on to therapy. It needs to be incorporated into each patient interaction to succeed.

What are the Obstacles to Self Management?

In an article by Norris & Kilbride (2013) whilst exploring self management in stroke, it was acknowledged there were various obstacles to self management which need addressing. They included professional models, practice and expectations.

Institutional demands and perceived wishes of some stroke survivors. Therapists who were part of the study reflected that during their professional training they developed a sense that the expectation was that the therapists hold the knowledge. They also felt that the initial medicalization of the stroke at the acute stage created a sense of dependency of the client on professionals.

The issue of time was a large obstacle to promoting self management along with the issue of some stroke clients expecting the professionals to make them better. Therapists highlighted concerns when the stroke survivor had difficulties with making decisions and with balancing supporting clients to take risks to develop insight.

Therefore, we need to call for self management to be part of a wider initiative to improve care through educating occupational therapy practitioners and applying best evidence to our practice. More consideration of these obstacles needs to be considered for self management to be taken up across the board.

Further Resources and References

• Norris & Kilbride, 2014. From dictatorship to a reluctant democracy: Stroke therapists talking about self-management. Disability Rehabilitation. 36(1): 32-8 https://pubmed.ncbi.nlm.nih.gov/23594054/
• Mckevitt et al. 2011. Self reported long term needs after stroke. Stroke. 42(5):1398-403 https://pubmed.ncbi.nlm.nih.gov/21441153/
• The Health Foundation. Evidence: Helping people to help themselves. A review of evidence considering whether its worthwhile to support self management. May 2011.
• Agency for Healthcare Research and Quality, “Why is Self management Important?” https://www.ahrq.gov/ncepcr/tools/self-mgmt/why.html
• Pearson ML, et al. 2007. Patient Self-Management Support Programs: An Evaluation. Final Contract Report (Prepared by RAND Health under Contract No. 282-00-0005). Rockville, MD: Agency for Healthcare Research and Quality; November 2007. AHRQ Publication No. 08-0011.
• Kanaan SB. 2008. Promoting Effective Self-Management Approaches to Improve Chronic Disease Care: Lessons Learned. Oakland: California HealthCare Foundation; Available at: http://www.chcf.org/publications/2008/04/promoting-effective-selfmanagement-approaches-t o-improve-chronic-disease-care-lessons-learned
• Bodenheimer T, Lorig K, Holman H, et al. 2002. Patient self-management of chronic disease in primary care. JAMA 20;288(19):2469-75.