Be aware of and identify existing factors that could result in further health problems. This includes smoking, nutrition, alcohol, physical activity and stress.

It is paramount to establish a relationship based on mutual trust and respect. Clear explanations, using appropriate language are essential. The ability to listen to and understand the patient’s and carer’s comments is essential in a collaborative process.

Areas for assessment include health beliefs, knowledge, attitudes, behaviours, strengths, barriers, motivation to change, confidence and importance placed on patient’s health. The capacity of the carer should also be assessed.

Involves all personnel who are involved in delivering a care plan for a patient, from the initial planning stages to a pre-determined completion date.

Individuals who have had similar experiences act as excellent role models for those with chronic conditions.

Work that actively encourages individuals or groups to be healthy. The focus is on building health related frameworks, developing action plans and incorporating resources.

Understanding how a patient’s culture may inform their behaviours, values, beliefs and basic assumptions.⁽²⁾ It includes understanding the local community and its needs, and the specific communication skills that are culturally respectful. The art in some instances is to incorporate and to collaborate with cultural and spiritual health providers. The use of an interpreter may be appropriate.

Identify, support and sustain positive aspects of health and use interventions and methods to support the patient and carer.

Models that improve understanding of human behaviour and ways to change it. This includes the choices that individuals make in their lives and processes that can be used to help with change.

A process that can be used to support behaviour change.

A setting which allows open discussion of the patient’s problem and the associated feelings and consequences.

A plan of action which is SMART; specific, measurable, achievable, realistic and timely. Patient goals should be clearly identified and a pathway to achieve them be established.

The ability to assist the patient with problem-solving skills. This includes identifying and analysing an issue, presenting the facts and discussing potential solutions, within the constraints of time and resources.

Establishing working relationships with all professionals related with the patient and establishing roles and responsibilities within the team. It incorporates many skills already mentioned, such as effective communication, to successfully integrate all parties.

A systematic approach to self-management support.

To inform current practice and support positive changes to patient support.

There are a range of techniques that can be used based on theories of organisational change, culture and models of change, group behaviour and values.

The health professional requires an understanding of the evidence that supports their chosen practice.

This includes support services, available resources and activities within the community of the patient and carer.