Supporting Autonomy and Self-Determination

Autonomy means being independent and not relying on others.

Self-determination is the way in which a person controls their life, being able to make decisions that affect their life.

Supporting autonomy

You can help a service user achieve autonomy by supporting them to use their existing strengths to achieve independent or interdependent living.

Several key factors lead to autonomy, such as:

• supportive social networks
• choices
• stable health
• security and income
• good fitness levels
• informal supports
• timely packages of care
• community involvement
• goals
• preventative health measures 
• responsiveness to changes in condition
• assessment and early intervention/treatment of conditions

In our lives, we aim to be as independent as possible, although we may sometimes be dependent/interdependent on others. When people feel they have some control over their lives and can exercise their rights, they are more likely to be independent/interdependent. Autonomy is achieved when there is a balance between interdependence and independence.

Supporting self-determination

Self-determination is promoted through consultation with the tangata and their whānau. Whenever a decision is being made about healthcare and support, it is important to gain input from the recipient. Where possible, they should be able to detail their goals, voice their preferences, and choose the care and support they think will improve their wellbeing. Where cognition or communication is an issue, the whānau may be best placed to identify the tangata’s preferences.

Informed consent

Before agreeing to medical treatment or any sort of support or care, the tangata must provide informed consent. This means they have a clear understanding of the intervention being offered and any risks and benefits associated with it. They can then agree to the intervention under these terms or reject it and ask for an alternative. Note that some people cannot give informed consent, e.g. young children or people with cognitive impairment. In these cases, a guardian or person with power of attorney can provide consent. 

Advocacy

You may need to advocate for the tangata you are supporting. Advocacy is putting forward views or requests on behalf of another person to reach a desired outcome.

An issue requiring advocacy could be cultural, economic, social, legal, or related to support or care issues. It may involve whānau, communities affected by the issue, or other agencies or organisations providing support.

Tools

There are multiple tools that you can employ to support self-determination and autonomy in your clients. These include:

• personal plans
• learning plans
• legislation
• professional development and courses
• health models

What is a personal plan?

One tool used to achieve autonomy and self-determination is the personal plan. All people receiving support in a health and wellbeing setting will have a personal plan (sometimes referred to as a personal wellbeing or personal care plan). This plan will have been developed in consultation with the person and their whānau.

Personal plans outline how an organisation will support the person’s:

• treatment, rehabilitation, medications
• needs and goals
• daily activities 
• independence
• quality of life and wellbeing

The personal plan will outline the tasks and activities with which the person needs support. Support may be:

• physical
• social
• emotional
• health-related

The plan will include details of the planned interventions and care and support practices. Creating and implementing a personal plan will likely involve an interdisciplinary team. The skills and knowledge of each team member will combine to provide coordinated and holistic support for a person.

As a member of that team and as someone who may work frequently with the tangata being supported, it is important that you understand the processes of developing personal plans and the part you play in implementing the plan.

Developing a personal plan

Organisations have differing policies and procedures around developing personal plans. What follows is a generalised example.

Seeking help from a support organisation

The tangata may present themselves to a health or support organisation or be referred to one. Referrals can come from a number of sources, including a GP or hospital, whānau, or another agency already providing support.

Assessment

The assessment may be undertaken by a healthcare professional, an assessment unit within a healthcare provider or a Needs Assessment Service Coordination organisation (NASC). The assessor will determine the appropriate support and identify organisations that can provide that support.

Support provider plan development

Once the person has been referred to a support provider, that provider will perform its own assessment. This will identify the needs to be met and the best ways to provide that support. The personal plan is created based on this analysis.

Implementation

Implementation refers to putting the personal plan into action. It involves executing the strategies, interventions, and services outlined in the plan to address the person's identified needs. This phase requires collaboration among healthcare professionals, caregivers, and the care recipient to ensure the plan's components are properly executed. Implementation may involve the following:

• Providing medical treatments, therapies, and medications as prescribed.
• Assisting with activities of daily living (ADLs) and instrumental activities of daily living (IADLs).
• Facilitating social interactions, engagement in hobbies, and community activities.
• Monitoring and recording progress, changes, or challenges.
• Adapting the care environment for safety and accessibility.
• Communicating and coordinating with all relevant parties to ensure seamless execution.

Review

Regular reviews are essential to assess the effectiveness of the implemented strategies and interventions. Reviews involve evaluating whether the personal plan's goals are being achieved and if any adjustments or modifications are necessary. The review process may include the following:

• Periodic assessments of the person's physical, emotional, cognitive, and social wellbeing.
• Gathering input from the tangata, whānau, and involved professionals.
• Analysing any changes in the person's condition, preferences, or circumstances.
• Identifying areas of success and areas requiring improvement.
• Considering feedback and insights from caregivers and healthcare providers.

Update

Updating the personal plan involves making necessary changes based on the review's findings. Plans should be flexible and adaptable to accommodate the person's changing needs. Updates may include the following:

• Modifying interventions or services to better align with the person's evolving requirements.
• Setting new goals or adjusting existing ones.
• Incorporating new medical information, treatments, or medications.
• Altering the care environment to address safety concerns or changing mobility needs.
• Revising the plan to reflect the person's preferences and choices.

Incorporating these stages ensures that care remains responsive, customised, and effective over time. Regularly implementing, reviewing, and updating personal plans improves the person's quality of life and demonstrates a commitment to providing compassionate and comprehensive care that evolves along with their needs.

Personal planning example

The following case study contains details about a tangata receiving community care and the personal plan created by her service provider. Note that this is a general example; every organisation will have their own personal plan format.

What are learning plans?

A learning plan is another tool to support autonomy and self-determination. Learning or relearning skills can be a powerful tool to encourage client autonomy. Your client may need to learn a new method, such as a different way of getting up from a chair. Or they may need to learn to use a new piece of equipment, such as a walking aid.

As people learn one thing, it can build into another. For example, people might learn how to use a new motorised scooter which enables them to go into town to do their own shopping with confidence, make their own appointments, and visit friends. By learning to use a scooter, people have gained more control over their lives and become more independent.

To ensure that learning is ongoing, interesting, and effective, we need to provide support in a purposeful way. This helps to keep us focused on what we are trying to achieve and ensures that we don’t leave learning to chance. It also means checking on learning progress. This requires the use of a learning plan which is written with several purposes in mind.

• To provide a set of individual steps towards a goal or outcome.
• To help a person know what parts of a task they can undertake themselves.
• To help support workers understand their role in aspects of the task.
• For the person and support worker to know the milestones towards achieving a goal.
• To promote self-determination by writing the learning plan in conjunction with the client.

As a support worker you need to know:

• what you are supporting the tangata to learn/achieve
• the timeframes to achieve learning
• what boundaries you need to work within

You should be aware of your organisation’s policies and procedures around learning plans, as well as:

• what your expected input into the plan is
• how and what you are expected to implement from the plan
• what you are expected to report on

Multidisciplinary development

Multidisciplinary teams will contribute to the following plans:

• An occupational therapist (OT) may design the activities the person needs to achieve their goals and maximise skills and abilities. An OT also provides adaptive equipment.
• A physiotherapist may design a functional exercise programme for the person.
• A nurse may identify the physical, social, and emotional care needs.
• The tangata’s whānau may advocate the wishes of the person. The whānau may also have skills and qualities they can offer to the person.

You will be working within the plan to achieve the outcomes identified as important by the multidisciplinary team.

Types of learning support

By supporting the tangata in their learning, you will help to maximise their autonomy. The support you provide could include:

• functional exercise support
• practical support
• task breakdown
• helping a person to learn or relearn a skill

Functional exercise programmes

The physiotherapist and multidisciplinary team will develop the exercise programme. It may include strengthening or balance exercises or a gradual increase in the number of steps taken. Your role is to assist people to complete their exercises and incorporate them into their daily activities.

Practical support

Practical support is the support you give people to learn or re-learn a task or skill. These tasks or skills could include using the vacuum cleaner, washing machine, or performing personal care tasks.

Task breakdown

When a person is trying to learn or relearn a complex task, it can be helpful to break it down into smaller subtasks. Completing each subtask may give a sense of achievement. Your role will be to identify the subtasks and help the tangata to complete as many as they can, with the objective of eventually achieving the whole task.

Learning or relearning skills and tasks

Assisting people to learn or relearn skills can be an exciting and rewarding aspect of your work, especially when people gain the confidence and skills they need to function independently. Here are some examples of what you can help them do.

• Learn something new.
• Relearn a task that they were previously able to do independently.
• Modify a task so that they are able to do all or some of the task independently.
• Maintain function through using adaptive devices. This may mean learning, relearning, or modifying a skill if the device is to be used effectively.

Developing a learning plan

1. Identify client wishes – what do they want to learn?
2. Select training strategy – what would be the best way to teach and learn?
3. Identify resources – what is needed in order for the learning to occur?
4. Prepare for learning – ensure all resources are on hand and the client is ready to learn.
5. Implement the plan – perform the learning.
6. Monitor and record progress - it is important to measure what progress has been made so you can determine whether the learning is effective.
7. Make changes – if the learning does not have the desired outcomes, or the client is not enjoying it, or finding it too hard, the learning plan will need to be updated.

Reporting

You will need to report on progress. The format of the reporting will depend on organisational requirements. You may be required to complete a formal written progress report, or you may just be required discuss the tangata’s progress at a multidisciplinary meeting.

Legislation and professional development

Legislation and your own professional development are tools which can be leveraged to support tangata autonomy and self-determination.

Activity

Review the content on these topics for a refresher and complete the activity below to create a useful resource.

Health models

Health models are a great addition to your toolkit. Refresh your memory by reviewing content from earlier in the course on the following health models and complete the activity that follows.

• Te Whare Tapa Whā
• Te Wheke
• Fonofale

Activity

A review of health models in Aotearoa.

Examples of strategies

Strategies are approaches you can use to help tangata achieve autonomy and self-determination. Examples include:

• using mentoring and facilitation
• communication skills
• working in a multidisciplinary team
• the Let’s get real framework and the seven real skills
• natural supports of the tangata – e.g. friends and whānau
• focusing on the tangata’s strengths
• working to overcome barriers to engagement through community participation
• Pae Ora strategies

Some of these strategies have already been covered in this course.

Activity

Answer the questions below to apply what you have learned about how to promote tangata autonomy and self-determination.

The importance of participation

Encouraging your client to participate in their community is an important strategy to promote autonomy. Self-determination is reinforced by discussing options and allowing the tangata to select appropriate options.

Identifying opportunities for community participation and social inclusion should start with the person’s goals, abilities, interests, and preferences. A person-centred approach will help you work collaboratively with the person to identify and choose activities and opportunities for inclusion that match their interests. This is important because selecting activities that match the person’s interests will increase the likelihood of success and reinforce self-determination.

Watch: InDepth: Social Inclusion and Disability (2.11)

While watching the following video, take note of:

• some of the barriers to social inclusion for disabled people
• some of the benefits of social inclusion for disabled people

Selecting participation opportunities

In choosing opportunities and strategies for community participation and inclusion, you must consider the resources available in the community, the client’s situation, interests, skills, goals, support needs, and any other cultural factors.

There is little point in supporting or encouraging your client to engage in activities in which they are not interested. You also need to be realistic in identifying and choosing opportunities for participation. This means considering the person’s capabilities as well as their goals and wishes. For example, an interest in music may not be accompanied by the talent needed to become a concert pianist, so encourage your client instead to set their sights on a musical activity that is within their reach, such as:

• joining a choir
• learning to play an instrument
• joining a music appreciation group
• attending concerts
• listening to music with friends
• joining a band fan club

Include the person’s existing social and support networks, such as family members, friends and carers, and identify support networks and options within the chosen activity or group. For example, community groups, clubs and associations may have members or volunteers interested in supporting your client to join and participate. Developing ‘natural’ social networks and community support is an important aspect of participation and inclusion, as these will expand the person’s relationships and social roles.

The Pae Ora (Health Futures) Act was passed in 2022. From the Act, six strategies were developed to set the direction for how health services would meet the needs of New Zealanders. The strategies are as follows:

• The New Zealand Health Strategy
• Pae Tū: Hauora Māori Strategy
• Te Mana Ola: The Pacific Health Strategy
• The Women's Health Strategy
• The Health of Disabled People Strategy
• The Rural Health Strategy

Pae Ora provides strategies that can be used to support tangata self-determination and autonomy. The strategy that you use will depend on the needs of the service user that you are supporting.

Activity

To complete this activity, visit the Ministry of Health page listing the six strategies and click on the link for each strategy. Read the information provided, and complete the questions that follow. When you are done, download your work and save it as a useful resource.