EDUCATION
Self-care management education models in primary care Sue Lillyman, Natalie Farquharson
Sue Lillyman is Senior Lecturer, University of Worcester; Natalie Farquharson is Research Assistant, University of Worcester Email: [email protected]
C
linical commissioning groups are charged with meeting the needs of people with long-term conditions in their locality. For this reason, a literature review was undertaken to identify what ‘works’ and what ‘works well’ in relation to self-care management and educational frameworks. This approach has been undertaken in response to the increase in demand on health-care resources due to the ageing population and increased number of people living with long-term conditions. Self-management programmes were introduced as a different approach to meet the needs of people with long-term conditions, enabling them to manage their condition effectively within their own homes. However, enabling self-management is complex and, as a result, structured educational programmes have been developed within primary care to help support this client group to self-manage their condition. With this multitude of different models being developed, this article reviews the existing literature in relation to selfcare management education approaches in order to identify any models that worked well and which, if any, were the best models to adopt for staff working with this client group. Several themes emerged from the literature, including the theoretical underpinning of the programmes, method of delivery, duration of the programme, timing of the programme, group leaders, content of the programme and limitations of the educational programmes.
Abstract
Self-care management for people living with long-term conditions aims to assist the individual in taking responsibility for their own health. This literature review explores the value and content of the large range of educational models currently in use. Although no single model was found that addressed all the issues, several themes arose. These included the observation that educational models should be based on self-efficacy principles and patient-centred. Method of delivery favoured small groups, using a variety of approaches supported with written information. Duration of the programmes was mainly 6–8 weeks with a follow-up. Programmes should be offered when the patient is ready and not determined by the condition or at diagnosis. Debate remains over whether group leaders should be laypeople and professionals; however, a mixture of both offered the best outcomes. Programmes should not be problem-focused, offering space for support and experience sharing.
KEY WORDS
w Long-term conditions w Self-care w Self-management w Patient education w Self-efficacy
556
Background Many authors have found that education programmes have a positive effect on a patient’s self-care management of their condition (Coleman et al, 2008; Lorig et al, 2008; Yip et al, 2008; Breedland, 2011; Li et al, 2011; Rimington et al, 2011; Reeves et al, 2013). They reported improved self-efficiency, improvement in patient knowledge of their condition, behaviour change and reduction in symptom severity including pain, reduction in number of unplanned medical consultations, increased quality of life and improvement in specific health status. Rimington (2011), who cited the Cochrane review (Effing et al, 2009), identified that patients receiving self-management education were likely to have a reduction of at least one hospital admission. However Goodwin et al (2010) found that the current provision of quality information was variable and Brady et al (2009) and MacDonald et al (2008) suggest that there is a need to find new ways of delivering educational programmes for selfmanagement for people living with long-term conditions.
Methodology This study involved a review of existing literature and content analysis of national programmes.The literature was found using Academic Search Complete, CINAHL Plus with full-text, MEDLINE, PsycINFO, PsycARTICLES and Cochrane reviews using the key words ‘long-term conditions’, ‘self-care’, ‘education’, ‘self-care models’, ‘COPD’, ‘dementia’, ‘heart failure’, ‘arthritis’ and ‘stroke’. The literature search was confined to documents published between 2006 and 2013 in the UK and western countries such as the United States, Australia and the Netherlands. First, abstracts were examined to identify relevant information, particularly relating to self-care models in primary care in the UK or services abroad that are similar to that of the UK health-care system. Those with more obscure abstracts were examined further to evaluate their relevance to the subject. The reference sections of some articles were also used in order to identify further relevant publications that had not appeared in the initial literature search. Results obtained included: quantitative and qualitative research, literature reviews, Cochrane reviews, editorials, discussions, descriptive publications and reports. The literature search produced results that ranged from models of self-care relating to specific diagnoses to general models of self-care that could be applied to a range of long-term conditions.
British Journal of Community Nursing Vol 18, No 11
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 29, 2015. For personal use only. No other uses without permission. . All rights re
EDUCATION
Results
Theoretical underpinning Yip et al (2008) and Jones and Raizi (2011) reported that current research suggests that benefits are gained from programmes targeting self-management that are based on selfefficacy principles. These principles, according to Breedland (2011), increase the person’s confidence in their ability to perform a task or behaviour or change a specific cognitive state successfully. Using these principles can therefore assist the person in reviewing aspects of their lifestyle (such as diet or exercise) that may have an impact on their condition. Yip et al (2008) and Jones and Raizi (2011) also suggest that they should be designed to empower the person that is underpinned with a patient-centred philosophy as identified in the Department of Health (DH) Structured Patient Education in Diabetes Report (DH and Diabetes UK, 2005).When describing their approach to self-management, the majority of authors incorporated the social cognitive theory of Bandura (1986; 1995), which encourages a belief in one’s ability to achieve an action and to enhance self-efficacy, which is in turn strongly linked to outcome expectations (Lorig et al, 1999; DH, 2001; Wilson and Mayor, 2006; Allen et al, 2010; Chaplin et al, 2012). This approach is also demonstrated in the Expert Patients Programme approach (DH, 2001;Wilson and Mayor, 2006). Some authors combined this with the self-regulation model of Leventhal et al (2001), also seen in the Expert Patients Programme (DH, 2001; Expert Patients Programme Community Interest Company, 2013).
Method of delivery In their Cochrane report, Deakin et al (2005) found that the most effective method for delivering education on selfmanagement was unclear. However, Berzins et al (2009) found from their study that patient education appears to be best delivered when using a variety of methods, including individually tailored teaching sessions and small group discussions supported by written material. Corben and Rosen (2005) also highlighted that these programmes need to be flexible to fit with patients and others’ commitments. Many studies and authors used a small-group-based approach (DH, 2001; Berzins et al, 2009; Challis et al, 2010; Davies, 2010), although Deakin et al (2009) found that the size of the group did not change the effectiveness of the education. This was also reported by Duke et al (2009), who found that individual and group programmes had the same impact. It was also reported that the use of written information to support the taught elements of any educational programme was more effective for the patient (Coleman et al, 2008; Murray et al, 2009; Challis et al, 2010; Goodwin et al, 2010).
Duration of programmes The duration of the educational programmes remains unclear according to Riemsma et al (2003) and Deakin et al (2009), who state that the programme duration does not appear to change the effectiveness of the education. Courses identified in the literature tended to be between 3 and 8 weeks in duration and included the models of Coleman
British Journal of Community Nursing Vol 18, No 11
et al (2008) (the Osteoarthritis of the Knee (OAK) programme); South et al (2010) (community-based self-care training initiative); the Expert Patients Programme (Expert Patients Programme Interest Company, 2013), which was 6 weeks; and the Breedland (2011) FIT programme, which involves an intensive 8-week training programme where educational input is combined with exercise (see Table 1 for examples of courses). Regardless of the duration, Deakin et al (2009) suggested that providing additional sessions on an annual basis resulted in long-lasting benefits to health and psychosocial outcomes. This was also found by Renders et al (2009) in their review, where organisational interventions with regular prompted recall and review improved the outcome.
Timing of programmes Chaplin et al (2012) reported that people who were newly diagnosed found it hard to be in groups with people who were ‘further on’ in terms of deterioration of their condition. Hehir et al (2008) concur and suggest that patients should not be offered these programmes in the first few weeks of their diagnosis. Hirsche et al (2011) and Jones and Riazi (2011) noted the significance of early versus timely interventions and suggest that programmes should be entered when the patient is ready to take them. Therefore, the decision to start on the programme should be on an individually decided basis. However, as Breedland et al (2011) point out, providing these programmes implies that people are capable of performing the actions required, and again should be considered on an individual basis in relation to the person’s mental and physical condition. Brady et al (2009) also highlighted lack of attendance at classes but did not give reasons why, while Berzins et al (2009) noted that it remains unknown how best to support people over 75 years of age who have different needs.
Group leaders Laypeople There appears to be some disagreement in the literature relating to laypeople leading programmes versus professional leaders. The Expert Patients Programme (DH, 2001) has been central to spreading good self-care and self-management delivered by a network of trained laypeople with long-term conditions. Foster et al (2009) reported that lay-led self-management education programmes may lead to small, short-term improvements in self-efficacy, self-rated health, cognitive symptoms management and frequency of aerobic exercise. They found no significant effects with layperson leaders, as opposed to professional leaders in programme delivery on improving psychological health, symptoms or health-related quality of life. However, Chaplin et al (2012) found that although laypeople can deliver the content of the course effectively, they may not be able to answer any questions that might arise. This is particularly relevant since, according to Barlow et al (2009), the questions tend to be related to medical issues. Coleman et al (2008) also reported that the orientation should be towards skills and expertise as well as support, rather than the support and empathy orientation framework offered by laypeople.
557
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 29, 2015. For personal use only. No other uses without permission. . All rights re
EDUCATION
Table 1. Problems reported at registration Programme ‘I’m taking charge of my arthritis’
Communitybased selfcare training initiative
Delivered by and duration Delivered by: health-care professional on individual Duration: weekly 1-hour visits for 6 weeks Delivered by: public health professionals
Expert Patients Programme
Duration: 3–6 week period Delivered by laypeople living with a long-term condition
FIT
Duration: 6-week course Delivered by multidisciplinary team in small groups
Osteoarthritis of the Knee (OAK)
Duration: 8-week course Delivered by: health-care professionals in small groups
Input
Comments
Reference
Same health-care professional visits the person’s home and aims to develop a coaching relationship
Aimed at frail older people who are housebound due to arthritis
Laforest et al (2008)
Includes a personal action plan Six units based on subjects such as: attitudes to health, management of stress and anxiety, healthy lifestyle and management of minor conditions
Used for people across all sections of the adult population. Includes written information with course contents and follow-up exercises
South et al (2010)
Includes information such as healthy lifestyles, changing diet, types of exercise, dealing with pain and medicine management
Delivered to adults with all types of long-term conditions
Expert Patients Programme Interest Company (2013)
60 minutes cycling each week
Used for people with rheumatoid arthritis
Breedland (2011)
Reported significant benefit in aerobic capacity but not in muscle strength For people with osteoarthritis of the knee
Coleman et al (2008)
60 minutes sport each week 30 minutes aqua/jogging twice a week Six educational sessions for 2.5 hours per week with written information
Duration: 6-week course
558
Draws on social cognitive theory
Outcome: reduced pain and improved quality of life
Health-care professionals
Nurses
Hadjistavropoulos (2012) found that using therapists and facilitators enhanced the effects of self management programmes, especially where there are treatment implications, such as the principles of joint protection (Coleman et al, 2008) and relevant information on self-management for people with specific conditions. The National Institute for Health and Care Excellence (NICE) (2003) guidelines suggest that the programmes are delivered to groups by trained multidisciplinary teams using diverse teaching approaches tailored to meet the individual’s needs. The team, according to Challis et al (2010) and Chaplin et al (2012), can include health educators, nurses, mental health workers, physicians, trained laypeople, physiotherapists, occupational therapists, psychologists, dietitians and rehabilitation assistants. Deakin et al (2009) found no evidence to suggest that programmes are more effective if delivered by physicians, dietitians or nurses provided they are trained to deliver the programmes. Norweg et al (2008) delivered their programme in pairs to promote a vicarious experience and to optimise learning. MacDonald et al (2007) noted that current ways of working are unlikely to be sufficient to support patient self-management. They point to a need for education to equip nurses with techniques to work effectively.
Nurses, according to Davies (2010) and Renders et al (2009), play a pivotal role in providing advice, guidance, education, facilitating adherence to treatment and support to people with long-term conditions. MacDonald et al (2007) and Wilson et al (2006) also highlight the need for education to equip nurses with techniques to work effectively with patients dealing with the longer-term effects of their chronic conditions and to facilitate appropriate responses to expert patients and organisational issues. They also reported that nurses were more anxious about expert patients compared with other professionals. Renders et al (2009) reported that multiple interventions in which the patient education was added, or in which the role of the nurse was enhanced, also had favourable effects upon patient health outcomes.
Content of programmes According to Swendeman et al (2009) and Chaplin et al (2009), people with long-term conditions need to maximise their own sense of control and feel enabled to manage their lives by playing an active part, and informed role, in health-care decisionmaking to change behaviours and social relationships. This, according to Naylor et al (2013), can be achieved through a structured patient education programme for people with longterm conditions. However, according to DH and Diabetes UK (2005), it should include a structured written curriculum.
British Journal of Community Nursing Vol 18, No 11
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 29, 2015. For personal use only. No other uses without permission. . All rights re
EDUCATION
Chaplin et al (2012) suggest that the contents of the programme should be based on priorities from the service user and carer perspectives. However, Palmer et al (2012) found that the patient and doctor perspectives also needed to be integrated to gain most benefit for the patient and be clinically meaningful. According to Corben and Rosen (2005), these perspectives should remain within the context of the patients’ own lives and not be based on a clinical model. Chaplin et al (2012) found that simply providing information, even when essential and accurate, did not help people to self-manage any better. Deakin et al (2009) suggested that the programmes include therapeutic patient education with principles of empowerment, participation and adult learning (Deakin et al, 2009). However, information packages combined with health information could be useful, according to the review of interactive health communication by Murray et al (2009), which found that the communication applications had a positive effect on users and resulted in them becoming more knowledgeable, feeling better and socially supported and may have improved behaviours and clinical outcomes compared with those who did not use this approach. As noted above, programmes can include information-giving and exercises as well as using other media such as DVDs, computer programs and mobile/‘app’ communications. Many patients found that the most helpful programme involved hearing other people’s experiences (DH, 2007; Chaplin et al, 2012).This was echoed by Hirsche et al (2011), who found that self-efficacy was improved through social comparisons and social connections. Hirsche et al (2011) also found social comparison to be an important process in enhancing self-efficacy. Hamnes et al (2011) and Laakkonen et al (2012) both reported the importance of sharing experiences and social support for the acceptance and management of life with a long-term condition. However, Chaplin et al (2012) found that this did not occur, and many groups tended to focus on negative aspects and gave the example of management of problems rather than providing space for social comparison. Trudeau et al (2010) found in their study that patients wanted information regarding the progression of the disease as well as practical advice. However, Barlow et al (2009) identified that some patients found some course formats too rigid, too rushed and lacking time for discussion. Local delivery plans should be used by clinical commissioning groups to enhance education and training and this, according to Goodwin et al (2010), should include access to accredited and standardised training in long-term conditions management in general practice with referral to local specialist teams. This should include an orientation towards skills and expertise as well as support (Coleman et al, 2008), and time and space to discuss feelings associated with the condition (Hehir et al, 2008).
Carers and self-management programmes Forducey et al (2012) noted the importance of educating and ensuring cooperation of the family and care-givers. This was also echoed by the King’s Fund (2012). Chaplin et al (2012)
British Journal of Community Nursing Vol 18, No 11
included the carers in their first module and then provided parallel groups for the carer and patient for the remainder of the programme. Kett et al (2010) included focused coping as well as the emotional support and the need to include culturally specific programmes (Silverman et al, 2008; Swendeman et al, 2009).
Limitations of educational programmes Effing et al (2009) identified that there is still insufficient data to formulate clear recommendations regarding the form and content of self-management education programmes.There remains some conflict in the findings, such as the Cochrane review by Duke et al (2009), who reported that there was no significant difference in glycaemic control in diabetic patients receiving education and those receiving usual care. They also reported that there was no significant difference in quality of life, selfmanagement skills or knowledge between the two groups. However, Reeves et al (2013) found that the majority of programmes had positive outcomes in diabetic care, emergency department culture and patient satisfaction. However, they did not include patients with long-term conditions in the review.
Conclusion Many of the authors included in this literature review concluded their studies by suggesting that there is further research needed in relation to education and self-care management programmes. There was no one self-management education programme that was identified that suits all people with long term conditions for all ages. A summary of the themes identified is as follows: w Theoretical underpinning of the programmes should be based on self-efficacy principles and patient-centred w Most found small groups useful and that using a variety of approaches including written information helped the patients more w Optimum duration of the programme remains unclear from literature, but most running for 6–8 weeks with follow-up either by phone or annual meeting appeared effective w The programme should commence when the patient is ready and should not be determined by the condition or at diagnosis w It remains unclear in the literature whether between laypeople or professional leaders are better leading, but the main findings are that both lay and professional leaders need appropriate training and a mixed approach appears to offer the best outcomes w Programmes should be patient-centred and should not only focus on problems; space should be offered for support and sharing of experiences. BJCN Allen KD, Oddone EZ, Coffman CJ et al (2010) Telephone-based self-management of osteoarthritis: a randomized trial. Ann Intern Med 153(9): 570–9 Bandura A (1986) Social Foundations of Thought and Action: A Social Cognitive Theory. Prentice Hall, New Jersey Bandura A (1995) Exercise of personal and collective efficacy in changing societies. In: Bandura A, ed. Self-efficacy in Changing Societies. Cambridge University Press, New York: pp 1–45 Barlow J, Edwards R,Turner A (2009) The experience of attending a lay-led, chronic
559
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 29, 2015. For personal use only. No other uses without permission. . All rights re
EDUCATION
disease self-management programme from the perspective of participants with multiple sclerosis. Psychol Health 24(10): 1167–80 Berzins K, Reilly S, Abell J, Hughes J, Challis D (2009) UK self-care support initiatives for older patients with long-term conditions: a review. Chronic Illn 5: 56–72 Brady TJ, Jernick SL, Hootman JM, Sniezek JE (2009) Public health interventions for arthritis: expanding the toolbox of evidence-based interventions. J Womens Health (Larchmt) 18(12): 1905–17 Breedland I, van Scheppingen C, Leijsma M,Verheij-Jansen NP, van Weert E (2011) Effects of a group-based exercise and educational program on physical performance and disease self-management in rheumatoid arthritis: a randomized controlled study. Phys Ther 91(6): 879–93 Challis, D, Huges J, Berzins K, Reilly S, Abell J, Stewart K (2010) Self–care and case management in long-term conditions: the effective management of critical interfaces. Report for the National Institute for Health Research Service Delivery Organisations Programmes. http://tinyurl.com/nq269hh (accessed 21 October 2013) Chaplin H, Hazan J, Wilson P (2012) Self-management for people with long-term neurological conditions. Br J Community Nurs 17(6): 250–7 Coleman S, Briffa K, Conroy H, Prince R, Carroll G, McQuade J (2008) Short and medium-term effects of an education self-management program for individuals with osteoarthritis of the knee, designed and delivered by health professionals: a quality assurance study. BMC Musculoskelet Disord 9: 117 Corben S, Rosen P (2005) Self-management for long-term conditions: patient perspectives on the way ahead. Working Paper, King’s Fund, London. http://tinyurl. com/obszex5 (accessed 21 October 2013) Davies NJ (2010) Improving self-management for patients with long-term conditions. Nurs Stand 24(25): 49–56 Deakin TA, McShane CE, Cade JE, Williams R (2009) Group-based training for self-management strategies in people with type 2 diabetes mellitus (review). In: The Cochrane Collaboration, Issue 1. Wiley Department of Health (2001) The Expert Patient: A New Approach to Chronic Disease Management for the 21st Century. http://tinyurl.com/pmtmcmx (accessed 21 October 2013) Department of Health and Diabetes UK (2005) Structured Patient Education in Diabetes: Report from the Patient Education Working Group. http://tinyurl.com/ ossy6dw (accessed 21 October 2013) Department of Health (2007) Research Evidence on the Effectiveness of Self Care Support. http://tinyurl.com/q2uec97 (accessed 22 October 2013) Duke SAS, Colagiuri S, Colagiuri R (2009) Individual patient education for people with type 2 diabetes mellitus (review). In: The Cochrane Collaboration, Issue 1. Wiley Effing T, Monninkhof EEM, van der Valk PP et al (2009) Self-management education for patients with chronic obstructive pulmonary disease (review). In: The Cochrane Collaboration, Issue 4. Wiley Expert Patients Programme Interest Company (2013) What we do. http://tinyurl. com/ntaohr2 (accessed 21 October 2013) Forducey PG, Glueckauf RL, Bergquist TF, Maheu MM,Yutsis M (2012) Telehealth for persons with severe functional disabilities and their caregivers: facilitating selfcare management in the home setting. Psychol Serv 9(2): 144–62 Foster G, Taylor SJC, Eldridge S, Ramsay J, Griffiths CJ (2009) Self-management education programmes led by lay leaders for people with chronic health conditions (review). In: The Cochrane Collaboration, Issue 1. Wiley. Goodwin N, Curry N, Maylor C, Ross S, Duldig W (2010) Managing people with long-term conditions. An inquiry into the quality of General Practice in England. King’s Fund, London. http://tinyurl.com/nef7vax (accessed 21 October 2013) Hadjistavropoulos T (2012) Self-management of pain in older persons: helping people help themselves. Pain Med 13 Suppl 2: S67–71 Hamnes B, Hauge MI, Kjeken I, Hagen KB (2011) ‘I have come here to learn how to cope with my illness, not to be cured’: a qualitative study of patient expectations prior to a one-week self-management programme. Musculoskeletal Care 9(4): 200–10 Hehir M, Carr M, Davis B et al (2008) Nursing support at the onset of rheuma-
Learning points w Self-management education programmes for people with long term conditions should be based on self-efficacy principles and patient centred
w The method of delivery can be in small groups over a period of a minimum of 3 weeks but needs to include written information and follow-up
w Patients should be invited to participate when they feel ready and not determined by the condition or at diagnosis
w During the programmes there should be time for the participants to share their experiences and provide support to each other
560
toid arthritis: time and space for emotions, practicalities and self-management. Musculoskeletal Care 6(2): 124–34 Hirsche RC,Williams B, Jones A, Manns P (2011) Chronic disease self-management for individuals with stroke, multiple sclerosis and spinal cord injury. Disabil Rehabil 33(13–14): 1136–46 Jones F, Riazi A (2011) Self-efficacy and self-management after stroke: a systematic review. Disabil Rehabil 33(10): 797–810 Kett C, Flint J, Openshaw M, Raza K, Kumar K (2010) Self-management strategies used during flares of rheumatoid arthritis in an ethnically diverse population. Musculoskeletal Care 8(4): 204-14 Laakkonen ML, Hölttä EH, Savikko N, Strandberg TE, Suominen M, Pitkälä KH (2012) Psychosocial group intervention to enhance self-management skills of people with dementia and their caregivers: study protocol for a randomized controlled trial. Trials 13: 133 Laforest S, Poirier M-C, Nour K, Ginac M, Parisien M, Lankoande M (2008) ‘I’m taking charge of my arthritis’: designing a targeted self-management programme for frail seniors. Phys Occupat Therapist Geriatric 26(4): 45–66 Leventhal H, Leventhal EA, Cameron L (2001) Representations, procedures, and effect in illness self-regulation: a perceptual–cognitive model. In: Baum A, Revenson TA, Singer JE, eds. Handbook of Health Psychology. Lawrence Erlbaum, New Jersey: pp. 19–47 Li T, Wu HM, Wang F et al (2011) Education programmes for people with diabetic kidney disease (review). Cochrane Collaboration, Issue 6. Wiley Lorig KR, Sobel DS, Stewart AL et al (1999) Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial. Med Care 37(1): 5–14 Lorig KR, Ritter PL, Dost A, Plant K, Laurent DD, McNeil J (2008) The expert patient online: a one-year study of an internet-based self-management programme for people with long term conditions. Chronic Illn 4: 247–56 MacDonald W, Rogers A, Blakeman T, Bower P (2008) Practice nurses and the facilitation of self-management in primary care. J Adv Nurs 62(2): 191–9 Murray E, Burns J, See Tai S, Lai R, Nazareth I (2009) Interactive health communication applications for people with chronic disease (review). Cochrane Collaboration, Issue 1. Wiley Naylor C, Imison C, Addicott R (2013) Transforming Our Health Care System: Ten Priorities for Commissioners. King’s Fund, London. http://tinyurl.com/d35hlhb (accessed 21 October 2013) National Institute for Health and Care Excellence (2003) Guidance on the use of patient-education models for diabetes. http://tinyurl.com/ngf2qoq (accessed 21 October 2013) Norweg A, Bose P, Snow G, Berkowitz ME (2008) A pilot study of a pulmonary rehabilitation programme evaluated by four adults with chronic obstructive pulmonary disease. Occup Ther Int 15(2): 114–32 Palmer D, El Miedany Y (2012) PROMs: a novel approach to arthritis self-management. Br J Nurs 21(10): 601–7 Reeves S, Perrier L, Goldman J, Freeth D, Zwarenstein M (2013) Interprofessional education: effects on professional practice and health care outcomes (update) (review). Cochrane Collaboration, Issue 3. Wiley Renders CM, Valk GD, Griffin SJ, Wagner E, van Eijk JT, Assendelft WJJ (2009) Interventions to improve the management of diabetes mellitus in primary care, outputs and community settings (review) . Cochrane Collaboration, Issue 1. Wiley Rimington GJ (2011) Treating COPD: are self-management plans worth the effort? Practice Nurs 41(19): 38–43 Riemsma RP, Kirwan JR, Taal E, Rasker JJ (2003) Patient education for adults with rheumatoid arthritis. Cochrane Database Syst Rev 2003(2). DOI: 10.1002/14651858.CD003688 Silverman M, Nutini J, Musa D, King J, Albert S (2008) Daily temporal self-care responses to osteoarthritis symptoms by older African Americans and whites. J Cross-Cultural Geront 23(4): 319–37 South J, Darby F, Bagnall A, White A (2010) Implementing a community-based self care training initiative: a process evaluation. Health Soc Care Community 18(6): 662–70 Swendeman D, Ingram BL, Rotheram-Borus MJ (2009) Common elements in self-management of HIV and other chronic illnesses: an integrative framework. AIDS Care 21(10): 1321–34 King’s Fund (2012) From Vision to Action: Making Patient-centred Care a Reality. http:// tinyurl.com/p7hmeey (accessed 21 October 2013) Trudeau KJ, Ainscough JL, Pujol LA, Charity S (2010) What arthritis pain practitioners and patients want in an online self-management programme. Musculoskeletal Care 8(4): 189–96 Wilson PM, Mayor V (2006) Long-term conditions. 2: supporting and enabling selfcare. Br J Community Nurs 11(1): 6–10 Yip Y, Sit JW,Wong DYS, Chong SYC, Chung LH (2008) A 1-year follow-up of an experimental study of a self-management arthritis programme with an added exercise component of clients with osteoarthritis of the knee. Psychol Health Med 13(4): 402–14
British Journal of Community Nursing Vol 18, No 11
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 29, 2015. For personal use only. No other uses without permission. . All rights re
Self-care management education models in primary care Sue Lillyman, Natalie Farquharson
Sue Lillyman is Senior Lecturer, University of Worcester; Natalie Farquharson is Research Assistant, University of Worcester Email: [email protected]
C
linical commissioning groups are charged with meeting the needs of people with long-term conditions in their locality. For this reason, a literature review was undertaken to identify what ‘works’ and what ‘works well’ in relation to self-care management and educational frameworks. This approach has been undertaken in response to the increase in demand on health-care resources due to the ageing population and increased number of people living with long-term conditions. Self-management programmes were introduced as a different approach to meet the needs of people with long-term conditions, enabling them to manage their condition effectively within their own homes. However, enabling self-management is complex and, as a result, structured educational programmes have been developed within primary care to help support this client group to self-manage their condition. With this multitude of different models being developed, this article reviews the existing literature in relation to selfcare management education approaches in order to identify any models that worked well and which, if any, were the best models to adopt for staff working with this client group. Several themes emerged from the literature, including the theoretical underpinning of the programmes, method of delivery, duration of the programme, timing of the programme, group leaders, content of the programme and limitations of the educational programmes.
Abstract
Self-care management for people living with long-term conditions aims to assist the individual in taking responsibility for their own health. This literature review explores the value and content of the large range of educational models currently in use. Although no single model was found that addressed all the issues, several themes arose. These included the observation that educational models should be based on self-efficacy principles and patient-centred. Method of delivery favoured small groups, using a variety of approaches supported with written information. Duration of the programmes was mainly 6–8 weeks with a follow-up. Programmes should be offered when the patient is ready and not determined by the condition or at diagnosis. Debate remains over whether group leaders should be laypeople and professionals; however, a mixture of both offered the best outcomes. Programmes should not be problem-focused, offering space for support and experience sharing.
KEY WORDS
w Long-term conditions w Self-care w Self-management w Patient education w Self-efficacy
556
Background Many authors have found that education programmes have a positive effect on a patient’s self-care management of their condition (Coleman et al, 2008; Lorig et al, 2008; Yip et al, 2008; Breedland, 2011; Li et al, 2011; Rimington et al, 2011; Reeves et al, 2013). They reported improved self-efficiency, improvement in patient knowledge of their condition, behaviour change and reduction in symptom severity including pain, reduction in number of unplanned medical consultations, increased quality of life and improvement in specific health status. Rimington (2011), who cited the Cochrane review (Effing et al, 2009), identified that patients receiving self-management education were likely to have a reduction of at least one hospital admission. However Goodwin et al (2010) found that the current provision of quality information was variable and Brady et al (2009) and MacDonald et al (2008) suggest that there is a need to find new ways of delivering educational programmes for selfmanagement for people living with long-term conditions.
Methodology This study involved a review of existing literature and content analysis of national programmes.The literature was found using Academic Search Complete, CINAHL Plus with full-text, MEDLINE, PsycINFO, PsycARTICLES and Cochrane reviews using the key words ‘long-term conditions’, ‘self-care’, ‘education’, ‘self-care models’, ‘COPD’, ‘dementia’, ‘heart failure’, ‘arthritis’ and ‘stroke’. The literature search was confined to documents published between 2006 and 2013 in the UK and western countries such as the United States, Australia and the Netherlands. First, abstracts were examined to identify relevant information, particularly relating to self-care models in primary care in the UK or services abroad that are similar to that of the UK health-care system. Those with more obscure abstracts were examined further to evaluate their relevance to the subject. The reference sections of some articles were also used in order to identify further relevant publications that had not appeared in the initial literature search. Results obtained included: quantitative and qualitative research, literature reviews, Cochrane reviews, editorials, discussions, descriptive publications and reports. The literature search produced results that ranged from models of self-care relating to specific diagnoses to general models of self-care that could be applied to a range of long-term conditions.
British Journal of Community Nursing Vol 18, No 11
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 29, 2015. For personal use only. No other uses without permission. . All rights re
EDUCATION
Results
Theoretical underpinning Yip et al (2008) and Jones and Raizi (2011) reported that current research suggests that benefits are gained from programmes targeting self-management that are based on selfefficacy principles. These principles, according to Breedland (2011), increase the person’s confidence in their ability to perform a task or behaviour or change a specific cognitive state successfully. Using these principles can therefore assist the person in reviewing aspects of their lifestyle (such as diet or exercise) that may have an impact on their condition. Yip et al (2008) and Jones and Raizi (2011) also suggest that they should be designed to empower the person that is underpinned with a patient-centred philosophy as identified in the Department of Health (DH) Structured Patient Education in Diabetes Report (DH and Diabetes UK, 2005).When describing their approach to self-management, the majority of authors incorporated the social cognitive theory of Bandura (1986; 1995), which encourages a belief in one’s ability to achieve an action and to enhance self-efficacy, which is in turn strongly linked to outcome expectations (Lorig et al, 1999; DH, 2001; Wilson and Mayor, 2006; Allen et al, 2010; Chaplin et al, 2012). This approach is also demonstrated in the Expert Patients Programme approach (DH, 2001;Wilson and Mayor, 2006). Some authors combined this with the self-regulation model of Leventhal et al (2001), also seen in the Expert Patients Programme (DH, 2001; Expert Patients Programme Community Interest Company, 2013).
Method of delivery In their Cochrane report, Deakin et al (2005) found that the most effective method for delivering education on selfmanagement was unclear. However, Berzins et al (2009) found from their study that patient education appears to be best delivered when using a variety of methods, including individually tailored teaching sessions and small group discussions supported by written material. Corben and Rosen (2005) also highlighted that these programmes need to be flexible to fit with patients and others’ commitments. Many studies and authors used a small-group-based approach (DH, 2001; Berzins et al, 2009; Challis et al, 2010; Davies, 2010), although Deakin et al (2009) found that the size of the group did not change the effectiveness of the education. This was also reported by Duke et al (2009), who found that individual and group programmes had the same impact. It was also reported that the use of written information to support the taught elements of any educational programme was more effective for the patient (Coleman et al, 2008; Murray et al, 2009; Challis et al, 2010; Goodwin et al, 2010).
Duration of programmes The duration of the educational programmes remains unclear according to Riemsma et al (2003) and Deakin et al (2009), who state that the programme duration does not appear to change the effectiveness of the education. Courses identified in the literature tended to be between 3 and 8 weeks in duration and included the models of Coleman
British Journal of Community Nursing Vol 18, No 11
et al (2008) (the Osteoarthritis of the Knee (OAK) programme); South et al (2010) (community-based self-care training initiative); the Expert Patients Programme (Expert Patients Programme Interest Company, 2013), which was 6 weeks; and the Breedland (2011) FIT programme, which involves an intensive 8-week training programme where educational input is combined with exercise (see Table 1 for examples of courses). Regardless of the duration, Deakin et al (2009) suggested that providing additional sessions on an annual basis resulted in long-lasting benefits to health and psychosocial outcomes. This was also found by Renders et al (2009) in their review, where organisational interventions with regular prompted recall and review improved the outcome.
Timing of programmes Chaplin et al (2012) reported that people who were newly diagnosed found it hard to be in groups with people who were ‘further on’ in terms of deterioration of their condition. Hehir et al (2008) concur and suggest that patients should not be offered these programmes in the first few weeks of their diagnosis. Hirsche et al (2011) and Jones and Riazi (2011) noted the significance of early versus timely interventions and suggest that programmes should be entered when the patient is ready to take them. Therefore, the decision to start on the programme should be on an individually decided basis. However, as Breedland et al (2011) point out, providing these programmes implies that people are capable of performing the actions required, and again should be considered on an individual basis in relation to the person’s mental and physical condition. Brady et al (2009) also highlighted lack of attendance at classes but did not give reasons why, while Berzins et al (2009) noted that it remains unknown how best to support people over 75 years of age who have different needs.
Group leaders Laypeople There appears to be some disagreement in the literature relating to laypeople leading programmes versus professional leaders. The Expert Patients Programme (DH, 2001) has been central to spreading good self-care and self-management delivered by a network of trained laypeople with long-term conditions. Foster et al (2009) reported that lay-led self-management education programmes may lead to small, short-term improvements in self-efficacy, self-rated health, cognitive symptoms management and frequency of aerobic exercise. They found no significant effects with layperson leaders, as opposed to professional leaders in programme delivery on improving psychological health, symptoms or health-related quality of life. However, Chaplin et al (2012) found that although laypeople can deliver the content of the course effectively, they may not be able to answer any questions that might arise. This is particularly relevant since, according to Barlow et al (2009), the questions tend to be related to medical issues. Coleman et al (2008) also reported that the orientation should be towards skills and expertise as well as support, rather than the support and empathy orientation framework offered by laypeople.
557
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 29, 2015. For personal use only. No other uses without permission. . All rights re
EDUCATION
Table 1. Problems reported at registration Programme ‘I’m taking charge of my arthritis’
Communitybased selfcare training initiative
Delivered by and duration Delivered by: health-care professional on individual Duration: weekly 1-hour visits for 6 weeks Delivered by: public health professionals
Expert Patients Programme
Duration: 3–6 week period Delivered by laypeople living with a long-term condition
FIT
Duration: 6-week course Delivered by multidisciplinary team in small groups
Osteoarthritis of the Knee (OAK)
Duration: 8-week course Delivered by: health-care professionals in small groups
Input
Comments
Reference
Same health-care professional visits the person’s home and aims to develop a coaching relationship
Aimed at frail older people who are housebound due to arthritis
Laforest et al (2008)
Includes a personal action plan Six units based on subjects such as: attitudes to health, management of stress and anxiety, healthy lifestyle and management of minor conditions
Used for people across all sections of the adult population. Includes written information with course contents and follow-up exercises
South et al (2010)
Includes information such as healthy lifestyles, changing diet, types of exercise, dealing with pain and medicine management
Delivered to adults with all types of long-term conditions
Expert Patients Programme Interest Company (2013)
60 minutes cycling each week
Used for people with rheumatoid arthritis
Breedland (2011)
Reported significant benefit in aerobic capacity but not in muscle strength For people with osteoarthritis of the knee
Coleman et al (2008)
60 minutes sport each week 30 minutes aqua/jogging twice a week Six educational sessions for 2.5 hours per week with written information
Duration: 6-week course
558
Draws on social cognitive theory
Outcome: reduced pain and improved quality of life
Health-care professionals
Nurses
Hadjistavropoulos (2012) found that using therapists and facilitators enhanced the effects of self management programmes, especially where there are treatment implications, such as the principles of joint protection (Coleman et al, 2008) and relevant information on self-management for people with specific conditions. The National Institute for Health and Care Excellence (NICE) (2003) guidelines suggest that the programmes are delivered to groups by trained multidisciplinary teams using diverse teaching approaches tailored to meet the individual’s needs. The team, according to Challis et al (2010) and Chaplin et al (2012), can include health educators, nurses, mental health workers, physicians, trained laypeople, physiotherapists, occupational therapists, psychologists, dietitians and rehabilitation assistants. Deakin et al (2009) found no evidence to suggest that programmes are more effective if delivered by physicians, dietitians or nurses provided they are trained to deliver the programmes. Norweg et al (2008) delivered their programme in pairs to promote a vicarious experience and to optimise learning. MacDonald et al (2007) noted that current ways of working are unlikely to be sufficient to support patient self-management. They point to a need for education to equip nurses with techniques to work effectively.
Nurses, according to Davies (2010) and Renders et al (2009), play a pivotal role in providing advice, guidance, education, facilitating adherence to treatment and support to people with long-term conditions. MacDonald et al (2007) and Wilson et al (2006) also highlight the need for education to equip nurses with techniques to work effectively with patients dealing with the longer-term effects of their chronic conditions and to facilitate appropriate responses to expert patients and organisational issues. They also reported that nurses were more anxious about expert patients compared with other professionals. Renders et al (2009) reported that multiple interventions in which the patient education was added, or in which the role of the nurse was enhanced, also had favourable effects upon patient health outcomes.
Content of programmes According to Swendeman et al (2009) and Chaplin et al (2009), people with long-term conditions need to maximise their own sense of control and feel enabled to manage their lives by playing an active part, and informed role, in health-care decisionmaking to change behaviours and social relationships. This, according to Naylor et al (2013), can be achieved through a structured patient education programme for people with longterm conditions. However, according to DH and Diabetes UK (2005), it should include a structured written curriculum.
British Journal of Community Nursing Vol 18, No 11
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 29, 2015. For personal use only. No other uses without permission. . All rights re
EDUCATION
Chaplin et al (2012) suggest that the contents of the programme should be based on priorities from the service user and carer perspectives. However, Palmer et al (2012) found that the patient and doctor perspectives also needed to be integrated to gain most benefit for the patient and be clinically meaningful. According to Corben and Rosen (2005), these perspectives should remain within the context of the patients’ own lives and not be based on a clinical model. Chaplin et al (2012) found that simply providing information, even when essential and accurate, did not help people to self-manage any better. Deakin et al (2009) suggested that the programmes include therapeutic patient education with principles of empowerment, participation and adult learning (Deakin et al, 2009). However, information packages combined with health information could be useful, according to the review of interactive health communication by Murray et al (2009), which found that the communication applications had a positive effect on users and resulted in them becoming more knowledgeable, feeling better and socially supported and may have improved behaviours and clinical outcomes compared with those who did not use this approach. As noted above, programmes can include information-giving and exercises as well as using other media such as DVDs, computer programs and mobile/‘app’ communications. Many patients found that the most helpful programme involved hearing other people’s experiences (DH, 2007; Chaplin et al, 2012).This was echoed by Hirsche et al (2011), who found that self-efficacy was improved through social comparisons and social connections. Hirsche et al (2011) also found social comparison to be an important process in enhancing self-efficacy. Hamnes et al (2011) and Laakkonen et al (2012) both reported the importance of sharing experiences and social support for the acceptance and management of life with a long-term condition. However, Chaplin et al (2012) found that this did not occur, and many groups tended to focus on negative aspects and gave the example of management of problems rather than providing space for social comparison. Trudeau et al (2010) found in their study that patients wanted information regarding the progression of the disease as well as practical advice. However, Barlow et al (2009) identified that some patients found some course formats too rigid, too rushed and lacking time for discussion. Local delivery plans should be used by clinical commissioning groups to enhance education and training and this, according to Goodwin et al (2010), should include access to accredited and standardised training in long-term conditions management in general practice with referral to local specialist teams. This should include an orientation towards skills and expertise as well as support (Coleman et al, 2008), and time and space to discuss feelings associated with the condition (Hehir et al, 2008).
Carers and self-management programmes Forducey et al (2012) noted the importance of educating and ensuring cooperation of the family and care-givers. This was also echoed by the King’s Fund (2012). Chaplin et al (2012)
British Journal of Community Nursing Vol 18, No 11
included the carers in their first module and then provided parallel groups for the carer and patient for the remainder of the programme. Kett et al (2010) included focused coping as well as the emotional support and the need to include culturally specific programmes (Silverman et al, 2008; Swendeman et al, 2009).
Limitations of educational programmes Effing et al (2009) identified that there is still insufficient data to formulate clear recommendations regarding the form and content of self-management education programmes.There remains some conflict in the findings, such as the Cochrane review by Duke et al (2009), who reported that there was no significant difference in glycaemic control in diabetic patients receiving education and those receiving usual care. They also reported that there was no significant difference in quality of life, selfmanagement skills or knowledge between the two groups. However, Reeves et al (2013) found that the majority of programmes had positive outcomes in diabetic care, emergency department culture and patient satisfaction. However, they did not include patients with long-term conditions in the review.
Conclusion Many of the authors included in this literature review concluded their studies by suggesting that there is further research needed in relation to education and self-care management programmes. There was no one self-management education programme that was identified that suits all people with long term conditions for all ages. A summary of the themes identified is as follows: w Theoretical underpinning of the programmes should be based on self-efficacy principles and patient-centred w Most found small groups useful and that using a variety of approaches including written information helped the patients more w Optimum duration of the programme remains unclear from literature, but most running for 6–8 weeks with follow-up either by phone or annual meeting appeared effective w The programme should commence when the patient is ready and should not be determined by the condition or at diagnosis w It remains unclear in the literature whether between laypeople or professional leaders are better leading, but the main findings are that both lay and professional leaders need appropriate training and a mixed approach appears to offer the best outcomes w Programmes should be patient-centred and should not only focus on problems; space should be offered for support and sharing of experiences. BJCN Allen KD, Oddone EZ, Coffman CJ et al (2010) Telephone-based self-management of osteoarthritis: a randomized trial. Ann Intern Med 153(9): 570–9 Bandura A (1986) Social Foundations of Thought and Action: A Social Cognitive Theory. Prentice Hall, New Jersey Bandura A (1995) Exercise of personal and collective efficacy in changing societies. In: Bandura A, ed. Self-efficacy in Changing Societies. Cambridge University Press, New York: pp 1–45 Barlow J, Edwards R,Turner A (2009) The experience of attending a lay-led, chronic
559
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 29, 2015. For personal use only. No other uses without permission. . All rights re
EDUCATION
disease self-management programme from the perspective of participants with multiple sclerosis. Psychol Health 24(10): 1167–80 Berzins K, Reilly S, Abell J, Hughes J, Challis D (2009) UK self-care support initiatives for older patients with long-term conditions: a review. Chronic Illn 5: 56–72 Brady TJ, Jernick SL, Hootman JM, Sniezek JE (2009) Public health interventions for arthritis: expanding the toolbox of evidence-based interventions. J Womens Health (Larchmt) 18(12): 1905–17 Breedland I, van Scheppingen C, Leijsma M,Verheij-Jansen NP, van Weert E (2011) Effects of a group-based exercise and educational program on physical performance and disease self-management in rheumatoid arthritis: a randomized controlled study. Phys Ther 91(6): 879–93 Challis, D, Huges J, Berzins K, Reilly S, Abell J, Stewart K (2010) Self–care and case management in long-term conditions: the effective management of critical interfaces. Report for the National Institute for Health Research Service Delivery Organisations Programmes. http://tinyurl.com/nq269hh (accessed 21 October 2013) Chaplin H, Hazan J, Wilson P (2012) Self-management for people with long-term neurological conditions. Br J Community Nurs 17(6): 250–7 Coleman S, Briffa K, Conroy H, Prince R, Carroll G, McQuade J (2008) Short and medium-term effects of an education self-management program for individuals with osteoarthritis of the knee, designed and delivered by health professionals: a quality assurance study. BMC Musculoskelet Disord 9: 117 Corben S, Rosen P (2005) Self-management for long-term conditions: patient perspectives on the way ahead. Working Paper, King’s Fund, London. http://tinyurl. com/obszex5 (accessed 21 October 2013) Davies NJ (2010) Improving self-management for patients with long-term conditions. Nurs Stand 24(25): 49–56 Deakin TA, McShane CE, Cade JE, Williams R (2009) Group-based training for self-management strategies in people with type 2 diabetes mellitus (review). In: The Cochrane Collaboration, Issue 1. Wiley Department of Health (2001) The Expert Patient: A New Approach to Chronic Disease Management for the 21st Century. http://tinyurl.com/pmtmcmx (accessed 21 October 2013) Department of Health and Diabetes UK (2005) Structured Patient Education in Diabetes: Report from the Patient Education Working Group. http://tinyurl.com/ ossy6dw (accessed 21 October 2013) Department of Health (2007) Research Evidence on the Effectiveness of Self Care Support. http://tinyurl.com/q2uec97 (accessed 22 October 2013) Duke SAS, Colagiuri S, Colagiuri R (2009) Individual patient education for people with type 2 diabetes mellitus (review). In: The Cochrane Collaboration, Issue 1. Wiley Effing T, Monninkhof EEM, van der Valk PP et al (2009) Self-management education for patients with chronic obstructive pulmonary disease (review). In: The Cochrane Collaboration, Issue 4. Wiley Expert Patients Programme Interest Company (2013) What we do. http://tinyurl. com/ntaohr2 (accessed 21 October 2013) Forducey PG, Glueckauf RL, Bergquist TF, Maheu MM,Yutsis M (2012) Telehealth for persons with severe functional disabilities and their caregivers: facilitating selfcare management in the home setting. Psychol Serv 9(2): 144–62 Foster G, Taylor SJC, Eldridge S, Ramsay J, Griffiths CJ (2009) Self-management education programmes led by lay leaders for people with chronic health conditions (review). In: The Cochrane Collaboration, Issue 1. Wiley. Goodwin N, Curry N, Maylor C, Ross S, Duldig W (2010) Managing people with long-term conditions. An inquiry into the quality of General Practice in England. King’s Fund, London. http://tinyurl.com/nef7vax (accessed 21 October 2013) Hadjistavropoulos T (2012) Self-management of pain in older persons: helping people help themselves. Pain Med 13 Suppl 2: S67–71 Hamnes B, Hauge MI, Kjeken I, Hagen KB (2011) ‘I have come here to learn how to cope with my illness, not to be cured’: a qualitative study of patient expectations prior to a one-week self-management programme. Musculoskeletal Care 9(4): 200–10 Hehir M, Carr M, Davis B et al (2008) Nursing support at the onset of rheuma-
Learning points w Self-management education programmes for people with long term conditions should be based on self-efficacy principles and patient centred
w The method of delivery can be in small groups over a period of a minimum of 3 weeks but needs to include written information and follow-up
w Patients should be invited to participate when they feel ready and not determined by the condition or at diagnosis
w During the programmes there should be time for the participants to share their experiences and provide support to each other
560
toid arthritis: time and space for emotions, practicalities and self-management. Musculoskeletal Care 6(2): 124–34 Hirsche RC,Williams B, Jones A, Manns P (2011) Chronic disease self-management for individuals with stroke, multiple sclerosis and spinal cord injury. Disabil Rehabil 33(13–14): 1136–46 Jones F, Riazi A (2011) Self-efficacy and self-management after stroke: a systematic review. Disabil Rehabil 33(10): 797–810 Kett C, Flint J, Openshaw M, Raza K, Kumar K (2010) Self-management strategies used during flares of rheumatoid arthritis in an ethnically diverse population. Musculoskeletal Care 8(4): 204-14 Laakkonen ML, Hölttä EH, Savikko N, Strandberg TE, Suominen M, Pitkälä KH (2012) Psychosocial group intervention to enhance self-management skills of people with dementia and their caregivers: study protocol for a randomized controlled trial. Trials 13: 133 Laforest S, Poirier M-C, Nour K, Ginac M, Parisien M, Lankoande M (2008) ‘I’m taking charge of my arthritis’: designing a targeted self-management programme for frail seniors. Phys Occupat Therapist Geriatric 26(4): 45–66 Leventhal H, Leventhal EA, Cameron L (2001) Representations, procedures, and effect in illness self-regulation: a perceptual–cognitive model. In: Baum A, Revenson TA, Singer JE, eds. Handbook of Health Psychology. Lawrence Erlbaum, New Jersey: pp. 19–47 Li T, Wu HM, Wang F et al (2011) Education programmes for people with diabetic kidney disease (review). Cochrane Collaboration, Issue 6. Wiley Lorig KR, Sobel DS, Stewart AL et al (1999) Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial. Med Care 37(1): 5–14 Lorig KR, Ritter PL, Dost A, Plant K, Laurent DD, McNeil J (2008) The expert patient online: a one-year study of an internet-based self-management programme for people with long term conditions. Chronic Illn 4: 247–56 MacDonald W, Rogers A, Blakeman T, Bower P (2008) Practice nurses and the facilitation of self-management in primary care. J Adv Nurs 62(2): 191–9 Murray E, Burns J, See Tai S, Lai R, Nazareth I (2009) Interactive health communication applications for people with chronic disease (review). Cochrane Collaboration, Issue 1. Wiley Naylor C, Imison C, Addicott R (2013) Transforming Our Health Care System: Ten Priorities for Commissioners. King’s Fund, London. http://tinyurl.com/d35hlhb (accessed 21 October 2013) National Institute for Health and Care Excellence (2003) Guidance on the use of patient-education models for diabetes. http://tinyurl.com/ngf2qoq (accessed 21 October 2013) Norweg A, Bose P, Snow G, Berkowitz ME (2008) A pilot study of a pulmonary rehabilitation programme evaluated by four adults with chronic obstructive pulmonary disease. Occup Ther Int 15(2): 114–32 Palmer D, El Miedany Y (2012) PROMs: a novel approach to arthritis self-management. Br J Nurs 21(10): 601–7 Reeves S, Perrier L, Goldman J, Freeth D, Zwarenstein M (2013) Interprofessional education: effects on professional practice and health care outcomes (update) (review). Cochrane Collaboration, Issue 3. Wiley Renders CM, Valk GD, Griffin SJ, Wagner E, van Eijk JT, Assendelft WJJ (2009) Interventions to improve the management of diabetes mellitus in primary care, outputs and community settings (review) . Cochrane Collaboration, Issue 1. Wiley Rimington GJ (2011) Treating COPD: are self-management plans worth the effort? Practice Nurs 41(19): 38–43 Riemsma RP, Kirwan JR, Taal E, Rasker JJ (2003) Patient education for adults with rheumatoid arthritis. Cochrane Database Syst Rev 2003(2). DOI: 10.1002/14651858.CD003688 Silverman M, Nutini J, Musa D, King J, Albert S (2008) Daily temporal self-care responses to osteoarthritis symptoms by older African Americans and whites. J Cross-Cultural Geront 23(4): 319–37 South J, Darby F, Bagnall A, White A (2010) Implementing a community-based self care training initiative: a process evaluation. Health Soc Care Community 18(6): 662–70 Swendeman D, Ingram BL, Rotheram-Borus MJ (2009) Common elements in self-management of HIV and other chronic illnesses: an integrative framework. AIDS Care 21(10): 1321–34 King’s Fund (2012) From Vision to Action: Making Patient-centred Care a Reality. http:// tinyurl.com/p7hmeey (accessed 21 October 2013) Trudeau KJ, Ainscough JL, Pujol LA, Charity S (2010) What arthritis pain practitioners and patients want in an online self-management programme. Musculoskeletal Care 8(4): 189–96 Wilson PM, Mayor V (2006) Long-term conditions. 2: supporting and enabling selfcare. Br J Community Nurs 11(1): 6–10 Yip Y, Sit JW,Wong DYS, Chong SYC, Chung LH (2008) A 1-year follow-up of an experimental study of a self-management arthritis programme with an added exercise component of clients with osteoarthritis of the knee. Psychol Health Med 13(4): 402–14
British Journal of Community Nursing Vol 18, No 11
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 29, 2015. For personal use only. No other uses without permission. . All rights re
