Abstract WP374: A nurse dyad model for collaborative action planning and goal attainment to support patient self-management of stroke risk factors

Background and Purpose: Patient self-management (SM) of stroke risk factors is critical to prevent second stroke. Development of an action plan to reach behavior goals is established for chronic disease SM. In collaborative planning, patients identify a goal and then a healthcare provider helps develop action plan to attain the goal. We pilot-tested a model where nurses in stroke ward and in primary care worked as dyads to support stroke patients in setting goals. Nurses have been identified as front line health care providers for patient education and SM support. We conducted an IRB approved pilot of a nurse dyad model to determine feasibility of coaching patients in goal-setting and the Goal Attainment Measure for Stroke (GAM-S).

Methods: A pre-experimental, pre/post design was applied. Ten registered nurses and 26 stroke patients were recruited from neurology at DeBakey VA Center. Nurses delivered one-on-one educational sessions to patients admitted with stroke and set goals and action plans in patients’ medical records. Nurses in primary care clinic called patients 2-weeks after discharge to evaluate goal attainment, which was documented and scored using GAM-S. The GAM-S components are scored as, 2 = attained, 1 = partially attained, and 0 = not attained.

Results: Twenty six patients were enrolled: 24 males (92%) and 2 females (8%). Mean age was 67 years with 54% White, 34% African American, and 12% Hispanic. Of the 26 patients who completed GAM-S, 57% achieved a maximum total score of 8 for goal attainment. The mean GAM-S score was 6.7.

Conclusions: Implementation of a nurse dyad model for collaborative action planning is feasible and shows promise for engaging patients in self-management of stroke risk factors. Findings will help design a self-management support intervention for stroke survivors using a nurse dyad delivery model.