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

Patients and informal caregivers in the lead: a qualitative study on the experiences of patients, informal caregivers, and healthcare professionals with involvement in treatment, e-health and self-management programs

BACKGROUND

A significant proportion of patients and informal caregivers favor an active role in decisions concerning their health. Simultaneously, governments aim to shift treatment from a professional care setting to a community setting, in light of an ageing population, a decreasing number of health workers and allocation of scarce resources. This transition of care solicits patients' and informal caregivers' ability to self-manage. Therefore, the Maastricht University Medical Centre + has established the Academy for Patients and Informal caregivers. The aim is to proactively and professionally support patients and their informal caregivers to enhance their self-management. For that, the Academy offers activities in three categories: (1) instruction of nursing techniques, (2) training of e-health competencies and (3) the provision of self-management programs. Both patients with an episodic care need, as well as patients and informal caregivers with chronic illness, are eligible to participate in the Academy's activities. However, little is known about the experience of these interventions from the perspective of patients, informal caregivers and healthcare professionals.

METHODS

We conducted semi-structured interviews with 15 patients, 8 informal caregivers and 19 health care professionals who either participated in, referred to or received patients from the Academy. Topics revolved around self-management and the Quadruple aim, covering topics such as patient experiences, healthcare costs, health and well-being of the population and improving work life for health professionals. Data were analyzed using thematic analysis.

RESULTS

Patients and caregivers experienced an increase in the ability to manage health needs independently, leading to increased mental well-being and self-efficacy. They felt recognized as partners in care, although managing illness needs came with its own burdens. Health care professionals indicated that they felt assured of the quality, uniformity and availability of activities due to its central organization, with instruction nurses finding greater meaning in their work. On the level of health care systems, participants in this study mentioned a decrease in use of formal healthcare, whilst enabling a more equitable division of care.

CONCLUSION

Stakeholders' experiences with the Academy for Patients and Informal caregivers indicate that participation contributes to development of self-management, whilst also improving working conditions, reducing the appeal to formal care and advancing equity in healthcare. The burden for patients and informal caregivers is to be considered in future developments.

Nurses' perspectives on challenges and facilitators when implementing a self-management support intervention as an everyday healthcare practice: A qualitative study

AIM

To explore registered nurses' perspectives on challenges and facilitators to implementing a telephone-based self-management support (SMS) intervention (Proactive Health Support) as an everyday healthcare practice, during the early stages of implementation.

DESIGN

Data were collected using a qualitative research design involving focus-group interviews and participant observations.

METHODS

We conducted participant observation following nine nurses and four focus group interviews with 14 nurses. Data were analysed using thematic analyses.

RESULTS

Proactive Health Support was implemented in units organized independently of the existing organizational units within healthcare services. This independent organization, along with the intervention's generic (non-disease specific) design, empowered nurses to become autonomous practitioners capable of prioritizing the operationalization of SMS as an everyday healthcare practice. However, unlearning already embedded medical practices and establishing new nursing roles necessary to accommodate the intervention in practice was experienced a challenge. Education and supervision were identified as valuable tools for successful implementation.

CONCLUSION

Our study highlights the significance of organizational context and autonomy in successful SMS implementation. Balancing external factors like organizational context, priority and time is vital, but navigating the internal shift in professional practice is equally crucial. Role transition processes can constitute challenges demanding accommodation.

IMPLICATIONS FOR THE PROFESSION

From a nursing perspective, this study highlights that practising SMS requires substantial training and education. Generic SMS interventions can introduce higher levels of contingency due to their versatile nature. Thus, equipping nurses with competencies that enable them to navigate this unpredictability flexibly is crucial.

IMPACT

Policymakers and administrators should allocate resources and support implementation processes in ways that accommodate both internal and external conditions to facilitate nurses in delivering effective SMS.

REPORTING METHOD

This study adheres to the SRQR guideline.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Nursing Students' Self-Efficacy and Performance in Self-Management Support for Patients in Rural Primary Care

ABSTRACT

There is currently no evidence of undergraduate nursing students' self-efficacy and performance in self-management support for chronic diseases in rural primary care. Using the Self-Efficacy and Performance in Self-Management Support instrument, this quasi-experimental study assessed students' self-efficacy and performance in self-management support before and after implementation of a primary care enhanced curriculum. Nursing students ( n = 140) reported a significant increase in total mean scores (pretest, M = 268.01; posttest, M = 289.51), p = .0001. Providing a primary care enhanced curriculum increased nursing students' self-efficacy and performance in self-management support.

What factors contribute to cancer survivors' self-management skills? A cross-sectional observational study

PURPOSE

Many cancer survivors, facing the consequences of their disease and its treatment, have medical and supportive aftercare needs. However, limited knowledge exists regarding the relationship between support needs and survivors' self-management skills. The study aim is to explore factors contributing to cancer survivors' self-management skills.

METHODS

A cross-sectional study was conducted among cancer survivors (n = 277) of two outpatient oncology clinics at a university hospital in the Netherlands. Patients with head and neck cancer (n = 55) who had received radiotherapy and cisplatin or cetuximab were included, as well as patients who had undergone hematopoietic stem cell transplantation (n = 222). The primary outcome was self-management skills, assessed using the Partners in Health Scale (PIH), which comprises two subscales: knowledge and coping (PIH-KC), and recognition and management of symptoms, and adherence to treatment (PIH-MSA). Secondary outcomes were quality of life (EORTC QLQ-C30), self-efficacy (SECD6), patient-centered care (CAPHS), and social support (HEIQ). Machine learning-based Random Forest models were employed to construct associative models. Feature Importance (FI) was used to express the contribution to the model.

RESULTS

High emotional quality of life (FI = 33.1%), increased self-efficacy (FI = 22.2%), and greater social support (FI = 18.2%) were identified as key factors contributing to cancer survivors' self-management knowledge (PIH-KC). Furthermore, greater support from professionals (FI = 36.1%) and higher self-efficacy (FI = 18.2%) were found to benefit participants' recognition and management, and therapy adherence (PIH-MSA).

CONCLUSIONS

A patient-centered relationship between nurses and cancer survivors is essential for therapy adherence and the management of aftercare needs. Training to provide this holistic self-management support is required.

What is meant by 'integrated personalized diabetes management': A view into the future and what success should look like

Integrated personalized diabetes management (IPDM) has emerged as a promising approach to improving outcomes in patients with diabetes mellitus (DM). This care approach emphasizes the integration and coordination of different providers, including physicians, nurses, dietitians, social workers and pharmacists. The goal of IPDM is to provide patients with personalized care that is tailored to their needs. This review addresses the concept of integrated care and the use of technology (including data, software applications and artificial intelligence) as well as managerial, regulatory and financial aspects. The implementation and upscaling of digitally enabled IPDM are discussed, with elaboration of successful practices and related evidence. Finally, recommendations are made. It is concluded that the adoption of digitally enabled IPDM on a global level is inevitable, considering the challenges created by an increasing prevalence of patients with DM and the need for better outcomes and improvement of health system sustainability.

Managing mental health in chronic care in general practice: a feasibility study of the Healthy Mind intervention

BACKGROUND AND OBJECTIVE

Mental health issues are common among patients with chronic physical conditions. This study aims to evaluate the feasibility of the Healthy Mind intervention, a general practice-based programme that provides problem-solving therapy (PST) to patients with poor mental well-being and type 2 diabetes (T2D) and/or ischaemic heart disease (IHD).

DESIGN AND SETTING

A one-arm feasibility study was conducted in three general practices in the Central Denmark Region.

INTERVENTION

Eight healthcare providers from the included general practices underwent a two-day course to acquire PST skills. Screening for poor mental health was carried out at the annual chronic care consultation for T2D or IHD, and PST sessions were offered to patients on indication of poor mental health. Nine patients received PST.

METHODS

Semi-structured interviews with eight healthcare providers and six patients were conducted. Data were analysed deductively focusing on appropriateness, acceptability and fidelity of the intervention.

RESULTS

The intervention was considered appropriate for the patient group and the general practice setting. The providers acknowledged PST as a valuable tool for managing psychological issues in general practice, and the patients perceived PST as an effective and tangible treatment. Since practice nurses' schedules were generally better suited for longer consultations, they were often the preferred intervention providers. The intervention was largely delivered as intended. However, the GPs generally expected patients to prefer a more directive approach, which sometimes challenged their role as facilitator and guide.

CONCLUSION

The Healthy Mind intervention was found to be feasible, and the results support proceeding to a full-scale evaluation trial.

Self-management support (SMS) in primary care practice: a qualitative focus group study of care professionals' experiences

BACKGROUND

To support self-management of chronically ill persons, innovative approaches of care practice are being developed. Unfortunately, many self-management supporting interventions struggle to achieve reliable and consistent improvements at various levels (patient, provider and healthcare system level). One possible strategy to facilitate translating theory into practice, is to consider the healthcare professionals' perspective prior to the development of new interventions. An exploration of their knowledge and opinion about barriers and facilitators is necessary before employing any self-management support (SMS) intervention. Therefore, our study aims to explore care professionals' perspectives about SMS within the Flemish primary care setting.

METHODS

This study used a qualitative study design to examine SMS in primary care setting. Five focus groups were conducted, grouped into three waves. Participants were healthcare professionals in Flanders representing different disciplines and settings. A maximum variation purposive sampling was used to recruit participants. For the data analysis, the framework of thematic networks by Attride-Stirling was applied.

RESULTS

A total of 34 healthcare professionals participated. Three global themes related to SMS were derived from the thematic analysis: (1) Characteristics, (2) Support strategies, (3) Barriers and facilitators. SMS was characterised as a collaboration-based and person-centred approach. A variety of supporting strategies were mentioned by the focus group participants. Most strategies consisted of informing and educating patients. Complementary to individual strategies, collaborative strategies were deemed necessary to support self-management. Regarding barriers and facilitators, different patient-related factors were identified. Additionally, competencies of healthcare providers and external factors seem to hinder the implementation of SMS in practice.

CONCLUSIONS

This focus group study highlights the importance of a collaborative, person-centred approach to SMS in the context of chronic diseases. Our findings point to the need for interventions that raise awareness and address barriers associated with SMS. Since generic SMS does not exist, the road to success is a growth process in which support must be adapted to the individual patient.

Content Validition and Psychometric Evaluation of the Self-efficacy and Performance in Self-management Support Instrument for Physiotherapists

OBJECTIVE

To develop and psychometrically test the Self-Efficacy and Performance in Self-Management Support instrument for physiotherapists (SEPSS-PT), based on the SEPSS-36, the corresponding instrument for nurses.

DESIGN

Instrument development including content validation and psychometric evaluation (construct validity, factor structure, and reliability).

SETTING

Data were collected from literature, expertmeetings, and online questionnaire PARTICIPANTS: Next to a comprehensive literature study, experts (self-management experts (n=2); physiotherapists (n=10); patients (n=6)) and physiotherapists and physiotherapy students (n=334), participated in different stages of the study.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Not applicable. A literature study (n=42 reviews) and consultations with physiotherapists and patients identified the specific content for physiotherapy. The Five-A's model and overarching competencies of "supportive partnership attitude", were used to structure the items. Psychometric evaluation of the draft questionnaire (40 items) was tested in a sample of 334 physiotherapists and physiotherapy students from the Netherlands, of whom 33 filled out the questionnaire twice to establish the test-retest reliability.

RESULTS

Confirmatory factor analyses revealed satisfactory fit indices for both the 6-factor model and hierarchical model, with best fit for the 6-factor model. The questionnaire discriminated between physiotherapists and physiotherapy students, and between physiotherapists who did or did not consider self-management support important. The overall internal consistency (Cronbach's alpha) was high, both for the self-efficacy and the performance items. In most of the subscales, test-retest intra-class correlation coefficients for both overall self-efficacy and performance were good, but in 3 subscales insufficient for performance.

CONCLUSION

The SEPSS-PT questionnaire is a 40-item, Likert-scaled instrument with good content and construct validity, good internal consistency and reliability, and sufficient test-retest reliability. Future research in a larger and more diverse sample could confirm stability and discriminating power.

Self-Management of Diabetes and Associated Factors among Patients Seeking Chronic Care in Tshwane, South Africa: A Facility-Based Study

The burden of diabetes continues to increase in South Africa and a significant number of diabetes patients present at public primary healthcare facilities with uncontrolled glucose. We conducted a facility-based cross-sectional study to determine the diabetes self-management practices and associated factors among out-patients in Tshwane, South Africa. An adapted validated questionnaire was used to collect data on sociodemography, diabetes knowledge, and summaries of diabetes self-management activities measured in the previous seven days, and over the last eight weeks. Data were analysed using STATA 17. A final sample of 402 diabetes out-patients was obtained (mean age: 43 ± 12 years) and over half of them were living in poor households. The mean total diabetes self-management of score was 41.5 ± 8.2, with a range of 21 to 71. Almost two thirds of patients had average self-management of diabetes, and 55% had average diabetes knowledge. Twenty-two percent of patients had uncontrolled glucose, hypertension (24%) was the common comorbidity, and diabetic neuropathy (22%) was the most common complication. Sex [male: AOR = 0.55, 95% CI: 0.34-0.90], race [Coloured: AOR = 2.84, 95% CI: 1.69-4.77 and White: AOR = 3.84, 95% CI: 1.46-10.1], marital status [divorced: AOR = 3.41, 95% CI: 1.13-10.29], social support [average: AOR = 2.51, 95% CI: 1.05-6.00 and good: AOR = 4.49, 95% CI: 1.61-7.57], body mass index [obesity: AOR = 0.31, 95% CI: 0.10-0.95], diabetes knowledge [average: AOR = 0.58, 95% CI: 0.33-0.10 and good: AOR = 1.86, 95% CI: 0.71-4.91], and uncontrolled glucose [AOR = 2.97, 95% CI: 1.47-5.98] were factors independently predictive of diabetes self-management. This study emphasizes that the self-management of diabetes was mostly on average among patients and was associated with the aforementioned factors. Innovative approaches are perhaps needed to make diabetes education more effective. Face-to-face sessions delivered generally during clinic visits should be better tailored to the individual circumstances of diabetes patients. Considerations should be given to the options of leveraging information technology to ensure the continuity of diabetes education beyond clinic visits. Additional effort is also needed to meet the self-care needs of all patients.

Development of a Core Set of Self-Management Support Needs of Esophageal Cancer Patients: Results from a Delphi Study among Healthcare Professionals

Objective. We aimed to gain consensus on HCPs’ perspectives on self-management support information needs of patients with esophageal cancer during the preoperative phase. Methods. Based on the literature, observations of clinical consultations, and hospital patient information leaflets, a survey was created. HCPs were surveyed twice about their opinion on importance of information, from “not essential” to “absolutely essential,” using Delphi methods. Topics were included in the second round if predetermined criteria were met. To be included in the final list, topics had to meet criteria for consensus and stability. Results. 64 information items and 6 sources of support were identified. Survey response rates were 59% (68 out of 116, first round) and 75% thereafter. The final list included 33 topics, including logistical information, expectations for future health condition, complications, follow-up care, nutrition during treatment, and nutrition during recovery as topics with 100% agreement. Consensus on the source of support was reached for face-to-face contact, written information, information video, and a case manager. Conclusion. This study provides a list of important topics, from the perspectives of HCPs, to guide the systematic provision of education to support EC patients’ self-management during the preoperative phase. Additionally, the most preferred sources of support were face-to-face contact and a case manager.

Scale-up of a chronic care model-based programme for type 2 diabetes in Belgium: a mixed-methods study

BACKGROUND

Type 2 diabetes (T2D) is an increasingly dominant disease. Interventions are more effective when carried out by a prepared and proactive team within an organised system - the integrated care (IC) model. The Chronic Care Model (CCM) provides guidance for its implementation, but scale-up of IC is challenging, and this hampers outcomes for T2D care. In this paper, we used the CCM to investigate the current implementation of IC in primary care in Flanders (Belgium) and its variability in different practice types.

METHODS

Belgium contains three different primary-care practice types: monodisciplinary fee-for-service practices, multidisciplinary fee-for-service practices and multidisciplinary capitation-based practices. Disproportional sampling was used to select a maximum of 10 practices for each type in three Flemish regions, leading to a total of 66 practices. The study employed a mixed methods design whereby the Assessment of Chronic Illness Care (ACIC) was complemented with interviews with general practitioners, nurses and dieticians linked to the 66 practices.

RESULTS

The ACIC scores of the fee-for-service practices - containing 97% of Belgian patients - only corresponded to basic support for chronic illness care for T2D. Multidisciplinary and capitation-based practices scored considerably higher than traditional monodisciplinary fee-for-service practices. The region had no significant impact on the ACIC scores. Having a nurse, being a capitation practice and having a secretary had a significant effect in the regression analysis, which explained 75% of the variance in ACIC scores. Better-performing practices were successful due to clear role-defining, task delegation to the nurse, coordination, structured use of the electronic medical record, planning of consultations and integration of self-management support, and behaviour-change intervention (internally or using community initiatives). The longer nurses work in primary care practices, the higher the chance that they perform more advanced tasks.

CONCLUSIONS

Besides the presence of a nurse or secretary, also working multidisciplinary under one roof and a capitation-based financing system are important features of a system wherein IC for T2D can be scaled-up successfully. Belgian policymakers should rethink the role of paramedics in primary care and make the financing system more integrated. As the scale-up of the IC varied highly in different contexts, uniform roll-out across a health system containing multiple types of practices may not be successful.

Primary health care nurses' knowledge, self-efficacy and performance of diabetes self-management support

BACKGROUND

Patients living with diabetes are primarily managed and supported by nurses in primary health care (PHC). Therefore, PHC nurses require knowledge of diabetes and confidence (self-efficacy) to perform diabetes self-management support (SMS).

AIM

This study evaluated the diabetes knowledge, self-efficacy and performance of diabetes SMS by PHC nurses.

SETTING

Primary health care facilities in King Sabata Dalindyebo subdistrict, O.R. Tambo district, Eastern Cape.

METHODS

A quantitative cross-sectional and simple correlational design was used. Registered nurses (n = 100) completed a validated self-reporting questionnaire to measure diabetes knowledge, self-efficacy and performance of SMS.

RESULTS

Participants' diabetes knowledge mean scores were high (mean of 11.9, standard deviation [s.d.] 1.8, out of 14). Self-efficacy scores (mean 18.91, s.d. 3.2 out of 24) were higher than performance of SMS scores (mean 17.81, s.d. 3.3 out of 24). Knowledge was not associated with self-efficacy or performance, but self-efficacy was positively correlated with performance of SMS (r = 0.78, p 0.01). Nurses with a postgraduate qualification in primary care nursing had significantly higher diabetes knowledge scores (mean = 92.9 vs. 83.8; p = 0.03), and years of experience as a nurse were positively correlated with the performance of SMS (r = 0.21, p = 0.05).

CONCLUSION

Diabetes knowledge of PHC nurses in this study does not translate into self-efficacy and the performance of SMS in practice, indicating the need for specific SMS training, support by experienced mentors, appropriate guidelines and comprehensive integrated chronic care systems.Contribution: This is the first study to report on the SMS self-efficacy and performance of PHC nurses in South Africa.

How nurses support self-management of hospitalized patients through verbal communication: a qualitative study

BACKGROUND

Patients' self-management of the implications of their disease(s) is becoming increasingly important. Research shows that hospitalization disrupts established self-management routines. Nurses can play an important role in supporting patients' self-management. The aim of this study is to describe how nurses support the self-management of hospitalized patients through verbal communication during routine nursing care.

METHODS

A qualitative descriptive study, using overt, non-participant observations was conducted on three wards of a general teaching hospital in the Netherlands. A total of 215 hours of nursing work during 49 shifts was observed. Data was analyzed using thematic analysis based on the six phases of Braun and Clarke.

RESULTS

Our observations showed that nurses discuss patients' self-management mainly in short conversations during the care provision. Nurses ask patients about their self-management at home and stimulate patients to express their opinions and to be involved in the care process. Three themes reflect how nurses support self-management: 'Discussing patient's self-management', 'Enhancing patient's involvement in care' and 'Focusing on patient's perspective'.

CONCLUSION

Hospital nurses have methods to support hospitalized patients' self-management but it does not seem to be an integral part of daily practice. Given current developments in healthcare, it is reasonable to argue that self-management should be given greater emphasis within the hospital setting, requiring a collaborative approach with patients and other healthcare professionals across the care continuum.

Active Health Governance—A Conceptual Framework Based on a Narrative Literature Review

Health policies are regarded as a governance mechanism crucial for reducing health inequity and improving overall health outcomes. Policies that address chronic conditions or health inequity suggest a governance shift toward active health over past decades. However, the current literature in health policy largely focused on some specific health policy changes and their tangible outcomes, or on specific inequality of health policies in gender, age, racial, or economic status, short of comprehensively responding to and addressing the shift. This is exacerbated further by a common confusion that equates health policy with health care policy, which has been burdened by increased population ageing, growing inequalities, rising expenditures, and growing social expectations. This study conducted a narrative literature review to comprehensively and critically analyze the most current knowledge on health policy in order to help us establish a theoretical framework on active health governance. The comprehensive framework proposed in this paper identifies the main elements of a well-defined active health governance and the interactions between these elements. The proposed framework is composed of four elements (governance for health, social determinants of health, lifestyle determinants of health, and health system) and three approaches (whole-of-government approach, whole-of-society approach, and lifespan/life-course approach) that are dynamically interacted to achieve two active health outcomes (health equity and health improvement). The framework provides a conceptual solution to the issues of current literature on health policy and practically serves as a new guide for health policymaking.

The views of healthcare professionals on self-management of patients with advanced cancer: An interview study

OBJECTIVES

Self-management of patients with advanced cancer is challenging. Although healthcare professionals may play a crucial role in supporting these patients, scant scientific attention has been paid to their perspectives. Therefore, we examined healthcare professionals' views on self-management and self-management support in this population.

METHODS

We conducted qualitative interviews with 27 purposively sampled medical specialists (n = 6), nurse specialists (n = 6), general practitioners (n = 8) and homecare/ hospice nurses (n = 7) in the Netherlands. Transcripts were analysed using thematic analysis.

RESULTS

Healthcare professionals experienced self-management of patients with advanced cancer to be diverse, dynamic and challenging. They adopted instructive, collaborative and advisory roles in self-management support for this population. Whereas some professionals preferred or inclined towards one role, others indicated to switch roles, depending on the situation.

CONCLUSIONS

Just like patients with advanced cancer, healthcare professionals differ in their views and approaches regarding self-management and self-management support in this population. Therefore, instructive, collaborative and advisory self-management support roles will all be useful under certain circumstances.

PRACTICE IMPLICATIONS

Healthcare professionals can support self-management by being aware of their own views and communicating these clearly to their patients and colleagues. Education in self-management support should include self-reflection skills and discuss the relation between self-management and professional care.

Health care professionals' perspectives on self-management for people with Parkinson's: qualitative findings from a UK study

BACKGROUND

Parkinson's disease is a long-term, complex health condition. To improve or maintain quality of life, people with Parkinson's can have an active involvement in their care through self-management techniques. Given the complexity and individualization of self-management, people with Parkinson's will need support and encouragement from their healthcare professionals (HCPs). Despite the key role HCPs have in this, research has seldom explored their perspectives and understanding of self-management for people with Parkinson's.

METHODS

Multi-disciplinary teams providing care for people with Parkinson's across London, Coventry and Hertfordshire were approached and took part in either one of four focus groups or individual interviews. Forty-two HCPs, including a range of specialist doctors, general practitioners, allied health professionals, nurses, and social workers, took part in this study. Interviews were transcribed and analysed using thematic analysis to identify themes.

RESULTS

Four themes were developed from the data: 1) Empowerment of patients through holistic care and being person-centred; 2) Maximising motivation and capability for patients, for example using asset based approaches and increasing opportunities; 3) importance of empowerment of carers to support self-management and 4) contextual barriers to self-management such as the social context.

CONCLUSIONS

This study is the first to explore the perspectives of HCPs on self-management in people with Parkinson's. Our findings have identified important considerations surrounding empowerment, motivation, carers and contextual barriers to better understand how we enable effective self-management techniques in people with Parkinson's. Research should build on these findings on to develop acceptable and effective self-management tools for use in practice with people affected by Parkinson's.

Are We Transitioning Toward Person-centered Practice on Self-management Support? An Explorative Case Study Among Rheumatology Outpatient Clinic Nurses in Norway

Introduction

There are only a few studies investigating nurses’ views on self-management in the care of patients with rheumatic diseases.

Objective

The aim of this study is to explore how Norwegian rheumatology outpatient nurses describe their ways of supporting patients’ self-management focusing on the core dimensions of person-centered self-management support.

Methods

Ten individual semistructured interviews with rheumatology outpatient nurses were conducted in Norway from March to September 2017. The interviews were audiorecorded and transcribed verbatim. NVIVO was used to support a systematic analysis of themes and patterns.

Results

Nurses’ views on self-management support fell into three approaches; (1) narrowly biomedically orientated, (2) biomedically and holistic, and (3) person-centered. The nurse's views of self-management support varied and did not fully align with the core dimensions of person-centered practice.

Conclusion

The findings indicate that the biomedical paradigm continues to influence Norwegian rheumatology outpatient clinic nurses’ approach to self-management support. If person-centered principles of self-management support are to be translated into standard nursing practice, including identifying and supporting patient-defined self-management goals and processes, there is a need to challenge established structures in health care systems.

Identification of the Most Suitable App to Support the Self-Management of Hypertension: Systematic Selection Approach and Qualitative Study

BACKGROUND

Smartphone apps are increasingly being used to aid in hypertension self-management, and a large and ever-growing number of self-management apps have been commercially released. However, very few of these are potentially effective and secure, and researchers have yet to establish the suitability of specific hypertension apps to particular contexts.

OBJECTIVE

The aim of this study is to identify the most suitable hypertension app in the context of Saudi Arabia and its health system.

METHODS

This study used a 2-stage approach to selecting the most suitable app for hypertension self-management. First, a systematic selection approach was followed to identify a shortlist of the most suitable apps according to the criteria of potential effectiveness, theoretical underpinning, and privacy and security. Second, an exploratory qualitative study was conducted to select the most suitable from the shortlist: 12 doctors were interviewed, and 22 patients participated in 4 focus groups. These explored participants' attitudes towards self-management apps in general, and their views towards the apps identified via the systematic selection process. The qualitative data were analyzed using framework analysis.

RESULTS

In the first stage, only 5 apps were found to be potentially effective while also having a theoretical underpinning and protecting users' data. In the second stage, both doctors and patients were generally interested in using hypertension apps, but most had no experience with these apps due to a lack of awareness of their availability and suitability. Patients and doctors liked apps that combine intuitive interfaces with a pleasant and clear visual design, in-depth features (eg, color-coded feedback accompanied with textual explanations), activity-specific reminders, and educational content regarding hypertension and potential complications. When the pros and cons of the 5 apps were discussed, 3 apps were identified as being more suitable, with Cora Health rated the highest by the participants.

CONCLUSIONS

Only 5 apps were deemed potentially effective and secure. Patients' and doctors' discussions of the pros and cons of these 5 apps revealed that 3 out of the 5 are clearly more suitable, with the Cora Health app being judged most suitable overall.

Factors influencing nurses' provision of self-management support for patients with chronic illnesses: A systematic mixed studies review

BACKGROUND

Self-management support is considered an important task for nurses working in chronic care provision. The complex nature of self-management support makes it necessary to clarify the factors affecting the behaviour of nurses in supporting patients living with chronic illnesses.

OBJECTIVE

The aim of this review is to synthesize the factors influencing the provision of self-management support as perceived by nurses in the care for patients living with a chronic illness.

DESIGN

A systematic mixed studies review.

DATA SOURCE

Studies published in English from 1999 to April 2020 were extracted from five databases: CINAHL, PubMed, Cochrane library, EMBASE, and Web of Science.

REVIEW METHOD

The selection process was guided by PICo (Population, phenomenon of Interest, and Context). Studies that highlighted factors associated with the provision of self-management support among nurses, within the context of the top four non-communicable chronic diseases, were included. The risk of bias was carefully assessed. Using data-based convergent synthesis, the identified factors were synthesized and tabulated. The clusters of factors organized under each theme were approved by all researchers in discussion meetings.

RESULTS

In total, sixteen studies met the inclusion criteria; out of these, seven were qualitative, seven quantitative, and two mixed methods studies. The review identified nurses' perspectives regarding factors influencing self-management support at the patient, nurse, care relationship, education and training, organization and healthcare system, and intra- and inter-professional levels. The review provided evidence that these factors are interdependent in nature.

CONCLUSION

This review proposed considering a framework of interdependent factors influencing self-management support. It highlighted the need to come up with a comprehensive definition of self-management support that takes into account the emotional aspect as well as patient-as-partner approach. The proposed framework can be useful in tailoring multi-faceted interventions to strengthen nurses' supportive role in self-management of chronic care. Future studies should focus on exploring contextually relevant factors impacting nurses' supportive role in self-management.

Patient Activation, Depressive Symptoms, and Self-Rated Health: Care Management Intervention Effects among High-Need, Medically Complex Adults

The purpose of this randomized controlled trial (n = 268) at a Federally Qualified Health Center was to evaluate the outcomes of a care management intervention versus an attention control telephone intervention on changes in patient activation, depressive symptoms and self-rated health among a population of high-need, medically complex adults. Both groups had similar, statistically significant improvements in patient activation and self-rated health. Both groups had significant reductions in depressive symptoms over time; however, the group who received the care management intervention had greater reductions in depressive symptoms. Participants in both study groups who had more depressive symptoms had lower activation at baseline and throughout the 12 month study. Findings suggest that patients in the high-need, medically complex population can realize improvements in patient activation, depressive symptoms, and health status perceptions even with a brief telephone intervention. The importance of treating depressive symptoms in patients with complex health conditions is highlighted.

Empowerment among adult patients with type 2 diabetes: age differentials in relation to person-centred primary care, community resources, social support and other life-contextual circumstances

BACKGROUND

Rising prevalence of type 2 diabetes (T2D), also among younger adults, constitutes a growing public health challenge. According to the person-centred Chronic Care Model, proactive care and self-management support in combination with community resources enhance quality of healthcare and health outcomes for patients with T2D. However, research is scarce concerning the importance of person-centred care and community resources for such outcomes as empowerment, and the relative impact of various patient support sources for empowerment is not known. Moreover, little is known about the association of age with these variables in this patient-group. This study, carried out among patients with T2D, examined in three age-groups (27-54, 55-64 and 65-75 years) whether person-centred care and diabetes-related social support, including community support and possibilities to influence community health issues, are associated with patient empowerment, when considering possible confounding factors, such as other quality of care indicators and psychosocial wellbeing. We also explored age differentials in empowerment and in the proposed correlates of empowerment.

METHOD

Individuals from a register-based sample with T2D participated in a cross-sectional survey (participation 56%, n = 2866). Data were analysed by descriptive statistics and multivariate logistic regression analyses.

RESULTS

Respondents in the youngest age-group were more likely to have low empowerment scores, less continuity of care, and lower wellbeing than the other age-groups, and to perceive less social support, but a higher level of person-centred care than the oldest group. Community support, including possibilities to influence community health issues, was independently and consistently associated with high empowerment in all three age-groups, as was person-centred care in the two older age-groups. Community support was the social support variable with the strongest association with empowerment across age-groups. Moreover, vitality was positively and diabetes-related distress negatively associated with high empowerment in all age-groups, whereas continuity of care, i.e. having a family/regular nurse, was independently associated in the youngest age-group only.

CONCLUSION

Person-centred care and community support, including possibilities to influence community health issues, supports empowerment among adults with T2D. Findings suggest that age is related to most correlates of empowerment, and that younger adults with T2D have specific healthcare needs.

Diabetes care provided by national standards can improve patients' self-management skills: A qualitative study of how people with type 2 diabetes perceive primary diabetes care

BACKGROUND

The increasing incidence of type 2 diabetes mellitus [T2DM] has resulted in extensive research into the characteristics of successful primary diabetes care. Even if self-management support and continuity are increasingly recognized as important, there is still a need for deeper understanding of how patients' experiences of continuity of care coincide with their needs for self-management and/or self-management support.

OBJECTIVE

To gain a deeper understanding of how people with T2DM perceive Swedish primary diabetes care and self-management support.

METHODS

This qualitative study used focus groups as the means for data collection. Participants were identified through a purposive sampling method differing in age, sex, diabetes duration and latest registered glycated haemoglobin level. Twenty-eight participants formed five focus groups. Qualitative content analysis was applied to interview transcripts.

RESULTS

The main theme emerging from the focus group data was that diabetes care provided by national standards improved self-management skills. Two themes that emerged from the analysis were (a) the importance of a clarification of structures and procedures in primary diabetes care and (b) health-care staff 'being there' and providing support enables trust and co-operation to enhance self-management.

CONCLUSIONS

Individual patients' self-management resources are strengthened if the importance of providing relational continuity, management continuity and informational continuity is considered. Patients also need assistance on 'how' self-management activities should be performed.

PATIENT CONTRIBUTION

Prior to the study, one pilot focus group was conducted with patients to obtain their perspectives on the content of the planned focus groups; thus, patients were involved in both planning and conduct of the study.

Nurses' perceptions of self-management and self-management support of older patients during hospitalization

Four focus group interviews were held with nurses, recruited from eight wards of two general hospitals, to explore nurses' perceptions of self-management and self-management support of older patients during hospitalization. A thematic analyze of the interview transcripts was conducted. Regarding nurses understanding of self-management two perceptions emerged namely 'being self-reliant' and 'being in control'. In terms of their understanding self-management support three perceptions emerged: encouraging patients to perform activities of daily living (ADL); stimulating patient participation; and increasing patients' awareness. We also found seven themes relating to nurses' beliefs regarding older patients' self-management and self-management support during hospitalization. Results indicate that nurses have a limited understanding of self-management and do not fully understand what is expected from them with regards to inpatients' self-management. It is feasible to argue that addressing nurses' beliefs can influence nurses intention and behavior regarding supporting older inpatients' self-management.

Self-management support activities in primary care: A qualitative study to compare provision across common health problems

OBJECTIVE

To explore the views of primary care teams about the provision of self-management support to patients with common health problems.

METHODS

Semi-structured interviews were conducted with twenty-one members of the primary care team from thirteen general practices. Interviews were transcribed verbatim, and analysed using the 'Framework' approach.

RESULTS

Three categories and six sub-categories illustrating different self-management support activities across common health problems were identified from the analysis of interviews, and contributed to one major theme and one cross-cutting theme. Referral and signposting were frequently used to facilitate patient engagement with external services and resources. Practitioners faced some challenges in balancing medical management and psychosocial support and motivating patients to engage with self-management.

CONCLUSIONS

Primary care teams described providing a wide range of self-management support activities, but the pattern of use varied for different types of health problem. These patterns may have been influenced, in part, by general practices focusing upon achieving financially incentivised quality improvement goals.

PRACTICE IMPLICATIONS

To improve self-management support, practitioners need a digital repository of services/resources, motivational interviewing skills, an understanding of the optimum duration and pattern of consultations, and incentivised targets that match a biopsychosocial model of care.

Chronic Diseases and Associated Factors among Older Adults in Loja, Ecuador

(1) Background: This study aimed to explore the symptoms, functional status, and depression in patients with chronic diseases in Loja, Ecuador. (2) Methods: A cross-sectional study was carried out with patients over 60 years old having at least one chronic disease and cared for in healthcare centers of the Health Ministry of Ecuador or living in associated geriatric centers. (3) Results: The sample comprised 283 patients with a mean age of 76.56 (SD 7.76) years. The most prevalent chronic diseases were chronic obstructive pulmonary disease, followed by arterial hypertension and diabetes. Patients with a joint disease had the worst scores for the majority of the symptoms assessed with the Edmonton Scale. Cancer, dementia, and arterial hypertension contributed the most to the dependence levels assessed with the Barthel Index. Dementia contributed the most to the poor performance status evaluated with the Karnofsky Performance Status. Cancer and diabetes contributed the most to depression. Patients with a higher number of chronic diseases reported worse functional status. (4) Conclusions: Targeted interventions to address symptoms, functional status, and depression in patients with chronic diseases are needed.

Self-Management Education for Persons with Parkinson's Disease and Their Care Partners: A Quasi-Experimental Case-Control Study in Clinical Practice

Background

Parkinson's disease is a neurodegenerative condition with both physical and mental consequences that affect many aspects of everyday life. Persons with Parkinson's disease and their care partners want guidance from healthcare services in order to develop skills to adjust to life with a long-term condition. The Swedish National Parkinson School is a dyadic self-management programme to support both persons with Parkinson's disease and care partners.

Objective

To assess the outcomes of the Swedish National Parkinson School as reported by participants.

Design

A quasi-experimental case-control study in clinical care using self-reported questionnaires. Participants. Swedish National Parkinson School was offered by health care professionals working in clinical care. Participants in the programme were also asked to participate in the study. A matched control group was recruited for a comparison of findings. In total, 92 persons with Parkinson's disease and 55 care partners were included. Settings. Five Swedish geriatric and neurologic outpatient clinics.

Method

Data were collected during 2015–2017, before and after participation in the National Parkinson School or before and after seven weeks of standard care. Outcomes were assessed using generic and Parkinson's specific questionnaires. Descriptive statistics were used to describe baseline characteristics. Mann–Whitney U and Chi² tests were used to test for between-group differences and within-group differences were tested by the Wilcoxon signed-ranks test.

Results

Improvements regarding health status, constructive attitudes and approaches, and skill and technique acquisition were found after the intervention among persons with Parkinson's disease. No changes were found among care partners.

Conclusion

The findings indicate that the Swedish National Parkinson School may improve health status and self-management among persons with Parkinson's disease, but further studies are needed to better understand the effects of the programme.

The Manage Care Model - Developing an Evidence-Based and Expert-Driven Chronic Care Management Model for Patients with Diabetes

BACKGROUND

Most current care models are disease- or symptom-focused and mostly do not account for the individual needs of patients with chronic diseases. The aim of this study was to develop an innovative, evidence-based and expert-based practice model for the management of patients with type 2 diabetes mellitus.

METHOD

An iterative approach was used combining systematic literature search with qualitative methods, including a standardised survey of experts in chronic care (n = 92), an expert workshop of professionals (n = 22) and a multilingual online survey (n = 659). Using three consensus meetings involving researchers, policy makers and experts in chronic care, a limited number of core components and care recommendations was set up to develop a new chronic care model.

RESULTS

The developed 'MANAGE CARE MODEL' includes aspects of the health and social care system, resources derived from the living environment, aspects of health promotion and prevention, as well as an expanded understanding of improved outcomes as an integral part of chronic care.

CONCLUSION

The MANAGE CARE MODEL provides guidance for the development and implementation of chronic care programs, regional networks and national strategies. Future research is needed to validate the model as an instrument of regional chronic care management.

A nurse-led self-management support intervention for patients and informal caregivers facing incurable cancer: A feasibility study from the perspective of nurses

PURPOSE

Investigation of the feasibility of recruitment through nurses of patients with incurable cancer, and the feasibility (adoption, usage) and nurses' evaluation of a nurse-led self-management support intervention, integrated in continuity home visits and based on the 5 A's Behavior Change Model.

METHOD

Questionnaire, registrations, evaluation forms, and interviews.

RESULTS

Recruitment was complicated; many patients were ineligible for participation, nurses appeared protective of their patients (gatekeeping), and recruitment during the first continuity home visit appeared to be a barrier as a lot of other issues had to be discussed. The adoption rate was 81%, meaning that 18 out of 22 nurses recruited were willing to use the intervention. The usage rate at the nurse level was 56%, meaning that 10 nurses applied the intervention in full (having applied all five A's) in at least one patient. Nurses used the intervention in full in 21 out of the 36 patients included, implying a usage rate at the patient level of 58%. Nurses' mean general satisfaction score for the intervention was 7.57 (range 0-10). Nurse were especially positive about the 5 A's model, and considered the continuity home visits to be an appropriate setting for the intervention.

CONCLUSIONS

Timing of recruitment and gatekeeping complicated recruitment of patients through nurses. Although nurses were positive about the intervention, nurses often did not fully apply the intervention. To improve its usage, it is suggested that nurses should first be trained in using the 5 A's model.

Rehabilitation From Addiction and Chronic Illnesses: A Comparative Analysis of the Narratives of Hungarian Patients

BACKGROUND

In Hungary the psychological care provided during the rehabilitation of patients with chronic illnesses is insufficient. Patients with addiction, on the other hand, appear to make more use of psychological services. Narratives of patients recovering from addiction and patients with various chronic illnesses were examined in order to gain a better understanding of psychological phenomena during rehabilitation.

METHODS

Semi-structured interviews were carried out. Narrative and thematic analysis was used in order to determine the structure and characteristics of patients' narratives.

RESULTS

The narratives of patients recovering from addiction were found to be more structured and uniform; they identified with their illness and played an active role in their recovery. Patients with a chronic illness mainly recounted passive events and physical difficulties. Stigmatization was mentioned by both groups.

IMPLICATIONS FOR PRACTICE

The level of stigmatization experienced by patients with a chronic illness may be one of the reasons why they use healthcare services more frequently than patients with an addiction. The authors believe that teaching patients to provide good narratives about suffering from and recovering from chronic illnesses may aid them in the rehabilitation process. An adaptive mixture of different illnesses and addiction narratives might be beneficial in the recovery process of various patient groups.

Between knowing and doing person-centredness: A qualitative examination of health professionals’ perceptions of roles in self-management support

Self-management is a contemporary model of chronic condition care that places expectations on, and roles for, both patients and health professionals. Health professionals are expected to form partnerships with their patients, and patients are expected to be active participants in their own care. In these new roles, control and responsibility for self-management are shared between people with chronic conditions and their health professionals. We still have limited knowledge about how these new roles are enacted in self-management support. In this article, we examine how health professionals perceive the roles of patients and professionals in chronic condition self-management, drawing on Bourdieu’s concepts of field, doxa and capital. In this qualitative study, 32 in-depth interviews were conducted with 11 health professionals in Sydney, Australia. Data were analysed thematically. Three themes were derived. First, there was incongruence between how participants characterised and enacted their roles. Second, participants compartmentalised clinical and non-clinical aspects of self-management support. Finally, the roles of health professionals entwined with emotions and judgements of patienthood revealed that the provision of self-management support was linked to a fit between individuals’ cultural health capital and the expectations governing the field. We argue that ‘taken for granted’ assumptions about self-management and self-management support must be challenged to mitigate negative social representations and unrealistic expectations placed on patients and health professionals, particularly those patients with less capital, who are more marginalised within clinical interactions.

Patients' perspective on self-management: type 2 diabetes in daily life

BACKGROUND

The number of type 2 diabetes mellitus (T2DM) patients and related treatment costs are rapidly increasing. Consequentially, more cost-effective and efficient strategies for the treatment of T2DM are needed. One such strategy is improving patients' self-management. As patients are more and more expected to self-manage their disease, it is important to provide them with suitable self-management support. This way, success of self-management will increase and complications and related costs of T2DM can be reduced. Currently, self-management support is developed mainly from the perspective of health professionals and caregivers, rather than patients. This research focused on gaining a better understanding of patients' perspectives on self-management and support.

METHODS

Semi-structured interviews, preceded by preparatory assignments, were conducted with ten patients with T2DM treated in Dutch primary care.

RESULTS

We found that patients experience 'active' self-management when recently diagnosed. As time progresses and no problems occur, patients do not experience their disease-related behaviour as self-management. Diabetes has 'just' become part of their daily life, now including new routines taking diabetes into account.

CONCLUSIONS

With this knowledge, support solutions can be designed and implemented that better fit the needs, preferences and abilities of patients with T2DM.

Key elements for the education and counselling of patients treated with oral anticancer drugs

PURPOSE

The process of education and counselling of patients treated with oral anticancer drugs, aimed to achieve adequate self-management, involves different stakeholders (i.e. physicians, oncology nurses, pharmacists) from primary and secondary care. However, currently no guiding principles exist on how to organize and perform education and counselling for these patients. Therefore, the purpose of this study was to develop and build consensus on key elements for the education and counselling in patients on oral anticancer drugs.

METHODS

A multi-method approach combining a literature search, semi-structured interviews with patients and healthcare professionals, and input from experts were used to develop an initial list of key elements. Subsequently, consensus was built in a two-round Delphi-study, involving patients and healthcare professionals from primary and secondary care. Key elements were retained if at least 80% of respondents in all groups considered the element as important or if in at least one group 90% consensus was reached.

RESULTS

The initial list contained 110 key elements, divided in 7 themes: coordination of care, patient contacts: style and content, medication counselling at the start of the treatment and during follow-up, psychosocial support, and involvement of family and friends. After the first Delphi round, 80% consensus was reached for 23 elements; 6 new key elements were added. After the second round, 80% consensus was reached for 51 out of 116 elements; 31 elements were added following the 90%-rule, yielding a list of 82 elements.

CONCLUSION

The final list of 82 key elements, obtained in this study, could be used to develop clinical pathways that guide adequate education and counselling of patients on oral anticancer drugs. Due to the open description, the implementation of these elements can be adapted to the specific context and composition of the oncology team.

Association between person and disease related factors and the planned diabetes care in people who receive person-centered type 2 diabetes care: An implementation study

AIMS

To assess the planned diabetes care for the coming year and its associated factors in patients with Type 2 diabetes who have a person-centered annual consultation.

METHODS

Implementation study of a new consultation model in 47 general practices (primary care) and 6 outpatient clinics (secondary care); 1200 patients from primary and 166 from secondary care participated. Data collection took place between November 2015 and February 2017. Outcomes: preferred monitoring frequency; referral to other health care provider(s); medication change. One measurement at the end of the consultation. We performed logistic regression analyses. Differences between primary and secondary care were analyzed.

RESULTS

Many patients arranged a monitoring frequency <4 times per year (general practices 19.5%, outpatient clinics 40%, p < .001). Type of provider (physician/nurse, OR 3.83, p < .001), baseline HbA1c (OR 1.02, p = .017), glucose lowering medication; and setting treatment goals (OR .65, p = .048) were associated with the chosen frequency. Independently associated with a referral were age (OR .99, p = .039), baseline glucose lowering medication and patients' goal setting (OR 1.52, p = .016). Medication change was associated with type of provider, baseline HbA1c, blood glucose lowering medication, quality of life (OR .80, p = .037) and setting treatment goals (OR 2.64, p = .001).

CONCLUSIONS

Not only disease but also person related factors, especially setting treatment goals, are independently associated with planned care use in person-centered diabetes care.

Patient-provider perspectives on self-management support and patient empowerment in chronic care: A mixed-methods study in a rural sub-Saharan setting

AIM

To explore how provision of self-management support to chronically-ill patients in resource-limited settings contributes to patient empowerment in chronic care.

DESIGN

Concurrent descriptive mixed methods research.

METHODS

A survey of 140 patients with chronic conditions administered at four time-points in 12 months. We conducted 14 interviews and four focus-group discussions with patients (N = 31); 13 healthcare provider interviews; and observations of four patient-support group meetings. Data were collected between April 2016 - May 2017 in rural Malawi. Qualitative data were analysed using a thematic approach and descriptive statistical analysis performed on survey data.

RESULTS

Healthcare professionals facilitated patient empowerment through health education, although literacy levels and environmental factors affected self-management guidance. Information exchanged during patient-provider interactions varied and discussions centred around medical aspects and health promoting behaviour. Less than 40% of survey patients prepared questions prior to clinic consultations. Health education was often unstructured and delegated to non-physician providers, mostly untrained in chronic care. Patients accessed psychosocial support from volunteer-led community home-based care programmes. HIV support-groups regularly interacted with peers and practical skills exchanged in a supportive environment, reinforcing patient's self-mangement competence and proactiveness in health care.

CONCLUSION

For optimal self-management, reforms at inter-personal and organizational level are needed including; mutual patient-provider collaboration, diversifying access to self-management support resources and restructuring patient support-groups to cater to diverse chronic conditions.

IMPACT

Our study provides insights and framing of self-management support and empowerment for patients in long-term care in sub-Saharan Africa. Lessons drawn could feed into designing and delivering responsive chronic care interventions.

Support Needs of People With Head and Neck Cancer Regarding the Disease and Its Treatment

OBJECTIVES

To provide insight into people's experiences in dealing with the consequences of head and neck cancer (HNC) in daily life and their needs for self-management support.

SAMPLE & SETTING

13 people with HNC who were successfully treated in the Department of Radiation Oncology at the Erasmus MC Cancer Institute in Rotterdam, the Netherlands.

METHODS & VARIABLES

Two focus groups and six individual interviews; data were analyzed with directed content analysis.

RESULTS

Most patients wished to receive professional support for dealing with post-treatment consequences. Apart from physical complaints, patients had difficulties in dealing with the emotional aspects of HNC and its treatment and struggled with building self-confidence to move on with their lives. Patients mentioned the importance of relatives being there for them but complained that their needs were not always met. Support from fellow patients was valued for their empathetic capacity.

IMPLICATIONS FOR NURSING

Nurses must provide self-management support that meets people's integral needs inherent in living with the consequences of HNC, particularly in the initial post-treatment period. Practical interventions could be useful.

Capturing motivating versus demotivating self-management support: Development and validation of a vignette-based tool grounded in Self-determination Theory

BACKGROUND

The trend towards more active involvement of patients in the management of their chronic condition requires professionals to interact in a way that facilitates patients' autonomy and motivation. A self-assessment tool that measures simultaneously motivating and demotivating interaction styles in counselling chronic ill patients is currently not available.

OBJECTIVES

Grounded in Self-Determination Theory, this study aimed to develop and validate a self-report tool that captures healthcare professionals' motivating (i.e., autonomy-support and structure) and demotivating (i.e., control and chaos) interaction styles while supporting patients towards self-management.

METHODS

The Situations In Self-management support - HealthCare Professionals (SIS-HCP) was developed throughout a five-phased psychometric validation study with (1) construct definition, (2) development of the vignette-based questionnaire, (3) ecological validation and piloting, (4) psychometric evaluation (round 1) by multidimensional scaling analysis, and (5) psychometric evaluation (round 2) by internal and construct validity, and reliability testing procedures in 5 independent samples (total N = 1133), between August 2015 and March 2018.

RESULTS

Multidimensional scaling analysis provided evidence for a two-dimensional structure, with motivating, relative to demotivating counselling and high, relative to low, directive counselling representing the two axes. Four styles could be distinguished: autonomy-support (rather motivating and non-directive), structure (rather motivating & directive), control (rather demotivating & directive) and chaos (rather demotivating & non-directive) within self-management support. The SIS-HCP demonstrated good construct validity, and high internal consistency and test-retest reliability.

CONCLUSION

The SIS-HCP is a vignette-based tool, which allows to explore, in an integrative way, which motivating (i.e., autonomy-support and structure) and demotivating (i.e., control and chaos) styles healthcare professionals use when counselling patients living with a chronic illness. The SIS-HCP might enhance professionals' awareness of their (de)motivating counselling styles and the extent to which they promote ownership among patients. The SIS-HCP represents an interesting addition to existing instruments which measure what professionals do in the field of self-management support, and how confident they feel doing so. The thorough process of development and validation led to a theoretical underpinned tool, with the identified (de)motivating dimensions yielding strong psychometric properties. The SIS-HCP can be used as a reflective tool for professionals and for tailored training.

Evaluating the feasibility of a nurse-led self-management support intervention for kidney transplant recipients: a pilot study

Background

To support effective self-management after kidney transplantation, a holistic nurse-led self-management support intervention was developed using the Intervention Mapping approach. The primary aim was to evaluate the feasibility, acceptability and fidelity of the intervention for kidney transplant recipients and professionals. The secondary aim was to explore preliminary effects on outcomes.

Methods

A pilot study was conducted in 2015–2017 to evaluate the intervention. Nurse Practitioners (NP) guided recipients in assessing 14 life areas using the Self-Management Web. Participants were supported in developing self-regulation skills which can be applied to self-management of the illness. Strategies included goal setting, action planning, and promotion of motivation and self-efficacy. Adult recipients from an outpatient clinic of a Dutch University Hospital who underwent their transplant at least 1 month ago, were invited to participate. NPs, nephrologists and recipients were interviewed to assess feasibility, fidelity and implementation experience. Consultations were videoed and analysed to assess fidelity. To assess the preliminary effects, the intervention group completed baseline (T0) and follow-up (T1) questionnaires on self-management behavior, self-efficacy, quality of life and quality of care. A historical control group of kidney transplant recipients completed the same questionnaires at T1.

Results

Twenty-seven recipients agreed to participate in the intervention group, of which 24 completed the intervention and 16 completed baseline and follow-up surveys. The control group consisted of 33 recipients. Professionals and recipients appraised the open, holistic focus of the intervention as a welcome addition to standard care and felt that this helped to build a relationship of trust. Recipients also felt they became more competent in problem-solving skills. The within-group analysis showed no significant increase in patients’ self-management skills. The between-groups analysis showed significantly higher medication adherence among the intervention group (P = 0.03; G = 0.81). The within-groups analysis showed a significantly higher perceived quality of care (P = 0.02) in the intervention group.

Conclusion

This holistic nurse-led self-management support intervention was found to be feasible and acceptable by professionals and recipients alike. This pilot had a small sample therefore further research is needed into the potential effects on self-management behavior and well-being of transplant recipients. ISRCTN Trial Registry: ISRCTN15057632 (registered retrospectively on 20-07-2018).

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1300-7) contains supplementary material, which is available to authorized users.

Supporting self-management of radiation-induced bowel and bladder dysfunction in pelvic-cancer rehabilitation: An ethnographic study

AIMS AND OBJECTIVES

To describe and understand strategies that oncological nurses use to support self-management of radiation-induced bowel and bladder issues in pelvic-cancer rehabilitation patients.

BACKGROUND

Nurse-led self-management of radiation-induced bowel and bladder issues holds the potential to support cancer survivors.

DESIGN

An ethnographic approach was applied in this study, which adhered to Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines.

METHODS

Data collection was conducted in Sweden between October 2015-April 2018, involving observations of nurses' daily work, formal and informal interviews, individual and group interviews, and reviews of relevant documents used in the studied practice. Furthermore, 15 supportive nurse-patient talks were observed, and an ethnographic analysis was performed.

RESULTS

The analysis identified the following three categories of nursing strategies that support self-management of radiation-induced bowel and bladder issues in pelvic-cancer rehabilitation patients: encouraging self-reflection, tailoring solutions together and keeping patients motivated. Nurses and patients jointly make sense of patients' symptoms using data that patients collect about themselves. Based on their shared understanding, they can co-create solutions to meet each individual patient's needs and develop routines to keep the patient motivated in performing the devised solutions.

CONCLUSIONS

The results indicate that the strategies nurses use to support patients in self-management of radiation-induced bowel and bladder issues entail intertwining patients' experiences with their nurses' medical knowledge and specific clinical practice. Nurses' strategies build on their ability to connect patients' experiences and the elements of their own work practice.

RELEVANCE TO CLINICAL PRACTICE

A deeper understanding of nurses' strategies to support self-management of radiation-induced bowel and bladder issues in pelvic-cancer rehabilitation patients can improve other self-management programmes, inform nurses' education and aid in the design of tools for pelvic-cancer rehabilitation support.

Diabetes self-management in three different income settings: Cross-learning of barriers and opportunities

The burden of type 2 diabetes is increasing rapidly, not least in Sub-Saharan Africa, and disadvantaged populations are disproportionally affected. Self-management is a key strategy for people at risk of or with type 2 diabetes, but implementation is a challenge. The objective of this study is to assess the determinants of self-management from an implementation perspective in three settings: two rural districts in Uganda, an urban township in South Africa, and socio-economically disadvantaged suburbs in Sweden. Data collection followed an exploratory multiple-case study design, integrating data from interviews, focus group discussions, and observations. Data collection and analysis were guided by a contextualized version of a transdisciplinary framework for self-management. Findings indicate that people at risk of or with type 2 diabetes are aware of major self-management strategies, but fail to integrate these into their daily lives. Depending on the setting, opportunities to facilitate implementation of self-management include: improving patient-provider interaction, improving health service delivery, and encouraging community initiatives supporting self-management. Modification of the physical environment (e.g. accessibility to healthy food) and the socio-cultural environment (i.e. norms, values, attitudes, and social support) may have an important influence on people's lifestyle. Regarding the study methodology, we learned that this innovative approach can lead to a comprehensive analysis of self-management determinants across different settings. An important barrier was the difficult contextualization of concepts like perceived autonomy and self-efficacy. Intervention studies are needed to confirm whether the pathways suggested by this study are valid and to test the proposed opportunities for change.

A Nurse-Led Self-Management Support Intervention (ZENN) for Kidney Transplant Recipients Using Intervention Mapping: Protocol for a Mixed-Methods Feasibility Study

Background

Optimal self-management in kidney transplant recipients is essential for patient and graft survival, reducing comorbidity and health care costs while improving the quality of life. However, there are few effective interventions aimed at providing self-management support after kidney transplantation.

Objective

This study aims to systematically develop a nurse-led, self-management (support) intervention for kidney transplant recipients.

Methods

The Intervention Mapping protocol was used to develop an intervention that incorporates kidney transplant recipients’ and nurses’ needs, and theories as well as evidence-based methods. The needs of recipients and nurses were assessed by reviewing the literature, conducting focus groups, individual interviews, and observations (step 1). Based on the needs assessment, Self-Regulation Theory, and the “5A’s” model, change objectives were formulated (step 2). Evidence-based methods to achieve these objectives were selected and subsequently translated into practical implementation strategies (step 3). Then, program materials and protocols were developed accordingly (step 4). The implementation to test the feasibility and acceptability was scheduled for 2015-2017 (step 5). The last step of Intervention Mapping, evaluation of the intervention, falls outside the scope of this paper (step 6).

Results

The intervention was developed to optimize self-management (support) after kidney transplantation and targeted both kidney transplant recipients and nurse practitioners who delivered the intervention. The intervention was clustered into four 15-minute sessions that were combined with regular appointments at the outpatient clinic. Nurses received a training syllabus and were trained in communication techniques based on the principles of Solution-Focused Brief Therapy and Motivational Interviewing; this entailed guiding the patients to generate their own goals and solutions and focus on strengths and successes. Kidney transplant recipients were encouraged to assess self-management challenges using the Self-Management Web and subsequently develop specific goals, action plans, and pursuit skills to solve these challenges.

Conclusions

The Intervention Mapping protocol provided a rigorous framework to systematically develop a self-management intervention in which nurses and kidney transplant recipients’ needs, evidence-based methods, and theories were integrated.

International Registered Report Identifier (IRRID)

DERR1-10.2196/11856

Self-efficacy and health-related quality of life: a cross-sectional study of primary care patients with multi-morbidity

BACKGROUND

Multi-morbidity in chronic long-term conditions is a major concern for health services. Self-management in concert with clinical care forms part of the effective management of multi-morbidity. Self-efficacy is a mechanism through which self-management can be achieved. Quality of life is adversely impacted by multi-morbidity but could be improved by effective self-management. This study examines the relationship between self-efficacy and quality of life in primary care patients with multi-morbidity.

METHODS

A cross-sectional survey was conducted with primary care patients in England. Potential participants were mailed a questionnaire containing quality of life measures (the EQ-5D-5L and the Long-Term Conditions Questionnaire (LTCQ)), the Disease Burden Impact Scale (DBIS) and the Self-efficacy for Managing Chronic Disease Scale. Descriptive statistics, analysis of variance and linear regression analyses were conducted to examine the relationship between quality of life (dependent variable), self-efficacy, and demographic and disease-related variables.

RESULTS

The 848 participants living with multi-morbidity reported a mean of 6.46 (SD 3.49) chronic long-term conditions, with the mean number of physical conditions 5.99 (SD 3.34) and mental health conditions 0.47 (SD 0.66). The mean scores were 15.45 (SD 12.00) for disease burden, 0.69 (SD 0.28) for the EQ-5D-5L, 65.44 (SD 23.66) for the EQ-VAS, and 69.31 (SD 21.77) for the LTCQ. The mean self-efficacy score was 6.69 (SD 2.53). The regression models were all significant at p < 0.001 (adjusted R2 > 0.70). Significant factors in all models were self-efficacy, disease burden and being permanently sick or disabled. Other factors varied between models, with the most notable being the presence of a mental health condition in the LTCQ model.

CONCLUSIONS

Multi-morbid primary care patients with lower self-efficacy and higher disease burden have lower quality of life. Awareness of self-efficacy levels among patients with multi-morbidity may help health professionals identify patients who are in need of enhanced self-management support. Providing self-management support for chronic disease has been hailed as a hallmark of good care. Higher self-efficacy may lead to enhanced quality of life in multi-morbidity.

Patients' experiences with a behaviour change intervention to enhance physical activity in primary care: A mixed methods study

Objective

To explore the experiences of patients at risk for cardiovascular disease in primary care with the Activate intervention in relation to their success in increasing their physical activity.

Methods

A convergent mixed methods study was conducted, parallel to a cluster-randomised controlled trial in primary care, using a questionnaire and semi-structured interviews. Questionnaires from 67 patients were analysed, and semi-structured interviews of 22 patients were thematically analysed. Experiences of patients who had objectively increased their physical activity (responders) were compared to those who had not (non-responders). Objective success was analysed in relation to self-perceived success.

Results

The questionnaire and interview data corresponded, and no substantial differences among responders and non-responders emerged. Participating in the intervention increased patients’ awareness of their physical activity and their physical activity level. Key components of the intervention were the subsequent support of nurses with whom patients’ have a trustful relationship and the use of self-monitoring tools. Patients highly valued jointly setting goals, planning actions, receiving feedback and review on their goal attainment and jointly solving problems. Nurses’ support, the use of self-monitoring tools, and involving others incentivised patients to increase their physical activity. Internal circumstances and external circumstances challenged patients’ engagement in increasing and maintaining their physical activity.

Conclusion

Patients experienced the Activate intervention as valuable to increase and maintain their physical activity, irrespective of their objective change in physical activity. The findings enable the understanding of the effectiveness of the intervention and implementation in primary care.

Trial registration

ClinicalTrials.gov NCT02725203.

Nurses' perceptions towards the delivery and feasibility of a behaviour change intervention to enhance physical activity in patients at risk for cardiovascular disease in primary care: a qualitative study

Background

Self-management support is widely accepted for the management of chronic conditions. Self-management often requires behaviour change in patients, in which primary care nurses play a pivotal role. To support patients in changing their behaviour, the structured behaviour change Activate intervention was developed. This intervention aims to enhance physical activity in patients at risk for cardiovascular disease in primary care as well as to enhance nurses’ role in supporting these patients. This study aimed to evaluate nurses’ perceptions towards the delivery and feasibility of the Activate intervention.

Methods

A qualitative study nested within a cluster-randomised controlled trial using semistructured interviews was conducted and thematically analysed. Fourteen nurses who delivered the Activate intervention participated.

Results

Three key themes emerged concerning nurses’ perceptions of delivering the intervention: nurses’ engagement towards delivering the intervention; acquiring knowledge and skills; and dealing with adherence to the consultation structure. Three key themes were identified concerning the feasibility of the intervention: expectations towards the use of the intervention in routine practice; perceptions towards the feasibility of the training programme; and enabling personal development.

Conclusions

Delivering a behaviour change intervention is challenged by the complexity of changing nurses’ consultation style, including acquiring corresponding knowledge and skills. The findings have increased the understanding of the effectiveness of the Activate trial and will guide the development and evaluation of future behaviour change interventions delivered by nurses in primary care.

Trial registration

ClinicalTrials.gov NCT02725203.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0888-1) contains supplementary material, which is available to authorized users.

The use and helpfulness of self-management strategies for depression: The experiences of patients

OBJECTIVE

To explore which of 50 self-management strategies are actually used and which are perceived as most helpful by patients in their day-to-day management of depression, in order to empower patients and promote active engagement in their own care.

METHODS

Retrospective study using an online self-report survey to assess the use and perceived helpfulness of 50 previously identified self-management strategies in 193 participants who recently recovered from a major depressive episode.

RESULTS

Forty-five of the 50 strategies were used by at least half of all participants and about one third of all participants perceived almost 50% of all strategies as (very) helpful. The most used strategies, such as 'finding strategies to create pleasurable distractions', 'engaging in leisure activities' or 'identifying the cause of the depression', were not always perceived as most helpful. In addition, the perceived most helpful strategies, such as 'completing treatment' and 'leaving the house regularly' were not always the most used ones.

CONCLUSIONS

Patients use and perceive a wide range of self-management strategies as helpful to recover from their depression. Patients use and perceive strategies about engagement in treatment and physical activities as being most helpful. These finding may contribute to the further development and implementation of self-management programs for the prevention or the rehabilitation of depression.

Patients experiences of self-management and strategies for dealing with chronic conditions in rural Malawi

BACKGROUND

The high burden of chronic communicable diseases such as HIV/AIDS, and an escalating rise of non-communicable diseases (NCDs) in Malawi and other sub-Saharan African countries, calls for a shift in how health care services are designed and delivered. Patient-centred care and patient self-management are critical elements in chronic care, and are advocated as universal strategies. In sub-Saharan Africa, there is need for more evidence around the practice of patient self-management, and how to best support patients with chronic conditions in the African context. Our study explored self-management practices of patients with different chronic conditions, and their strategies to overcome care challenges in a resource-constrained setting in Malawi.

METHODS

This is primarily a qualitative study, involving patients with different chronic conditions from one rural district in Malawi. Data are drawn from semi-structured questions of a survey with 129 patients (from the third of four-part data collection series), 14 in-depth interviews, and four focus-group discussions with patients (n = 31 respondents). A framework approach was used for qualitative analysis, and descriptive statistical analysis was performed on survey data.

RESULTS

Patients demonstrated ability to self-manage their conditions, though this varied between conditions, and was influenced by individual and external factors. Factors included: 1) ability to acquire appropriate disease knowledge; 2) poverty level; 3) the presence of support from family caregivers and community-based support initiatives; 4) the nature of one's social relations; and 5) the ability to deal with stressors and stigma. NCD and HIV comorbid patients were more disadvantaged in their access to care, as they experienced frequent drug stock-outs and incurred additional costs when referred. These barriers contributed to delayed care, poorer treatment adherence, and likelihood of poorer treatment outcomes. Patients proved resourceful and made adjustments in the face of (multiple) care challenges.

CONCLUSION

Our findings complement other research on self-management experiences in chronically ill patients with its analysis on factors and barriers that influence patient self-management capacity in a resource-constrained setting. We recommend expanding current peer-patient and support group initiatives to patients with NCDs, and further investments in the decentralisation of integrated health services to primary care level in Malawi.

'Physical activity, that's a tricky subject.' Experiences of health care professionals with physical activity in type 2 diabetes care

BACKGROUND

Based on a growing body of epidemiological and biomedical studies, physical activity (PA) is considered a cornerstone in type 2 diabetes treatment. However, it is also a practice embedded in daily life and, as such, may produce certain frictions as a topic in health care. The aim of this article is to give in-depth insight into experiences of health care professionals with the delivery of PA counselling to people with type 2 diabetes.

METHODS

This study is based on in-depth interviews with 24 Dutch professionals providing care to people with type 2 diabetes. They were asked to tell about their experiences with PA in different roles, both in their professional and personal lives. The interviews were audio-recorded and transcribed verbatim. Data analysis followed a narrative approach with not only a focus on what was told, but also on how this was constructed in interaction with the interviewer, the cultural resources that were drawn on and inconsistencies or alternatives that were presented. This narrative focus was used to explore how professionals made sense of their experiences with PA counselling within the wider sociocultural context.

RESULTS

While the professionals view PA as a foundation of type 2 diabetes treatment, they experience it to be a tricky subject. Two main areas of tension were identified: (1) the understanding of patient behaviour; and (2) professionals' views on responsibilities, both on their responsibilities as professionals and their notions on who is responsible for behaviour change.

CONCLUSIONS

Health care professionals providing PA counselling to people with type 2 diabetes have to navigate between possibilities within the diabetes care framework, options for an embedding of PA in the patient's lifeworld, and the professionals' opinions on and experiences with PA and healthy living from their own lifeworld. This makes PA a complex topic of care.