Implementing, embedding and integrating self-management support tools for people with long-term conditions in primary care nursing: A qualitative study
This article reports the findings of research to evaluate the implementation and embedding of a self-management support approach called WISE in primary care. The research found that the approach failed to be normalised in routine care, apart from handing out 'guidebooks' to patients.
It explores the challenges to embedding the WISE approach within the team and individual practice of practice nurses. These included concerns about workload, not feeling confident in their ability to implement the approach autonomously and the difficulty in changing established practice.
Researchers identified the key challenges as:
- The delegation, prioritisation and auditability of work associated with self-management support is not a priority for practices. This meant that for nurses, the work of providing self-management support had to be fitted between other tasks which were generally formulaic and box-ticking on computer templates, leading to cognitive and practical tensions for nurses.
- The responsibility for self-management is passed ‘down’ from General Practitioner to nurse to patient. The demarcation of roles within the practice impacted on how nurses viewed and dealt with self-management support. GPs delegated self-management support to nurses who in turn delegated responsibility to patients. In both cases, this was not necessarily an empowering process based in a partnership and shared decision-making approach
- Autonomous working practices provide space for optimal self-management support discussions between nurses and patients. Having autonomy allowed nurses to identify with acting in a patient-centred manner through establishing relationships with patients. However, in practice most nurses were not able to use their existing style of relating to engage patients in in-depth conversations and agendas about support or lifestyle behaviour change.
- Self-management support is not perceived as different enough to warrant the further investment of time and effort. Self-management support work was viewed in terms of being patient-centred; addressing lifestyle and behaviours and effecting change; and having time to listen – all of which were considered to be ‘normal practice’. This sense of there being nothing new translated into the view that there was no need for change.
- The lack of feasibility and success of changing behaviour is a demotivator of praxis. Changing people's behaviour is seen as difficult or impossible. Giving patients information and instructions was seen as easy and routine, but examples of how to motivate and engage people with new practices and behaviours were missing from the narratives of respondents.
- It's easy to dismiss or under-acknowledge the needs of patients. The PRISMS tool was easy to dismiss for several reasons: lack of time; it could open up too many complexities in structured time-limited consultations; practice systems were not geared up to support it; and cost to the practice.
- Self-management support resources need to be readily accessible and trustworthy. The guidebooks were seen as a positive benefit to patients, a nice ‘gift’ for nurses to hand out and superior to computer print outs. So long as the supplies were on the office shelf, they were easy to work with.
The authors conclude that supporting self-management through the encouragement of lifestyle change was problematic to realise with limited evidence of the development of the needed collaborative partnerships between patients and practitioners required by the ethos of self-management support.