Improving self-management skills: a whole systems approach

Use of participatory action research approach to develop a self-management resource for persons living with dementia

This article describes the use of a participatory action research (PAR) approach to developing a self-management resource for persons living with dementia and care partners. Despite growing evidence that persons with dementia are able to contribute in meaningful ways to decision-making about their care and life preferences, few opportunities exist for them to participate in the design of resources and services meant for them. There is also a need to support the self-management of persons living with dementia with the provision of accurate, high quality, user-friendly information. The Living Well with Dementia resource was developed through a partnership with persons with dementia, family members, Alzheimer Society representatives, primary care providers, and researchers. The methods used in the development of this resource are outlined in six steps employed in this process, from establishment of a PAR team to final resource creation. Informed by a whole systems approach, the resource brings together essential components of self-management into a comprehensive system of care and support for living. It empowers users to be active participants in the application of new knowledge to their lives. Better self-management has important implications for access to health care and quality of life for persons with dementia and care partners.

A randomised controlled trial, cost-effectiveness and process evaluation of the implementation of self-management for chronic gastrointestinal disorders in primary care, and linked projects on identification and risk assessment

Background

Chronic gastrointestinal disorders are major burdens in primary care. Although there is some evidence that enhancing self-management can improve outcomes, it is not known if such models of care can be implemented at scale in routine NHS settings and whether or not it is possible to develop effective risk assessment procedures to identify patients who are likely to become chronically ill.

Objectives

What is the clinical effectiveness and cost-effectiveness of an intervention to enhance self-management support for patients with chronic conditions when translated from research settings into routine care? What are the barriers and facilitators that affect the implementation of an intervention to enhance self-management support among patients, clinicians and organisations? Is it possible to develop methods to identify patients at risk of long-term problems with functional gastrointestinal disorders in primary care? Data sources included professional and patient interviews, patient self-report measures and data on service utilisation.

Design

A pragmatic, two-arm, practice-level cluster Phase IV randomised controlled trial evaluating outcomes and costs associated with the intervention, with associated process evaluation using interviews and other methods. Four studies around identification and risk assessment: (1) a general practitioner (GP) database study to describe how clinicians in primary care record consultations with patients who experience functional lower gastrointestinal symptoms; (2) a validation of a risk assessment tool; (3) a qualitative study to explore GPs’ views and experiences; and (4) a second GP database study to investigate patient profiles in irritable bowel syndrome, inflammatory bowel disease and abdominal pain.

Setting

Salford, UK.

Participants

People with long-term conditions and professionals in primary care.

Interventions

A practice-level intervention to train practitioners to assess patient self-management capabilities and involve them in a choice of self-management options.

Main outcome measures

Patient self-management, care experience and quality of life, health-care utilisation and costs.

Results

No statistically significant differences were found between patients attending the trained practices and those attending control practices on any of the primary or secondary outcomes. The intervention had little impact on either costs or effects within the time period of the trial. In the practices, self-management tools failed to be normalised in routine care. Full assessment of the predictive tool was not possible because of variable case definitions used in practices. There was a lack of perceived clinical benefit among GPs.

Limitations

The intervention was not implemented fully in practice. Assessment of the risk assessment tool faced barriers in terms of the quality of codting in GP databases and poor recruitment of patients.

Conclusions

The Whole system Informing Self-management Engagement self-management (WISE) model did not add value to existing care for any of the long-term conditions studied.

Future work

The active components required for effective self-management support need further study. The results highlight the challenge of delivering improvements to quality of care for long-term conditions. There is a need to develop interventions that are feasible to deliver at scale, yet demonstrably clinically effective and cost-effective. This may have implications for the piloting of interventions and linking implementation more clearly to local commissioning strategies.

Trial registration

Current Controlled Trial ISRCTN90940049.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 6, No. 1. See the NIHR Journals Library website for further project information.

Designing, Implementing, and Evaluating Mobile Health Technologies for Managing Chronic Conditions in Older Adults: A Scoping Review

Background

The current landscape of a rapidly aging population accompanied by multiple chronic conditions presents numerous challenges to optimally support the complex needs of this group. Mobile health (mHealth) technologies have shown promise in supporting older persons to manage chronic conditions; however, there remains a dearth of evidence-informed guidance to develop such innovations.

Objectives

The purpose of this study was to conduct a scoping review of current practices and recommendations for designing, implementing, and evaluating mHealth technologies to support the management of chronic conditions in community-dwelling older adults.

Methods

A 5-stage scoping review methodology was used to map the relevant literature published between January 2005 and March 2015 as follows: (1) identified the research question, (2) identified relevant studies, (3) selected relevant studies for review, (4) charted data from selected literature, and (5) summarized and reported results. Electronic searches were conducted in 5 databases. In addition, hand searches of reference lists and a key journal were completed. Inclusion criteria were research and nonresearch papers focused on mHealth technologies designed for use by community-living older adults with at least one chronic condition, or health care providers or informal caregivers providing care in the home and community setting. Two reviewers independently identified articles for review and extracted data.

Results

We identified 42 articles that met the inclusion criteria. Of these, described innovations focused on older adults with specific chronic conditions (n=17), chronic conditions in general (n=6), or older adults in general or those receiving homecare services (n=18). Most of the mHealth solutions described were designed for use by both patients and health care providers or health care providers only. Thematic categories identified included the following: (1) practices and considerations when designing mHealth technologies; (2) factors that support/hinder feasibility, acceptability, and usability of mHealth technologies; and (3) approaches or methods for evaluating mHealth technologies.

Conclusions

There is limited yet increasing use of mHealth technologies in home health care for older adults. A user-centered, collaborative, interdisciplinary approach to enhance feasibility, acceptability, and usability of mHealth innovations is imperative. Creating teams with the required pools of expertise and insight regarding needs is critical. The cyclical, iterative process of developing mHealth innovations needs to be viewed as a whole with supportive theoretical frameworks. Many barriers to implementation and sustainability have limited the number of successful, evidence-based mHealth solutions beyond the pilot or feasibility stage. The science of implementation of mHealth technologies in home-based care for older adults and self-management of chronic conditions are important areas for further research. Additionally, changing needs as cohorts and technologies advance are important considerations. Lessons learned from the data and important implications for practice, policy, and research are discussed to inform the future development of innovations.

Chronic Disease Self-Management by People With HIV

As HIV has transitioned into a chronic disease, reappraisal of clinical management has occurred with chronic disease self-management (CDSM) as one possibility. However, despite extensive work on CDSM across a range of diseases, little attention has focused on psychosocial contexts of the lives of people for whom programs are intended. This article reports semi-structured interviews used to explore health practices and motivations of 33 people with HIV (PWHIV) in Australia. Within participants' accounts, different forms of subjectivity and agency emerged with implications for how they understood and valued health-related behaviors. Four themes arose: health support and disclosure, social support and stigma, employment/structure, and health decisions beyond HIV. The experience of stigma and its intersection with CDSM remains relatively un-chartered. This study found stigma shapes agency and engagement with health. Decisions concerning health behaviors are often driven by perceived social and emotional benefit embedded in concerns of disclosure and stigma.

Behaviour change and social blinkers? The role of sociology in trials of self-management behaviour in chronic conditions

Individual-focused self-management interventions are one response to both an ageing society and the purported increase in chronic conditions. They tend to draw on psychological theories in self-management interventions, but over-reliance on these theories can reinforce a narrow focus on specified attitudinal and behavioural processes, omitting aspects of living with a chronic condition. While advances have been made in health behaviour change theory and practice, scant attention has been paid to the social, with the question of social context remaining under-theorised and under-explored empirically. This is particularly noticeable in trials of behaviour change interventions for self-management. The common sociological critique is that these ignore context and thus no explanation can be given as to why, for whom and under what circumstances a treatment works. Conversely, sociologists are criticised for offering no positive suggestions as to how context can be taken into account and for over-emphasising context with the risk of inhibiting innovation. This article provides an overview of these issues and provides examples of how context can be incorporated into the rigid method of trials of self-management for chronic conditions. We discuss modifications to both trial interventions and design that make constructive use of the concept of context.

Self-management for people with long-term neurological conditions

Although English government policy has encouraged the implementation of self-management programmes in services for people with long-term conditions, the evidence for their efficacy has been limited. People with long-term neurological conditions use community-based health services including community nursing, and have particular needs in regards to self-management. This article provides an overview of the evidence for the effectiveness of self-management interventions for people with long-term neurological conditions, in particular those with stroke, Parkinson's disease and multiple sclerosis. The current need for better interventions is highlighted, particularly the importance of providing condition-specific information and deliverance of interventions in a group setting to improve self-management outcomes. In response to weaknesses of previous self-management interventions for this population, an innovative Hertfordshire Neurological Service self-management programme is discussed, and the implications for future research are described.

Rethinking 'risk' and self-management for chronic illness

Self-management for chronic illness is a current high profile UK healthcare policy. Policy and clinical recommendations relating to chronic illnesses are framed within a language of lifestyle risk management. This article argues the enactment of risk within current UK self-management policy is intimately related to neo-liberal ideology and is geared towards population governance. The approach that dominates policy perspectives to 'risk' management is critiqued for positioning people as rational subjects who calculate risk probabilities and act upon them. Furthermore this perspective fails to understand the lay person's construction and enactment of risk, their agenda and contextual needs when living with chronic illness. Of everyday relevance to lay people is the management of risk and uncertainty relating to social roles and obligations, the emotions involved when encountering the risk and uncertainty in chronic illness, and the challenges posed by social structural factors and social environments that have to be managed. Thus, clinical enactments of self-management policy would benefit from taking a more holistic view to patient need and seek to avoid solely communicating lifestyle risk factors to be self-managed.

A cluster randomised controlled trial of the clinical and cost-effectiveness of a 'whole systems' model of self-management support for the management of long- term conditions in primary care: trial protocol

BACKGROUND

Patients with long-term conditions are increasingly the focus of quality improvement activities in health services to reduce the impact of these conditions on quality of life and to reduce the burden on care utilisation. There is significant interest in the potential for self-management support to improve health and reduce utilisation in these patient populations, but little consensus concerning the optimal model that would best provide such support. We describe the implementation and evaluation of self-management support through an evidence-based 'whole systems' model involving patient support, training for primary care teams, and service re-organisation, all integrated into routine delivery within primary care.

METHODS

The evaluation involves a large-scale, multi-site study of the implementation, effectiveness, and cost-effectiveness of this model of self-management support using a cluster randomised controlled trial in patients with three long-term conditions of diabetes, chronic obstructive pulmonary disease (COPD), and irritable bowel syndrome (IBS). The outcome measures include healthcare utilisation and quality of life. We describe the methods of the cluster randomised trial.

DISCUSSION

If the 'whole systems' model proves effective and cost-effective, it will provide decision-makers with a model for the delivery of self-management support for populations with long-term conditions that can be implemented widely to maximise 'reach' across the wider patient population.

TRIAL REGISTRATION NUMBER

ISRCTN: ISRCTN90940049.

Patient access to healthcare services and optimisation of self-management for ethnic minority populations living with diabetes: a systematic review

A higher risk of diabetes mellitus in South Asian and Black African populations combined with lower reported access and self-management-related health outcomes informed the aims of this study. Our aims were to synthesise and evaluate evidence relating to patient self-management and access to healthcare services for ethnic minority groups living with diabetes. A comprehensive search strategy was developed capturing a full range of study types from 1995-2010, including relevant hand-searched literature pre-dating 1995. Systematic database searches of MEDLINE, Cochrane, DARE, HTA and NHSEED, the British Nursing Index, CAB abstracts, EMBASE, Global Health, Health Management Information Consortium and PsychInfo were conducted, yielding 21,288 abstracts. Following search strategy refinement and the application of review eligibility criteria; 11 randomised controlled trials (RCTs), 18 qualitative studies and 18 quantitative studies were evaluated and principal results extracted. Results suggest that self-management practices are in need of targeted intervention in terms of patients' knowledge and understanding of their illness, inadequacy of information and language and communication difficulties arising from cultural differences. Access to health-care is similarly hindered by a lack of cultural sensitivity in service provision and under use of clinic-based interpreters and community-based services. Recommendations for practice and subsequent intervention primarily rest at the service level but key barriers at patient and provider levels are also identified.

A comprehensive evaluation of the impact of telemonitoring in patients with long-term conditions and social care needs: protocol for the whole systems demonstrator cluster randomised trial

Background

It is expected that increased demands on services will result from expanding numbers of older people with long-term conditions and social care needs. There is significant interest in the potential for technology to reduce utilisation of health services in these patient populations, including telecare (the remote, automatic and passive monitoring of changes in an individual's condition or lifestyle) and telehealth (the remote exchange of data between a patient and health care professional). The potential of telehealth and telecare technology to improve care and reduce costs is limited by a lack of rigorous evidence of actual impact.

Methods/Design

We are conducting a large scale, multi-site study of the implementation, impact and acceptability of these new technologies. A major part of the evaluation is a cluster-randomised controlled trial of telehealth and telecare versus usual care in patients with long-term conditions or social care needs. The trial involves a number of outcomes, including health care utilisation and quality of life. We describe the broad evaluation and the methods of the cluster randomised trial

Discussion

If telehealth and telecare technology proves effective, it will provide additional options for health services worldwide to deliver care for populations with high levels of need.

Trial Registration

Current Controlled Trials ISRCTN43002091

Research – a tool to empower or disrupt? The effects of research on those involved

Background

Research in clinical practice without attachment to a major academic institution can be fraught with difficulties. This article aims to explore some of the difficulties that can be encountered when carrying out research, using the example of a project aiming to use clinical practice to develop more relevant and realistic multidisciplinary outcome measures for the rehabilitation population. In this example, with patient and staff involvement, the reliability study successfully developed the Care Dependency Scale into such a tool.

Contents

This article does not present the results of the research, which will be presented separately; rather it describes the story of the research project, outlining both the challenges and benefits that transpired as a consequence of staff being involved in research in a small multidisciplinary rehabilitation centre.

Conclusions

While such research can present many challenges, endeavouring to overcome these can have positive outcomes for both staff and patients. In this case, participating in research proved to be a tool to empower both staff and patients and promoted changes in the Centre. Potential researchers should not be put off their investigations simply because they are not affiliated with an academic institution.

A critical review of self-management and educational interventions in inflammatory bowel disease

The purpose of this study was to examine self-management and educational interventions developed to support people with inflammatory bowel disease (IBD) and to identify which type of intervention seems to be most effective. The search was deliberately overinclusive to capture studies that evaluated educational and self-management interventions. The following databases were searched: MEDLINE, Embase, CINAHL, PsycINFO, the National Research Register, and Cochrane. Twenty-three studies were included. Thirteen of these were randomized controlled trials. The content of the interventions reviewed varied widely. As expected, it is the three studies that have explicitly labeled themselves as self-management interventions that have incorporated the greatest number of self-management techniques. Two of these studies reported the greatest number of improved outcomes in relation to symptom reporting, psychological well-being, and healthcare resource use. There is clearly a role for information in IBD, but this review supports research in other conditions that shows that education cannot be assumed to lead to improvements in health and well-being. Much of the research in this area focuses on education rather than self-management. Where self-management techniques have been applied, the findings tend to be more promising. Gastroenterology nurses (or in the United Kingdom, IBD specialist nurses) may be best placed to facilitate self-management in this group.

What makes a successful volunteer Expert Patients Programme tutor? Factors predicting satisfaction, productivity and intention to continue tutoring of a new public health workforce in the United Kingdom

OBJECTIVES

Better management of chronic conditions is a challenge for public health policy. The Expert Patients Programme was introduced into the United Kingdom to improve self-care in people with long-term conditions. To deliver self-care courses, the programme relies on the recruitment and continued commitment to delivering the courses of volunteer lay tutors who have long-term conditions. Ensuring the tutor workforce is productive, satisfied in their role and retained long-term is central to the viability of the programme. This exploratory study aimed to determine what factors predict productivity, intention to continue tutoring, and satisfaction in a sample of volunteer tutors from the Expert Patients Programme.

METHODS

A cross-sectional survey of 895 tutors was carried out and 518 (58%) responded. The questionnaire was designed to describe the characteristics, productivity, intention to continue tutoring, and satisfaction of tutors. Multiple linear regression analyses were used to examine the determinants of productivity, intention to continue tutoring, and satisfaction, such as patient demographics, attitudes, physical and mental health, mastery and self-esteem.

RESULTS

Attitudes relating to personal goals, and better health were significant predictors of satisfaction with the tutor role. Only a small proportion of the variance in productivity was accounted for, and tutors were more likely to be productive when they were single, homeowners, car owners, and had lower scores on the depression scale. Overall satisfaction and personal goals were predictors of intention to continue tutoring.

CONCLUSION

Demographic factors, health measures and attitudes each predicted different aspects of the experience of work conducted by the volunteer tutors. The results should prove useful for planning interventions to enhance the success of this new workforce initiative.

PRACTICE IMPLICATIONS

Attempts to increase participation in courses by people from deprived backgrounds are likely to be enhanced if tutors come from similar backgrounds. This study demonstrated that material advantage and attitudes that value personal goals were predictors of satisfaction and productivity in the tutor role. Specific incentives and strategies may be required to recruit and support tutors from more marginalised groups in order to ensure equitable access to effective self-care support for all.

The experience of self-management in adolescent women with spina bifida

It is essential for youth with chronic health conditions like spina bifida (SB) to develop self-management skills to combat vulnerability, achieve self-sufficiency, and transition to adulthood. The purpose of this qualitative study was to describe the experience of self-management in 31 adolescent women with SB. Three themes emerged from this study: (1) opportunities to engage in self-management activities--knowledge, skills, and aspirations; (2) dance of individuation--parental impact on self-management; and (3) advocacy within self-management--confronting discrimination and stigma. The findings indicate that assessment and interventions to enhance self-management in adolescent women with SB are critical for supporting the range of condition-related and life skills needed for a transition to adulthood and independent living.

Promoting patient engagement with self-management support information: a qualitative meta-synthesis of processes influencing uptake

Background

Patient information has been viewed as a key component of self-management. However, little attention has been given to methods of dissemination or implementation of effective information strategies. Previous problems identified with the use and implementation of patient information point to the need to explore the way in which patients engage with and use information to support self-management for chronic conditions.

Methods

Four published qualitative studies from a programme of research about self-management were analysed as a group; these included studies of the management of inflammatory bowel disease (IBD); self-help in anxiety and depression (SHADE); menorrhagia, treatment, information, and preference (MENTIP) study; and self-help for irritable bowel syndrome (IBS). For the analysis, we used an adapted meta-ethnographic approach to the synthesis of qualitative data in order to develop an evidence base.

Results

The ontological status and experience of the condition in everyday life was the most dominant theme to emerge from this synthesis. This, coupled with access to and experience of traditional health services responses, shaped the engagement with and use of information to support self-management. Five key elements were found which were likely to influence this: the perception and awareness of alternative self-management possibilities; the prior extent and nature of engagement with information; the extent of and ability to self-manage; opportunities for use of the information and the stage of the illness career; and congruence and synergy with the professional role.

Conclusion

People with chronic conditions need support from providers in both supply and engagement with information, in a way which gives legitimacy to the person's own self-management strategies and possible alternatives. Thus, a link could usefully be made between information offered, as well as patients' past experiences of self-management and engagement with services for their condition. The timeliness of the information should be considered, both in terms of the illness career and the type of condition (i.e., before depression gets too bad or time to reflect on existing knowledge about a condition and how it is to be managed) and in terms of the pre-existing relationship with services (i.e., options explored and tried).

More considered use of information (how it is provided, by whom, and at what point it should be introduced) is key to facilitating patients' engagement with and therefore use of information to support self-management.

Re-thinking the relationship between long-term condition self-management education and the utilisation of health services

Encouraging self-management has been viewed as one means of reducing health service utilisation and contributing to improved demand management. However, the processes and imputed relationship between self-management education skills and health service contact are poorly understood. This paper reports on data from an embedded qualitative study which ran alongside a randomised controlled trial in England designed to test the clinical and cost effectiveness of a self-care support policy which found no statistically significant reductions in health service utilisation. Drawing on concepts from the sociology of chronic illness, analyses suggest that the biographical and social context relevant to individuals' experience of living with a long-term condition, history of health service utilisation, and relationships with health professionals are relevant to understanding the impact of self-management education and related policies aimed at bringing about changes in service use. Our study suggests that future health policy assumptions about utilisation in the context of chronic disease management and self-care support polices may benefit by acknowledging the complex, contextual and recursive nature of health service utilisation operating in the life worlds of patients' experience of living with a long-term condition.

Training professionals to engage with and promote self-management

We have set out to investigate an approach to improve patients' ability to self-manage chronic illness. For effective health care in chronic disease, we believe patients need to work in partnership with their doctor; patient-centred consultations are one way to achieve this. This report describes our experience of training specialists in gastroenterology to consult in a patient-centred style as part of a complex self-management intervention in a randomized controlled trial (RCT) involving 700 patients with established inflammatory bowel disease (IBD) attending outpatient clinics. The training session aimed to provide specialists from nine randomly selected intervention sites with the basic skills to carry out the intervention. The training lasted 2 hours, and included background on the research and intervention, a demonstration video, role-play, and video-feedback training. The main findings of the RCT are presented (service use, enablement and satisfaction), and discussed in the light of the views of consultants and patients on the experience of putting the training into practice. The findings of our study confirm and highlight the value of training in patient-centred communication and its potential for promoting self-management effects; the training proved effective in enabling consultants in gastroenterology to establish guided self-management in patients with IBD.

Uncovering the limits of patient-centeredness: implementing a self-management trial for chronic illness

Research evaluating self-management of chronic conditions points to the effectiveness of interventions' changing the health behavior of individuals. However, we know little about how self-management is negotiated within health services. The authors designed a qualitative investigation to illuminate the quantitative findings of a randomized controlled trial (RCT) of a self-management program for people with inflammatory bowel disease. They conducted in-depth interviews with physicians and patients, and qualitative analysis illuminated the nature of doctor-patient encounters and possible reasons for lack of change in patient satisfaction with the consultation. The findings suggest that factors inhibiting effective patient-centered consultations include failure of physicians to incorporate expressed need relevant to people's self-management activities fully, interpretation of self-management as compliance with medical instructions, and the organization of outpatients' clinics. Giving attention to these barriers might maximize the opportunities for patient self-management of chronic illness based on a therapeutic alliance with health care professionals.

Patients' experiences of an open access follow up arrangement in managing inflammatory bowel disease

BACKGROUND

Improving access is a key policy issue in improving quality of care and extending patient choice and participation. People's experience of changing from fixed outpatient appointments to more flexible direct access arrangements for chronic disease has been underexplored.

OBJECTIVES

To examine patients' views on using an open system of access compared with fixed outpatient appointments as part of a guided self-management intervention for inflammatory bowel disease (IBD).

DESIGN

Embedded qualitative study undertaken alongside a randomised controlled trial. Semi-structured interviews were undertaken to obtain an in depth understanding of patients' experience of the change in access arrangements.

PARTICIPANTS

A purposive sample (n = 30) was drawn from the intervention group (n = 700) according to a range of responses to the trial baseline and follow up quantitative measures.

RESULTS

28 interviews were included in the analysis. Compared with the previous system of fixed appointments, preference for the new open access system was based on enhanced personal control in contacting services and the view that it fitted better with everyday routine management and the requirement for urgent medical contact when symptoms fail to respond to medication. Preference for retaining fixed appointments was based on a sense of security from gaining access which did not require the individual to initiate the request for medical help.

CONCLUSIONS

Open access may fit better with patients' self-management of their condition and everyday routines, roles and responsibilities. Ensuring that outpatient organisational arrangements and personnel are responsive to patient initiated requests for appointments is likely to impact on the acceptability of this type of access arrangement. Some people may continue to prefer the fixed appointment system which should be retained if patient choice is to be respected.

Patients' experiences of an open access follow up arrangement in managing inflammatory bowel disease

BACKGROUND

Improving access is a key policy issue in improving quality of care and extending patient choice and participation. People's experience of changing from fixed outpatient appointments to more flexible direct access arrangements for chronic disease has been underexplored.

OBJECTIVES

To examine patients' views on using an open system of access compared with fixed outpatient appointments as part of a guided self-management intervention for inflammatory bowel disease (IBD).

DESIGN

Embedded qualitative study undertaken alongside a randomised controlled trial. Semi-structured interviews were undertaken to obtain an in depth understanding of patients' experience of the change in access arrangements.

PARTICIPANTS

A purposive sample (n = 30) was drawn from the intervention group (n = 700) according to a range of responses to the trial baseline and follow up quantitative measures.

RESULTS

28 interviews were included in the analysis. Compared with the previous system of fixed appointments, preference for the new open access system was based on enhanced personal control in contacting services and the view that it fitted better with everyday routine management and the requirement for urgent medical contact when symptoms fail to respond to medication. Preference for retaining fixed appointments was based on a sense of security from gaining access which did not require the individual to initiate the request for medical help.

CONCLUSIONS

Open access may fit better with patients' self-management of their condition and everyday routines, roles and responsibilities. Ensuring that outpatient organisational arrangements and personnel are responsive to patient initiated requests for appointments is likely to impact on the acceptability of this type of access arrangement. Some people may continue to prefer the fixed appointment system which should be retained if patient choice is to be respected.

Emancipation in decision-making in women's health care

BACKGROUND

Emancipation as a nursing concept is derived from a long-standing history of social oppression and is easily addressed by both critical social theory and feminist theory. It is the apparent concept to describe a phenomenon witnessed in nursing when caring for women in the decision-making process about health care issues. Emancipation has been recognized by expert clinical observation.

AIM

The aim of this paper is to define the concept of emancipation for possible future application to nursing practice for the promotion of humanistic nursing care in women's health, specifically applied to the decision-making process.

METHOD

A literature search was carried out using the CINAHL database and the keywords nursing and emancipation, and covering the period 1985-2003. The Rodgers and Knafl (2000) method of concept analysis was then used to derive a conceptual meaning of emancipation that benefits patient care as well as professional nursing development. Emancipation is broken down into antecedents, attributes and consequences. Related concepts are also explored, compared and discussed to synthesize relevant characteristics.

FINDINGS

This concept analysis identifies emancipation in decision-making as a nursing phenomenon by discussing the antecedent of oppression and exploring the identified attributes: (a) empowerment, (b) personal knowledge, (c) social norms, (d) reflection and (e) flexible environment. The consequence of emancipation is free choice. It is a futuristic concept with strong historical ties in need of exploration and development within the context of women's health care in relation to decision-making.

CONCLUSIONS

The concept model illustrates emancipated decision-making, with its five attributes in relation to oppression as a non-linear phenomenon. Areas for further study include the exploration of the contribution of each critical attribute and its relationship to emancipated decision-making, and the decision-making process in relation to patient satisfaction and how long the person continues to adhere to the decision. Also the professional nursing role in promotion of emancipated decision-making is virtually unexplored, but is an important concept in the paradigm of shared decision-making about health care alternatives.

Incorporating patients' views and experiences of life with IBS in the development of an evidence based self-help guidebook

To become active partners in chronic illness management, patients need relevant information which clearly explains treatment choices. This paper describes a method of producing information to feed into production of a guidebook for people with irritable bowel syndrome (IBS). Users were involved throughout the development process. Five focus groups were held involving 23 people with IBS out of 147 who responded to a newspaper article asking for help with a study of self-care in IBS. Qualitative analysis of transcripts from these meetings formed the basis of guidebook development. Patients described their experiences, coping strategies, experiences of the healthcare system, treatments and social consequences of the condition. Medical literature searches were made to find answers to identified areas of information need. The book includes direct quotes from patients describing their own experiences. Guided and practical ways of support are required for people with IBS who want to self-manage their condition.

Improving patient involvement in chronic disease management: the views of patients, GPs and specialists on a guidebook for ulcerative colitis

Patient information, shared care and decision-making are recognised as beneficial to chronic disease management. As part of an RCT, opinions of ulcerative colitis patients and their doctors were sought on a guidebook designed to support self-care and mediate doctor/patient interaction during consultations. Semi-structured interviews were conducted with 6 specialists and 16 GPs. Patients' views were obtained from written responses to a postal questionnaire (136 replies). Inclusion of lay knowledge and clarification of treatment decision processes increased patients' perception of involvement in disease management through increased identification and awareness of others' self-management experiences. Doctors focused on the importance of improving patients' compliance and use of services. However, the guidebook was seldom used as it had been intended during consultations. Patients felt constrained by time limits and consultants did not actively encourage guidebook use. Based on the findings, we suggest an approach utilising the guidebook to improve patient participation in disease management.