Is Europe putting theory into practice? A qualitative study of the level of self-management support in chronic care management approaches

Are person-related and socio-structural factors associated with nurses' self-management support behavior? A correlational study

OBJECTIVE

To explore nurses' self-perceived behavior of supporting patients' self-management, and its association with person-related and socio-structural factors.

METHODS

Correlational study in a sample of nurses from nine general hospitals, three community healthcare organizations, and six private community practices. Nurses with >50% of their patients living with a chronic condition were eligible to participate. Data were collected at two time-points. Self-management support behavior was measured by the SEPSS-36 instrument. The person-related and socio-structural associated factors were derived from behavioral theories and measured by validated questionnaires.

RESULTS

Nurses (N=477) scored overall low on self-management support behavior. Nurses lacked mainly competencies in collaborative goalsetting, shared decision making and organizing follow-up. Factors predicting nurses' behavior in supporting patients' self-management were self-efficacy, priority, perceived supervisor support and training in self-management support. This model explained 51.7% of the variance in nurses' behavior.

CONCLUSION

To date, nurses do not optimally fulfil their role in supporting patients' self-management. Self-management support is practiced from a narrow medical point of view and primarily consists of informing patients, which is the lowest level of patient participation.

PRACTICE IMPLICATIONS

It is essential to better prepare and support nurses - and by extend all healthcare professionals - for the challenges of supporting patients' self-management.

Self-management support and eHealth for patients and informal caregivers confronted with advanced cancer: an online focus group study among nurses

BACKGROUND

Self-management by patients and informal caregivers confronted with advanced cancer is not self-evident. Therefore they might need self-management support from nurses. This article reports on nurses' perspectives on self-management support for people confronted with advanced cancer, and nurses' experiences with eHealth in this context.

METHODS

Six online focus groups were organized, with a total of 45 Dutch nurses with different educational levels and working in different care settings. Nurses were asked how they support patients and informal caregivers facing advanced cancer in managing physical and psychosocial problems in their daily life. Questions were also asked regarding the nurses' experiences with eHealth. Transcripts of the online focus group discussions were analyzed qualitatively following the principles of thematic analysis. The main themes derived from the analyses were ordered according to the elements in the 5 A's Behavior Change Model.

RESULTS

Within the scope of self-management support, nurses reported that they discuss the background, personal situation, wishes, and needs of advanced cancer patients ('Assess' in the 5 A's model), and they provide information about cancer and specifically the advanced type ('Advise'). However, nurses hardly give any advice on how patients can manage physical and psychological problems themselves and/or pay any attention to collaborative goal-setting ('Agree'). Neither do they explain how follow-up can be arranged ('Arrange'). In addition, they do not appear to pay much attention to self-management support for informal caregivers. Nurses' attitudes towards eHealth within the scope of self-management support are positive. They see many advantages, such as allowing advanced cancer patients to stay in charge of their own care and lives. However, nurses also explicitly stressed that eHealth can never be a substitute for personal contact between nurses and patients.

CONCLUSIONS

Nurses value self-management support and eHealth for advanced cancer patients and their informal caregivers. However, they seem to disregard important elements in the support of self-management, such as providing practical advice, collaborative goal-setting, and arrangement of follow-up. We recommend further promoting and clarifying the essence and importance of self-management support, including self-management support for informal caregivers.

Interventions and working relationships of voluntary organisations for diabetes self-management: A cross-national study

BACKGROUND

Diabetes has become a challenging health priority globally. Given the tensions of financially burdened health systems in Europe the mobilisation of community resources like voluntary organisations and community groups is seen as a health policy strategy to sustain the management of long-term conditions like diabetes. However, little is known about how this is happening in practice in Europe.

OBJECTIVES

To explore diabetes self-management interventions undertaken or promoted by voluntary organisations and community groups in Europe; and describe the types of working relationships between these organisations, European health systems and users when implementing diabetes self-management programmes in different areas.

DESIGN

A mixed method study (survey/qualitative interviews) was undertaken. This research formed part of a European project (7th Framework programme of the European Commission) exploring the link between resources, like community organisations, and peoples' capacities to manage long-term conditions.

SETTINGS

Six European countries (Bulgaria, Greece, Norway, Spain, the Netherlands and the United Kingdom) participated in the study. Three areas: deprived urban area, a relatively affluent urban area and a deprived rural area were purposefully selected.

PARTICIPANTS

Through a purposeful sample and bottom up strategies 749 representatives of voluntary organisations and community groups were recruited from the geographical areas above. Organisations with at least three members, existing for at least one year that could provide information or other type of support directly or indirectly relevant to patients with diabetes were included.

METHODS

Participants completed a 15 item questionnaire for the survey (n=749) and a voice recorded semi structured interview (n=300). Data collection focused on the type of activities and roles developed to promote health, and relationships and communication channels between organisations, health services and users. Descriptive and comparative statistical and qualitative content analyses were used.

RESULTS

Participants perceived they had better reach of people with health needs than health providers, filled the administration gaps left in their capacity to deal with basic diabetes practical needs, humanized care, and acted as mediators between services and communities. There were significant differences between countries in relation to the types of activities (p-value<0.001), roles (p-value<0.001) and funding sources (p-value<0.001) of organisations concerning diabetes self-management. In non-affluent countries organisations tend to promote social activities twice more often.

CONCLUSIONS

Community and voluntary organisations provide complimentary and on-going support in diabetes management. This involves a shift from focusing on the illness to also longing for social cohesion, sense of community and wellbeing in diabetes health practices and policies.

The articulation of neoliberalism: narratives of experience of chronic illness management in Bulgaria and the UK

The shift from social democratic to a neoliberal consensus in modern welfare capitalist states is characterised by an emphasis on individual responsibility, consumer choice, market rationality and growing social inequalities. There has been little exploration of how neoliberalism has shaped the environment within which chronic illness is experienced and managed. This article explores the different articulations of neoliberalism manifest in the arena of personal illness management in Bulgaria and the UK. People with type 2 diabetes discussed their experiences in terms of struggling with diet, diabetes as a personal failure, integrating illness management and valued activities, and the trustworthiness of the healthcare system. The UK narratives were framed within an individual responsibility discourse while in Bulgaria lack of resources dominated discussions, which were framed as structurally generated and unrelated to individual capabilities and choices. Respondents faced personal management challenges related to consumer and healthcare market failures in both countries. Differences in market regulation and emerging stakeholder and interest coalitions influenced users' expectations and their navigation and adaption to market failures in managing their everyday illnesses. The UK and Bulgarian articulations of neoliberalism can be described differently: the first as a logic of managed choice and the second as a logic of unmanaged consumerism.

Practice change in chronic conditions care: an appraisal of theories

Background

Management of chronic conditions can be complex and burdensome for patients and complex and costly for health systems. Outcomes could be improved and costs reduced if proven clinical interventions were better implemented, but the complexity of chronic care services appears to make clinical change particularly challenging. Explicit use of theories may improve the success of clinical change in this area of care provision. Whilst theories to support implementation of practice change are apparent in the broad healthcare arena, the most applicable theories for the complexities of practice change in chronic care have not yet been identified.

Methods

We developed criteria to review the usefulness of change implementation theories for informing chronic care management and applied them to an existing list of theories used more widely in healthcare.

Results

Criteria related to the following characteristics of chronic care: breadth of the field; multi-disciplinarity; micro, meso and macro program levels; need for field-specific research on implementation requirements; and need for measurement. Six theories met the criteria to the greatest extent: the Consolidate Framework for Implementation Research; Normalization Process Theory and its extension General Theory of Implementation; two versions of the Promoting Action on Research Implementation in Health Services framework and Sticky Knowledge. None fully met all criteria. Involvement of several care provision organizations and groups, involvement of patients and carers, and policy level change are not well covered by most theories. However, adaptation may be possible to include multiple groups including patients and carers, and separate theories may be needed on policy change. Ways of qualitatively assessing theory constructs are available but quantitative measures are currently partial and under development for all theories.

Conclusions

Theoretical bases are available to structure clinical change research in chronic condition care. Theories will however need to be adapted and supplemented to account for the particular features of care in this field, particularly in relation to involvement of multiple organizations and groups, including patients, and in relation to policy influence. Quantitative measurement of theory constructs may present difficulties.

What support is needed to self-manage a rheumatic disorder: a qualitative study

Background

Today, patients are expected to take an active role in the form of self-management. Given the burden of a rheumatic disorder, the patients cannot be expected to self-manage on their own. In order to develop self-management interventions that fit patients’ needs and preferences, it is essential to examine patients’ perspective on how support can be optimized. This study aimed to identify support needs of outpatients with rheumatic disorders and preferences for who should provide self-management support.

Methods

A qualitative study was conducted using focus groups and individual interviews with outpatients with rheumatic disorders treated in a Dutch university hospital. Interview data was analysed with Directed Content Analysis and coded with predetermined codes derived from our model about support needs of chronically ill patients. This model distinguished three types of support: instrumental, psychosocial and relational support.

Results

Fourteen patients participated in two focus group interviews and six were interviewed individually. Most patients preferred an active role in self-management. Nonetheless, they notably needed support in developing skills for self-managing their rheumatic disorder in daily life. The extent of support needs was influenced by disease stage, presence of symptoms and changes in one’s situation. A trusted relationship and partnership were conditional for receiving any kind of professional support. Patients wanted to be seen as experienced experts of living with a rheumatic disorder. Acquiring specific disease-related knowledge, learning how to deal with symptoms and fluctuations, talking about emotional aspects, and discussing daily life issues and disease-related information were identified as important elements of self-management support. It was considered crucial that support be tailored to individual needs and expertise. Professionals and relatives were preferred as support givers. Few patients desired support from fellow patients.

Conclusion

Self-management was primarily seen as patient’s own task. Above all, patients wanted to be seen as the experienced experts. Professionals’ self-management support should be focused on coaching patients in developing problem-solving skills, for which practical tools and training are needed.

The complexity of shaping self-management in daily practice

Background and context

Many countries are giving patients a more active role in health care, on both the individual and collective level. This study focuses on one aspect of the participation agenda on the individual level: self‐management. The study explores self‐management in practice, including the implications of the difficulties encountered.

Objective

To gain insight into the complexity of self‐management practice. This is crucial for developing both self‐management interventions and the participation policy agenda.

Methods

Qualitative semi‐structured interviews with experts (n=6) and patients with a chronic condition (n=20).

Results

In terms of level of involvement and type of activity, shaping self‐management in practice depends on personal and social dynamics, patients’ ideas of the good life and their interactions with care professionals. Clashes can arise when patients and professionals hold differing ideas, based on different values, about the level and type of patient involvement.

Discussion

The discussion on self‐management should account for the fact that how we define self‐management is very much a normative issue. It depends on the norms and values of patients, professionals and underlying health‐care policies. Differing ideas present professionals with ethical dilemmas which they should reflect on. However, professional reflection alone is not enough to deal with these dilemmas. The participation agenda needs far wider ranging reflection on how participation relates to other values in health care.

Connectivity, contest and the ties of self-management support for type 2 diabetes: a meta-synthesis of qualitative literature

This paper presents a meta-synthesis of the literature on community-based self-management to support experiences of people diagnosed with type 2 diabetes. The aim was to synthesise findings on both formal and informal self-management support with particular reference to the relevance and influence of the social context operating at different levels. The review forms part of EU-WISE, a project financed through EU's 7th Framework Programme. The review was performed by systematically searching MEDLINE, PubMed, EMBASE, CINAHL, PsycINFO and Web of Science for English language publications between 2005 and 2014 presenting research conducted in Europe on the experiences and perspectives of self-management concerns of patients diagnosed with type 2 diabetes. The search yielded 587 abstracts, which were reduced through search strategy refinement and eligibility and quality criteria to 29 papers that were included in the review. This review highlights the relevance of contextual factors operating at micro- and macro-levels. The synthesis yielded six second-order thematic constructs relating to self-management: sense of agency and identity, the significance and meaning of social networks, minimal disruption of everyday life, economic hardship, the problem of assigning patients' responsibility and structural influences of primary care. Using a line of argument synthesis, these themes were revisited, and a third-order construct, connectivity emerged which refers to how links in daily life are interwoven with peoples' social networks, local communities, economic and ideological conditions in society in a way which support self-management activities. This meta-synthesis indicates a need to heed the notion of connectivity as a means of mobilising and supporting the self-management strategies of people with type 2 diabetes in everyday life.

Is "disease management" the answer to our problems? No! Population health management and (disease) prevention require "management of overall well-being"

BACKGROUND

Disease management programs based on the chronic care model have achieved successful and long-term improvement in the quality of chronic care delivery and patients' health behaviors and physical quality of life. However, such programs have not been able to maintain or improve broader self-management abilities or social well-being, which decline over time in chronically ill patients. Disease management efforts, population health management initiatives and innovative primary care solutions are still mainly focused on clinical and functional outcomes and health behaviors (e.g., smoking cessation, exercise, and diet) failing to address individuals' overall quality of life and well-being. Individuals' ability to achieve well-being can be assessed with great specificity through the application of social production function (SPF) theory. This theory asserts that people produce their own well-being by trying to optimize the achievement of instrumental goals (stimulation, comfort, status, behavioral confirmation, affection) that provide the means to achieve the larger, universal goals of physical and social well-being.

DISCUSSION

A shift in focus from the management of physical function, disease limitations, and lifestyle behaviors alone to an approach that fosters self-management abilities such as self-efficacy and resource investment as well as overall quality of life, is urgently needed. Disease management interventions should be aimed at adequately addressing all difficulties chronically ill patients face in life, such as the effects of pain and fatigue on the ability to maintain a job and social life and to participate in activities promoting physical and social well-being. Patients' ability to maintain engagement in stimulating work and social activities with the people who are important to them may be even more important than aspects of disease self-management such as blood pressure or glycemic control. Interventions should aim to make chronically ill patients capable of managing their own well-being and adequately addressing their needs in a broader sense. So, is disease management the answer to our problems in the time of aging populations and increased prevalence of unhealthy lifestyles, chronic illnesses, and comorbidity? No! Effective (disease) prevention, disease management, patient-centered care, and high-quality chronic care and/or population health management calls for management of overall well-being.

Patients' readiness to receive psychosocial care during nurse-led routine diabetes consultations in primary care: A mixed methods study

BACKGROUND

Patients with type 2 diabetes mellitus face several emotional and social consequences of their chronic illness in their everyday life. Symptoms of distress and depression are prevalent. For providing psychosocial self-management support, nurses in primary care were trained to identify patients with psychosocial problems during routine medically-shaped diabetes consultations. However, detection rates appeared to be strikingly low.

OBJECTIVES

Our study aimed to examine patients' readiness to discuss psychosocial problems with nurses during diabetes consultations.

DESIGN

A mixed methods design was used in which qualitative data collection was followed up by quantitative data collection.

SETTING

Diabetes care in a regional group of family practices in the south of the Netherlands.

PARTICIPANTS

Type 2 diabetes patients with psychosocial problems, determined by a self-administered questionnaire.

METHODS

First, in-depth interviews (n=12) were conducted about patients' experiences with routine diabetes consultations and their perspective on a biopsychosocial care approach. Based on a qualitative content analysis, a structured questionnaire was designed to further explore the findings among a larger group of patients. This questionnaire was completed by 205 patients. The questionnaire included 14 items measuring patients' agreement with statements about diabetes care and the role of the nurse to focus on patients' emotional and social functioning.

RESULTS

The interviews showed that patients view a diabetes consultation primarily as a biomedical check-up, and do not perceive discussion of psychosocial well-being as an integral part of diabetes management. More than 90% of the sample showed a positive attitude towards current diabetes consultations. Patients' intentions and perceived needs regarding a biopsychosocial care approach of the nurse were variable. Younger patients seemed more open to discussing psychosocial problems with the nurse than patients over 65. Patients' openness to discussing psychosocial problems was not significantly (p<0.05) associated with the nurses being trained in the biopsychosocial self-management approach.

CONCLUSION

Patients see primary care nurses primarily as specialists regarding the biomedical management of diabetes. Although patients seemed to support the ideal of integrated care, they did not expect a discussion about psychosocial problems in diabetes consultations. The incorporation of systematic detection of patients with psychosocial problems in diabetes care requires endeavours to make patients acquainted with the new role of the nurse.

Effect of care management program structure on implementation: a normalization process theory analysis

Background

Care management in primary care can be effective in helping patients with chronic disease improve their health status, however, primary care practices are often challenged with implementation. Further, there are different ways to structure care management that may make implementation more or less successful. Normalization process theory (NPT) provides a means of understanding how a new complex intervention can become routine (normalized) in practice. In this study, we used NPT to understand how care management structure affected how well care management became routine in practice.

Methods

Data collection involved semi-structured interviews and observations conducted at 25 practices in five physician organizations in Michigan, USA. Practices were selected to reflect variation in physician organizations, type of care management program, and degree of normalization. Data were transcribed, qualitatively coded and analyzed, initially using an editing approach and then a template approach with NPT as a guiding framework.

Results

Seventy interviews and 25 observations were completed. Two key structures for care management organization emerged: practice-based care management where the care managers were embedded in the practice as part of the practice team; and centralized care management where the care managers worked independently of the practice work flow and was located outside the practice. There were differences in normalization of care management across practices. Practice-based care management was generally better normalized as compared to centralized care management. Differences in normalization were well explained by the NPT, and in particular the collective action construct. When care managers had multiple and flexible opportunities for communication (interactional workability), had the requisite knowledge, skills, and personal characteristics (skill set workability), and the organizational support and resources (contextual integration), a trusting professional relationship (relational integration) developed between practice providers and staff and the care manager. When any of these elements were missing, care management implementation appeared to be affected negatively.

Conclusions

Although care management can introduce many new changes into delivery of clinical practice, implementing it successfully as a new complex intervention is possible. NPT can be helpful in explaining differences in implementing a new care management program with a view to addressing them during implementation planning.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1613-1) contains supplementary material, which is available to authorized users.

Expectations and needs of patients with a chronic disease toward self-management and eHealth for self-management purposes

BACKGROUND

Self-management is considered as an essential component of chronic care by primary care professionals. eHealth is expected to play an important role in supporting patients in their self-management. For effective implementation of eHealth it is important to investigate patients' expectations and needs regarding self-management and eHealth. The objectives of this study are to investigate expectations and needs of people with a chronic condition regarding self-management and eHealth for self-management purposes, their willingness to use eHealth, and possible differences between patient groups regarding these topics.

METHODS

Five focus groups with people with diabetes (n = 14), COPD (n = 9), and a cardiovascular condition (n = 7) were conducted in this qualitative research. Separate focus groups were organized based on patients' chronic condition. The following themes were discussed: 1) the impact of the chronic disease on patients' daily life; 2) their opinions and needs regarding self-management; and 3) their expectations and needs regarding, and willingness to use, eHealth for self-management purposes. A conventional content analysis approach was used for coding.

RESULTS

Patient groups seem to differ in expectations and needs regarding self-management and eHealth for self-management purposes. People with diabetes reported most needs and benefits regarding self-management and were most willing to use eHealth, followed by the COPD group. People with a cardiovascular condition mentioned having fewer needs for self-management support, because their disease had little impact on their life. In all patient groups it was reported that the patient, not the care professional, should choose whether or not to use eHealth. Moreover, participants reported that eHealth should not replace, but complement personal care. Many participants reported expecting feelings of anxiety by doing measurement themselves and uncertainty about follow-up of deviant data of measurements. In addition, many participants worried about the implementation of eHealth being a consequence of budget cuts in care.

CONCLUSION

This study suggests that aspects of eHealth, and the way in which it should be implemented, should be tailored to the patient. Patients' expected benefits of using eHealth to support self-management and their perceived controllability over their disease seem to play an important role in patients' willingness to use eHealth for self-management purposes.

Profiling Patients' Healthcare Needs to Support Integrated, Person-Centered Models for Long-Term Disease Management (Profile): Research Design

Background:

This article presents the design of PROFILe, a study investigating which (bio)medical and non-(bio)medical patient characteristics should guide more tailored chronic care. Based on this insight, the project aims to develop and validate ‘patient profiles’ that can be used in practice to determine optimal treatment strategies for subgroups of chronically ill with similar healthcare needs and preferences.

Methods/Design:

PROFILe is a practice-based research comprising four phases. The project focuses on patients with type 2 diabetes. During the first study phase, patient profiles are drafted based on a systematic literature research, latent class growth modeling, and expert collaboration. In phase 2, the profiles are validated from a clinical, patient-related and statistical perspective. Phase 3 involves a discrete choice experiment to gain insight into the patient preferences that exist per profile. In phase 4, the results from all analyses are integrated and recommendations formulated on which patient characteristics should guide tailored chronic care.

Discussion:

PROFILe is an innovative study which uses a uniquely holistic approach to assess the healthcare needs and preferences of chronically ill. The patient profiles resulting from this project must be tested in practice to investigate the effects of tailored management on patient experience, population health and costs.

Experiences of food abstinence in patients with type 2 diabetes: a qualitative study

OBJECTIVE

People with type 2 diabetes often report pressure to abstain from many of life's pleasures. We tried to reconstruct these patients' sense of pressure to better understand how people with diabetes make sense of, and integrate, these feelings into their life.

DESIGN, SETTING AND PARTICIPANTS

A secondary analysis of narrative interviews with 14 patients with type 2 diabetes who are part of a website project.

MAIN OUTCOME MEASURES

Grounded theory-based analysis of narrative interviews, consisting of open, axial and selective coding.

RESULTS

People with type 2 diabetes felt obliged to give up many pleasures and live a life of abstinence. They perceived a pressure to display a modest culinary lifestyle via improved laboratory test results and weight. Their verbal efforts to reassure and distance themselves from excessiveness indicate a high moral pressure. With regard to the question of how to abstain, food and behaviour were classified into healthy and unhealthy. Personal rules sometimes led to surprising experiences of freedom.

CONCLUSIONS

People with diabetes have internalised that their behaviour is a barrier to successful treatment. They experience an intensive pressure to show abstinence and feel misjudged when their efforts have no visible effect. Taking into account this moral pressure, and listening to patients' personal efforts and strategies to establish healthy behaviours, might help to build a trusting relationship with healthcare providers.

Patient-perceived self-management tasks and support needs of people with chronic illness: generic or disease specific?

BACKGROUND

Self-management is widely accepted as an essential component of chronic care. Nevertheless, little is known about patients' perceptions of self-management.

PURPOSE

This study aims to explore which self-management tasks and support needs people with chronic illness perceive for themselves, and to establish whether these tasks and support needs are disease specific.

METHODS

A nationwide representative sample of 2,064 people with chronic disease filled in the Patient Assessment of Self-management Tasks questionnaire.

RESULTS

Many respondents perceive self-management tasks in the daily management of their condition, although few indicate a need for support. Respondents who feel a need for support in one aspect of self-management are likely to feel a need for support in other aspects as well. Type of disease has a small effect on self-management tasks and even smaller on support needs.

CONCLUSION

Although the self-management tasks patients perceive may be partly disease specific, self-management support does not necessarily need to be disease specific.

Perceived quality of chronic illness care is associated with self-management: Results of a nationwide study in the Netherlands

BACKGROUND

Healthcare providers are increasingly expected to help chronically ill patients understand their own central role in managing their illness. The aim of this study was to determine whether experiencing high-quality chronic illness care and having a nurse involved in their care relate to chronically ill people's self-management.

METHODS

Survey data from 699 people diagnosed with chronic diseases who participated in a nationwide Dutch panel-study were analysed using linear regression analysis, to estimate the association between chronic illness care and various aspects of patients' self-management, while controlling for their socio-demographic and illness characteristics.

RESULTS

Chronically ill patients reported that the care they received was of high quality to some extent. Patients who had contact with a practise nurse or specialised nurse perceived the quality of the care they received as better than patients who only had contact with a GP or medical specialist. Patients' perceptions of the quality of care were positively related to all aspects of their self-management, whereas contact with a practise nurse or specialised nurse in itself was not.

CONCLUSION

Chronically ill patients who have the experience to receive high-quality chronic illness care that focusses on patient activation, decision support, goal setting, problem solving, and coordination of care are better self-managers. Having a nurse involved in their care seems to be positively valued by chronically ill patients, but does not automatically imply better self-management.

Factors influencing the adoption of self-management solutions: an interpretive synthesis of the literature on stakeholder experiences

Background

In a research context, self-management solutions, which may range from simple book diaries to complex telehealth packages, designed to facilitate patients in managing their long-term conditions, have often shown cost-effectiveness, but their implementation in practice has frequently been challenging.

Methods

We conducted an interpretive qualitative synthesis of relevant articles identified through systematic searches of bibliographic databases in July 2014. We searched PubMed (Medline/NLM), Web of Science, LISTA (EBSCO), CINAHL, Embase and PsycINFO. Coding and analysis was inductive, using the framework method to code and to categorise themes. We took a sensemaking approach to the interpretation of findings.

Results

Fifty-eight articles were selected for synthesis. Results showed that during adoption, factors identified as facilitators by some were experienced as barriers by others, and facilitators could change to barriers for the same adopter, depending on how adopters rationalise the solutions within their context when making decisions about (retaining) adoption. Sometimes, when adopters saw and experienced benefits of a solution, they continued using the solution but changed their minds when they could no longer see the benefits. Thus, adopters placed a positive value on the solution if they could constructively rationalise it (which increased adoption) and attached a negative rationale (decreasing adoption) if the solution did not meet their expectations. Key factors that influenced the way adopters rationalised the solutions consisted of costs and the added value of the solution to them and moral, social, motivational and cultural factors.

Conclusions

Considering ‘barriers’ and ‘facilitators’ for implementation may be too simplistic. Implementers could instead iteratively re-evaluate how potential facilitators and barriers are being experienced by adopters throughout the implementation process, to help adopters to retain constructive evaluations of the solution. Implementers need to pay attention to factors including (a) cost: how much resource will the intervention cost the patient or professional; (b) moral: to what extent will people adhere because they want to be ‘good’ patients and professionals; (c) social: the expectations of patients and professionals regarding the interactive support they will receive; (d) motivational: motivations to engage with the intervention and (e) cultural: how patients and professionals learn and integrate new skills into their daily routines, practices and cultures.

Modelling self-management pathways for people with diabetes in primary care

BACKGROUND

Self-management support to facilitate people with type 2 diabetes to effectively manage their condition is complex to implement. Organisational and system elements operating in relation to providing optimal self-management support in primary care are poorly understood. We have applied operational research techniques to model pathways in primary care to explore and illuminate the processes and points where people struggle to find self-management support.

METHODS

Primary care clinicians and support staff in 21 NHS general practices created maps to represent their experience of patients' progress through the system following diagnosis. These were collated into a combined pathway. Following consideration of how patients reduce dependency on the system to become enhanced self-managers, a model was created to show the influences on patients' pathways to self-management.

RESULTS

Following establishment of diagnosis and treatment, appointment frequency decreases and patient self-management is expected to increase. However, capacity to consistently assess self-management capabilities; provide self-management support; or enhance patient-led self-care activities is missing from the pathways. Appointment frequencies are orientated to bio-medical monitoring rather than increasing the ability to mobilise resources or undertake self-management activities.

CONCLUSIONS

The model provides a clear visual picture of the complexities implicated in achieving optimal self-management support. Self-management is quickly hidden from view in a system orientated to treatment delivery rather than to enhancing patient self-management. The model created highlights the limited self-management support currently provided and illuminates points where service change might impact on providing support for self-management. Ensuring professionals are aware of locally available support and people's existing network support has potential to provide appropriate and timely direction to community facilities and the mobilisation of resources.

Self-management support: A qualitative study of ethical dilemmas experienced by nurses

OBJECTIVE

Policymakers increasingly focus their attention on stimulating patients' self-management. Critical reflection on this trend is often limited. A focus on self-management does not only change nurses' activities, but also the values underlying the nurse-patient relationship. The latter can result in ethical dilemmas.

METHODS

In order to identify possible dilemmas a qualitative study consisting of semi-structured interviews was conducted. Six experts on self-management and medical ethics and 15 nurses participated.

RESULTS

Nurses providing self-management support were at risk of facing three types of ethical dilemmas: respecting patient autonomy versus reaching optimal health outcomes, respecting patient autonomy versus stimulating patient involvement, and a holistic approach to self-management support versus safeguarding professional boundaries.

CONCLUSION

The ethical dilemmas experienced by nurses rest on different views about what constitutes good care provision and good self-management. Interviewed nurses had a tendency to steer patients in a certain direction. They put great effort into convincing patients to follow their suggestions, be it making the 'right choice' according to medical norms or becoming actively involved patients.

PRACTICE IMPLICATIONS

Because self-management support may result in clashing values, the development and implementation of self-management support requires deliberation about the values underlying the relationship between professionals and patients.

Voluntary Organizations and Community Groups as New Partners in Diabetes Self-management and Education: A Critical Interpretative Synthesis

PURPOSE

The purpose of this study is to critically review the literature on the role and work of voluntary organizations and community groups and volunteers in diabetes self-management programs. It seeks to explain how these organizations are located and could be integrated further within a broader system of support.

METHODS

A critical interpretative synthesis of the literature was undertaken as part of the conceptual development of a European research project. Evidence (2000-November 2014) was searched in databases, with the use of key terms, and limited to the languages of the participating countries. This was supplemented by an additional hand search and snowballing technique. A total of 21 articles were included in the review.

RESULTS

Evidence regarding the involvement of voluntary organizations in diabetes self-management programs mainly related to: the nature and remit of their work, responsibilities, and attributes; key strategies of programs accounting for success; motivations/barriers for engaging in volunteering participation; relationships between volunteers and users; and connections/tensions with formal services.

CONCLUSIONS

This review has uncovered a range of facets of voluntary organizations and community groups relevant for supporting diabetes self-management such as the context within which they act and the nature of relationships developed with community and health services. The principles of "assistance, support, sharing, and link" seem essential for this voluntary initiative in self-management to establish effective reciprocal collaboration with health professionals.

Lessons learnt from a cluster-randomised trial evaluating the effectiveness of Self-Management Support (SMS) delivered by practice nurses in routine diabetes care

OBJECTIVE

To evaluate the effectiveness of biopsychosocial Self-Management Support (SMS) delivered by practice nurses in routine diabetes care.

DESIGN

A pragmatic cluster-randomised controlled trial within a hybrid effectiveness-implementation study design. Practice nurses were cluster-randomised.

SETTING

A regional care group in the Netherlands consisting of 77 family practices. The study involved practice nurses (n=40) providing care to approximately 4000 patients with diabetes.

PARTICIPANTS

Patients with type 2 diabetes (n=264) selected by a self-administered questionnaire aimed at measuring emotional distress and diabetes-related reduced daily functioning.

INTERVENTION

Practice nurses in the intervention arm (n=19) were trained to integrate SMS into their routine consultations. SMS included detection of patients with emotional distress and reduced daily functioning, and supporting them when needed through problem solving and reattribution techniques. Practice nurses in the control arm (n=21) provided usual care.

MAIN OUTCOME MEASURES

The primary outcome measure was a dichotomised score on a Visual Analogue Scale that measured the perceived effect of diabetes on daily functioning. Secondary measures included patients' diabetes-related distress, quality of life, autonomy and participation, self-efficacy, self-management and glycaemic control. Outcomes were measured at baseline and at 4-month and 12-month follow-ups.

RESULTS

Only 16 of the 117 patients in the intervention arm (14%) who were found eligible by the posted research-driven screening questionnaire were detected by their practice nurses. Extra consultations for the self-management support were delivered to only 11 study participants. In the control arm, 147 patients received usual care. Multilevel analyses showed no significant differences in outcomes between the intervention and control arms.

CONCLUSIONS

SMS in its present form was not effective. The research-driven screening to select trial participants appeared to be inconsistent with nurse-led detection in routine practice. Adequate follow-up moments need to be built in to overcome barriers resulting from tension between the implementation and effectiveness parts of hybrid studies.

TRIAL REGISTRATION NUMBER

Current Controlled Trials NTR2764.

General Practitioners' vitamin K antagonist monitoring is associated with better blood pressure control in patients with hypertension--a cross-sectional database study

Background

Patients requiring anticoagulation suffer from comorbidities such as hypertension. On the occasion of INR monitoring, general practitioners (GPs) have the opportunity to control for blood pressure (BP). We aimed to evaluate the impact of Vitamin-K Antagonist (VKA) monitoring by GPs on BP control in patients with hypertension.

Methods

We cross-sectionally analyzed the database of the Swiss Family Medicine ICPC Research using Electronic Medical Records (FIRE) of 60 general practices in a primary care setting in Switzerland. This database includes 113,335 patients who visited their GP between 2009 and 2013. We identified patients with hypertension based on antihypertensive medication prescribed for ≥6 months. We compared patients with VKA for ≥3 months and patients without such treatment regarding BP control. We adjusted for age, sex, observation period, number of consultations and comorbidity.

Results

We identified 4,412 patients with hypertension and blood pressure recordings in the FIRE database. Among these, 569 (12.9 %) were on Phenprocoumon (VKA) and 3,843 (87.1 %) had no anticoagulation. Mean systolic and diastolic BP was significantly lower in the VKA group (130.6 ± 14.9 vs 139.8 ± 15.8 and 76.6 ± 7.9 vs 81.3 ± 9.3 mm Hg) (p < 0.001 for both). The difference remained after adjusting for possible confounders. Systolic and diastolic BP were significantly lower in the VKA group, reaching a mean difference of −8.4 mm Hg (95 % CI −9.8 to −7.0 mm Hg) and −1.5 mm Hg (95 % CI −2.3 to −0.7 mm Hg), respectively (p < 0.001 for both).

Conclusions

In a large sample of hypertensive patients in Switzerland, VKA treatment was independently associated with better systolic and diastolic BP control. The observed effect could be due to better compliance with antihypertensive medication in patients treated with VKA. Therefore, we conclude to be aware of this possible benefit especially in patients with lower expected compliance and with multimorbidity.

Self-management support from the perspective of patients with a chronic condition: a thematic synthesis of qualitative studies

BACKGROUND

Receiving adequate support seems to be crucial to the success of self-management. Although different empirical studies separately examined patients' preferences for self-management support (SMS), an overview is lacking.

OBJECTIVE

The aim of this qualitative review was to identify patients' needs with respect to SMS and to explore by whom this support is preferably provided.

SEARCH STRATEGY

Qualitative studies were identified from Embase, MEDLINE OvidSP, Web of science, PubMed publisher, Cochrane central, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO.

INCLUSION CRITERIA

Articles needed to meet all of the following criteria: (i) focuses on self-management, (ii) concerns adult patients with rheumatic diseases (rheumatoid arthritis and fibromyalgia), a variant of cancer or chronic kidney disease, (iii) explores support needs from the patients' perspective, (iv) uses qualitative methods and (v) published in English.

DATA EXTRACTION AND SYNTHESIS

A thematic synthesis, developed by Thomas and Harden, was conducted of the 37 included studies.

MAIN RESULTS

Chronic patients need instrumental support, psychosocial support and relational support from health-care professionals, family/friends and fellow patients to manage the chronic condition. Relational support is at the centre of the support needs and fuels all other types of support.

DISCUSSION AND CONCLUSIONS

Patients do not self-manage on their own. Patients expect health-care professionals to fulfil a comprehensive role. Support needs can be knitted together only when patients and professionals work together on the basis of collaborative partnership. Dynamics in support needs make it important to regularly assess patient needs.

Disease Management: The Need for a Focus on Broader Self-Management Abilities and Quality of Life

The study objective was to investigate long-term effects of disease management programs (DMPs) on (1) health behaviors (smoking, physical exercise); (2) self-management abilities (self-efficacy, investment behavior, initiative taking); and (3) physical and mental quality of life among chronically ill patients. The study also examined whether (changes in) health behaviors and self-management abilities predicted quality of life. Questionnaires were sent to all 5076 patients participating in 18 Dutch DMPs in 2010 (T0; 2676 [53%] respondents). Two years later (T1), questionnaires were sent to 4350 patients still participating in DMPs (1722 [40%] respondents). Structured interviews were held with the 18 DMP project leaders. DMP implementation improved patients' health behavior and physical quality of life, but mental quality of life and self-management abilities declined over time. Changes in patients' investment behavior predicted physical quality of life at T1 (P<.001); physical activity, investment behavior (both P<.05), and self-efficacy (P<.01) at T0, and changes in self-efficacy and investment behavior (both P<.001) predicted patients' mental quality of life at T1. The long-term benefits of these DMPs include successful improvement of chronically ill patients' health behaviors and physical quality of life. However, these programs were not able to improve or maintain broader self-management abilities or mental quality of life, highlighting the need to focus on these abilities and overall quality of life. As coproducers of care, patients should be stimulated and enabled to manage their health and quality of life.

Health workers' views of a program to facilitate physical health care in mental health settings: implications for implementation and training

OBJECTIVE

Physical comorbidities shorten the lifespan of people with severe mental illness therefore mental health clinicians need to support service users in risk factor-related behaviour change. We investigated mental health care workers' views of a physical health self-management support program in order to identify implementation requirements.

METHOD

Qualitative interviews were conducted with workers who had differing levels of experience with a self-management support program. Themes were identified using interpretive descriptive analysis and then matched against domains used in implementation models to draw implications for successful practice change.

RESULTS

Three main themes emerged related to: (1) understandings of disease management within job roles; (2) requirements for putting self-management support into practice; and (3) challenges of coordination in disease management. Priority domains from implementation models were inner and outer health service settings.

CONCLUSION

While staff training is required, practice change for care which takes account of both mental and physical health also requires changes in organisational frameworks.

Emerging trends in diabetes care practice and policy in The Netherlands: a key informants study

Background

Effective self-management is viewed as the cornerstone of diabetes care. Many interventions and policies are available to support self-management, but challenges remain regarding reaching specific subgroups and effectively changing lifestyles. Here, our aim was to identify emerging policies and practices regarding diabetes care in The Netherlands.

Methods

Study with a purposeful sample of key informants, covering a range of stakeholders. They were individually interviewed, using a flexible and semi-structured approach. A thematic analysis was done, guided by an international framework, which resulted in 28 themes.

Results

After a decade of investing in diabetes care in The Netherlands, stakeholders seem to have shifted their focus towards a view that effective self-management is expected in most people. The expectation is that individuals’ personal networks, community organizations and emerging information technologies will facilitate this. If support of self-management is required, this has to be provided by local coalitions of health and social care organizations, with involvement of municipalities. Poor reach in specific subgroups of the population, such as economically deprived people, is recognized but has not led to targeted policies.

Conclusions

The role of healthcare providers in supporting patients’ self-management in diabetes care seems to be changing in The Netherlands.

Evaluating chronic disease management in real-world settings in six European countries: Lessons from the collaborative DISMEVAL project

Objective

To describe the interventions, research methods and main findings of the international DISMEVAL project, in which the “real-world” impact of exemplary European disease management approaches was investigated in six countries using advanced analytic techniques.

Design

Across countries, the project captured a wide range of disease management strategies and settings; approaches to evaluation varied per country, but included, among others, difference-in-differences analysis and regression discontinuity analysis.

Setting

Austria, Denmark, France, Germany, The Netherlands, and Spain.

Participants

Health care providers and/or statutory insurance funds providing routine data from their disease management interventions, mostly retrospectively.

Intervention(s)

This study did not carry out an intervention but evaluated the impact of existing disease management interventions implemented in European care settings.

Main outcome measure(s)

Outcome measures were largely dependent on available routine data, but could concern health care structures, processes, and outcomes.

Results

Data covering 10 to 36 months were gathered concerning more than 154,000 patients with three conditions. The analyses demonstrated considerable positive effects of disease management on process quality (Austria, Germany), but no more than moderate improvements in intermediate health outcomes (Austria, France, Netherlands, Spain) or disease progression (Denmark) in intervention patients, where possible compared with a matched control group.

Conclusions

Assessing the “real-world” impact of chronic disease management remains a challenge. In settings where randomization is not possible and/or desirable, routine health care performance data can provide a valuable resource for practice-based evaluations using advanced analytic techniques.

Expert and experiential knowledge in the same place: patients' experiences with online communities connecting patients and health professionals

OBJECTIVE

To explore patients' experiences with online health communities in which both physicians and patients participate (i.e. patient-to-doctor or 'P2D' communities).

METHODS

A qualitative content analysis was conducted, based on observations in five P2D communities ranging from 8 to 21 months, and semi-structured interviews (N=17) with patients.

RESULTS

Patients consider information from physicians and peers as two distinct sources, value both sources differently and appreciate accessing both in the same web space. According to respondents, physicians can provide 'reliable' and evidence-based information, while patients add experience-based information. Patients use this information for multiple purposes, including being informed about scientific research and personal reflection.

CONCLUSION

Patients find P2D communities beneficial because they help patients to collect information from both medical experts and experiential experts in one place.

PRACTICE IMPLICATIONS

Patients use P2D communities to perform medical, emotional and lifestyle activities. The presence of physicians in P2D communities may inadvertently suggest that the quality of information used for the activities, is controlled. When information is not officially being checked, this should be stated explicitly on the website and supplemented with a statement that information is only indicative and that patients should at all times contact their own physicians.

Health communication cards as a tool for behaviour change

Individuals seeking healthcare treatment in the context of obesity often experience difficulty engaging in discussions around their health and face challenges finding consensus with practitioners on care plans that best suit their lives. The complex set of biological, social, and environmental variables that have contributed to the higher prevalence of obesity are well illustrated in the foresight obesity system map. Effectively understanding and addressing key variables for each individual has proven to be difficult, with clinicians facing barriers and limited resources to help address patients' unique needs. However, productive discussions inspired by patient centered care may be particularly effective in promoting behaviour change. Tools based on systems science that facilitate patient centered care and help identify behaviour change priorities have not been developed to help treat adult obesity. This project created and pilot tested a card based clinical communication tool designed to help facilitate conversations with individuals engaged in health behaviour change. The health communication cards were designed to help direct conversation between patients and healthcare providers toward issues relevant to the individual. Use of the cards to facilitate patient driven conversations in clinical care may help to streamline conversations, set realistic care plan goals, and improve long term rates of compliance.