Health care professionals' views about supporting patients' self‐management

Exploring self-management within hospital-based stroke care: current and future opportunities

PURPOSE

This study explored stroke self-management within a tertiary hospital setting from the perspectives of health professionals working across the continuum of stroke care.

MATERIALS AND METHODS

A qualitative descriptive design guided five focus groups in the acute stroke service (n = 2), inpatient rehabilitation (n = 2), and outpatient day hospital service (n = 1). Focus groups were transcribed verbatim and analysed using thematic analysis.

RESULTS

Twenty-eight health professionals participated representing medical, nursing, and allied health services. Two themes emerged from the data: Pieces of the puzzle illustrates the inconsistent understanding about self-management with elements of the puzzle described but rarely within the full concept of self-management; Readiness for self-management highlighted that although self-management should commence in the acute setting, there were many factors influencing why this was not always happening.

CONCLUSIONS

A consistent conceptualisation and approach to stroke self-management in the hospital setting is required. Interprofessional education and shared intentional language can enhance understanding and practice.IMPLICATIONS FOR REHABILITATIONUnderstanding and application of stroke self-management varies among members of hospital-based stroke teams.Health professionals working in hospital-based stroke care should use the term self-management with their patients.Education of healthcare teams is necessary to develop knowledge about self-management and develop consistent practices across the continuum of care.

La posture éducative, une pièce maîtresse au service de l’éducation thérapeutique du patient !

Introduction : La posture éducative est considérée par plusieurs auteurs comme la pierre angulaire pour le développement des compétences des professionnels de santé en éducation thérapeutique du patient (ETP) et plus largement l’intégration de cette ETP dans les pratiques professionnelles. Cependant, le terme reste à clarifier au vu des constats de définition polysémique ou tout simplement d’absence de définition. Objectifs/contributions : Cet article décrit les enjeux autour de la définition, de la reconnaissance et du développement du concept de posture éducative. L’article propose également une caractérisation pragmatique du concept organisée autour de 7 dimensions : la relation au temps (le bon moment, le temps qu’il faut), les bénéfices de la pratique d’ETP (bien-être des professionnels de santé), les émotions et sentiments (qualité des échanges, partage), le caractère professionnel de l’ETP (compétences biomédicales et éducatives requises), l’approche globale et interdisciplinaire (complexité de la personne, intérêt d’un travail d’équipe), le caractère éducatif de la relation de soins (éducation intégrée aux soins) et la dimension éthique (réflexion jugée indispensable). Discussion/conclusion : Cette étude ouvre des perspectives de transformations des formations professionnelles, ainsi que des recherches orientées sur les interventions pédagogiques pour faire de cette posture éducative un objet d’apprentissage à part entière.

Shifting mindsets: a realist synthesis of evidence from self-management support training

CONTEXT

Accompanying the growing expectation of patient self-management is the need to ensure health care professionals (HCPs) have the required attitudes and skills to provide effective self-management support (SMS). Results from existing training interventions for HCPs in SMS have been mixed and the evidence base is weaker for certain settings, including supporting people with progressive neurological conditions (PNCs). We set out to understand how training operates, and to identify barriers and facilitators to training designed to support shifts in attitudes amongst HCPs.

METHODS

We undertook a realist literature synthesis focused on: (i) the influence of how HCPs, teams and organisations view and adopt self-management; and (ii) how SMS needs to be tailored for people with PNCs. A traditional database search strategy was used alongside citation tracking, grey literature searching and stakeholder recommendations. We supplemented PNC-specific literature with data from other long-term conditions. Key informant interviews and stakeholder advisory group meetings informed the synthesis process. Realist context-mechanism-outcome configurations were generated and mapped onto the stages described in Mezirow's Transformative Learning Theory.

RESULTS

Forty-four original articles were included (19 relating to PNCs), from which seven refined theories were developed. The theories identified important training elements (evidence provision, building skills and confidence, facilitating reflection and generating empathy). The significant influence of workplace factors as possible barriers or facilitators was highlighted. Embracing SMS often required challenging traditional professional role boundaries.

CONCLUSION

The integration of SMS into routine care is not an automatic outcome from training. A transformative learning process is often required to trigger the necessary mindset shift. Training should focus on how individual HCPs define and value SMS and how their work context (patient group and organisational constraints) influences this process. Proactively addressing potential contextual barriers may facilitate implementation. These findings could be applied to other types of training designed to shift attitudes amongst HCPs.

Technology-assisted self-testing and management of oral anticoagulation therapy: a qualitative patient-focused study

BACKGROUND

Oral anticoagulation therapy requires regular blood testing to ensure therapeutic levels are maintained and excessive bleeding/clotting is avoided. Technology-assisted self-testing and management is seen as one of the key areas in which quality of care can be improved whilst reducing costs. Nevertheless, levels of patient engagement in self-testing and management remain low. To date, little research emphasis has been placed on understanding the patients' perspectives for low engagement. The typical approach adopted by healthcare providers is to provide patient education programmes, with the expectation that individual patients will change their behaviour and adopt new self-care strategies. However, if levels of patient engagement are to be increased, healthcare providers must also develop a better understanding of how their clinical service provision is perceived by patients and make adaptations.

OBJECTIVE

To explore patient views, needs and expectations of an anticoagulation service and the self-testing and management services provided.

METHODS

Interviews were conducted with 17 patients who currently engage in international normalised ratio (INR) self-testing and management. Thematic coding and analysis were carried out on the interview transcripts.

RESULTS

Four high-level themes emerged from interviews: (i) role of clinic, (ii) motivations for self-testing, (iii) managing INR and (iv) trust. The clinic was seen as adding value in terms of specifying testing frequency, dosage profiles and calibrating equipment. Prompt communication from clinic to patient was also valued, although more personalised/real-time communication would help avoid feelings of isolation. Patients felt more in control as self-tester/managers and often took decisions about treatment adjustments themselves. However, some also manipulated their own test results to avoid 'unnecessary' interventions.

CONCLUSIONS AND RECOMMENDATIONS

More personalised/real-time communication, pragmatic and collaborative patient-clinician partnerships and recognition of expert patient knowledge and expertise are needed if increased levels of engagement with self-testing and management service provision is to be realised.

Who is in control? Clinicians' view on their role in self-management approaches: a qualitative metasynthesis

OBJECTIVE

To explore clinician perceptions of involvement in delivery of self-management approaches.

SETTING

All healthcare settings.

DESIGN

EBSCO, Scopus and AMED databases were searched, in July 2013, for peer-reviewed studies in English reporting original qualitative data concerning perceptions of clinicians regarding their involvement in or integration of a self-management approach. Of 1930 studies identified, 1889 did not meet the inclusion criteria. Full text of 41 studies were reviewed by two independent reviewers; 14 papers were included for metasynthesis. Findings and discussion sections were imported into Nvivo-10 and coded line-by-line. Codes were organised into descriptive themes and cross-checked against original sources to check interpretation, and refined iteratively until findings represented an agreed understanding. Studies were appraised for quality.

RESULTS

Delivering self-management in practice appeared to be a complex process for many clinicians. The issue of 'control' arose in all studies, both in the qualitative data and authors' interpretations. The first theme: Who is in control?--represented ways clinicians talked of exercising control over patients and the control they expected patients to have over their condition. The second theme: Changing clinician views--reflected what appeared to be an essential transformation of practice experienced by some clinicians in the process of integrating self-management approaches into the practice. A range of challenges associated with shifting towards a self-management approach were reflected in the third theme, Overcoming challenges to change. Tensions appeared to exist around forming partnerships with patients. Strategies found helpful in the process of change included: dedicating time to practice reciprocity in communication style, peer support and self-reflection.

CONCLUSIONS

A consistent finding across studies is that 'control' is a key feature of how self-management is viewed by clinicians. They described challenges associated with the paradigm shift required to share or let go of control. Future research should identify whether strategies described by clinicians are key to successful self-management.