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Keywords:

  • chronic illness;
  • interviews;
  • primary care;
  • practice nurses;
  • qualitative research;
  • self-management

Abstract

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. What this paper adds
  5. Introduction
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Acknowledgements
  11. Author contributions
  12. References

Title. Practice nurses and the facilitation of self-management in primary care.

Aim.  This paper is a report of a study to explore practice nurse involvement in facilitation of self-management for long-term conditions.

Background.  In the United Kingdom chronic disease services have shifted from secondary care to general practice and from general practitioners to practice nurses. A new United Kingdom General Practice contract requires adherence to chronic disease management protocols, and facilitating self-management is recognized as an important component. However, improving self-management is a relatively new focus and little is known about the ways in which nurses engage with patient self-management and how they view work with patients in chronic disease clinics.

Method.  Semi-structured interviews with 25 practice nurses were carried out in 2004–2005. Interviews were audio-taped and transcribed verbatim. Analysis was informed by the ‘trajectory model’ and ‘personal construct’ theories.

Findings.  Main themes in the early stages of work with patients were: categorization of patients, diagnosis, and patient education. First impressions appeared to determine expectations of self-management abilities, although these were amenable to change. Intermediate stages were ‘ways of working’ (breaking the task down, cognitive restructuring and addressing dissonance, modelling ‘good’ behaviour, encouragement, listening, involving carers and referral) and maintaining relationships with patients. However, in the longer-term nurses seemed to lack resources beyond personal experience and intuitive ways of working for encouraging effective self-care.

Conclusion.  The ways of working identified are unlikely to be sufficient to support patients’ self-management, pointing to a need for education to equip nurses with techniques to work effectively with patients dealing with longer-term effects of chronic illness.


What is already known about this topic

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. What this paper adds
  5. Introduction
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Acknowledgements
  11. Author contributions
  12. References
  • • 
    The new general practice contract in the United Kingdom has increased practice nurses’ responsibility for measuring, monitoring and recording patients’ health status but pays little attention to how self-management might be supported and improved.
  • • 
    Chronic diseases are a significant burden on healthcare services and practice nurses are increasingly supporting patients with chronic illnesses.
  • • 
    There has been little research examining the context in which practice nurses work and support self-care with patients with chronic illness, or the way they view or carry out their work.

What this paper adds

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. What this paper adds
  5. Introduction
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Acknowledgements
  11. Author contributions
  12. References
  • • 
    Clarification is needed regarding the skills and competencies required by nurses to support patients living with chronic illnesses and help them to develop self-management skills.
  • • 
    Education for practice nurses in chronic disease management should address the social, psychological and emotional impact of living with a chronic illness.

Introduction

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. What this paper adds
  5. Introduction
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Acknowledgements
  11. Author contributions
  12. References

The shift towards chronic disease management (CDM) in general practice has involved an increase in, and redistribution of, tasks within the primary care work force. Much CDM is performed by nurses (Charles-Jones et al. 2003) and practice nurses working alongside general practitioners (GPs) in primary care are seen to be in a good position to provide advice, support and management in this area (Thorne 1993). In the United Kingdom (UK), a recent contract provides financial incentives for aspects of CDM carried out in general practice. These financial incentives have focussed attention on CDM (Department of Health 2004a). This has contributed to increased responsibility for nurses working in general practice in the measurement, monitoring and recording of the standards of care enshrined in the new GP contract (Department of Health 2004b).

A distinction has been made between self-care (seen as the actions of individuals undertaken as part of daily living in order to stay healthy and take care of long-term conditions) and self-care support (which is the facility that health and social care services provide to enable people to take better care of themselves) (Department of Health 2006). Components of self-care support include devices and technologies, information, professional education, self-care plans and awareness raising policies. A key initiative aimed at providing self-care support in the UK has been the Expert Patients Programme, which is a lay-led chronic disease self-management training programme. In addition to group-based self-management programmes such as the Expert Patients Programme, effective self-care support from healthcare professionals (including those working in primary care) is seen as a key resource in the management of long-term conditions (Department of Health 2006).

Despite the increasing role of practice nurses in setting up and running CDM clinics, relatively little attention has been given to the ways in which practice nurses work and support self-care as part of their role in CDM. Aspects of nursing work identified as requiring particular attention are the communication and co-ordination of care and clarification of appropriate skills and competencies (Parchman et al. 2005).

The study

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. What this paper adds
  5. Introduction
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Acknowledgements
  11. Author contributions
  12. References

Aim

The aim of the study was to explore practice nurse involvement in facilitation of self-management for long-term conditions.

Design

The study was qualitative in design and we used aspects of grounded and adaptive theorizing, i.e. blending aspects of an inductive–deductive approach (Murphy et al. 1998). Interviewing began with a humanistic approach designed to elicit the ways in which nurses themselves conceptualized and viewed their work. Aspects of adaptive theorizing (Layder 1998) were introduced through drawing on personal construct (Kelly 1991) and illness trajectory (Corbin & Strauss 1992) theories which sensitized us to themes emerging from the early analysis of interviews and informed our subsequent data analysis (see below). This type of inductive–deductive approach allows for movement between data collection and analysis and emergent design and analysis (Guba & Lincoln 1989), which is shaped as the study progresses in response to the researcher’s early observations, and by pre-existing conceptual frameworks relevant for furthering understanding of nurses work in this area.

Participants

The participants were 25 nurses located in two primary care trusts (PCTs) in North West England. The PCTs involved were two out of the eight pilot sites participating in the national evaluation of the EPP and were chosen for this study on a convenience basis because of their accessibility. A related study carried out with GPs (Blakeman et al. 2006) was the basis for the nurse recruitment. A purposive sample of GPs was selected from lists held by both PCTs. To ensure that a wide range of characteristics was sampled, GPs were selected according to sex, practice size and contractual status; any GPs who were known by PCT staff to have either an interest in the Expert Patients Programme or CDM were also invited to participate. For the purposes of the study reported here, contractual status was not taken into account in the analysis. At interview, GPs were asked if they would be willing for nurses working in CDM to be interviewed. With one exception all GPs agreed, and all nurses approached agreed to participate.

Data collection

Semi-structured face-to-face interviews were conducted between November 2004 and June 2005 and lasted 30–65 minutes. An interview guide provided a flexible framework for questioning and areas covered included nurses’ knowledge about and role in encouraging self-care, perceived barriers to self-care and attitudes towards the Expert Patients Programme. All interviews were conducted by the first author, audio-taped and professionally transcribed. The approach to interviewing combined a descriptive account from nurses of the way in which they worked and a more active interviewing style in which a dialogue between interviewer and interviewee results in the construction of meaning amenable to a more critical discursive approach to analysis.

Data analysis

In line with our approach to interviewing, strategies from a grounded theory approach (constant comparative method) (Strauss & Corbin 1998) were used alongside discursive analysis to aid data analysis. The transcripts were initially read for familiarization purposes, and initial open coding enabled some of the research questions to become more ‘grounded’ in the data (Glaser & Strauss 1967; Strauss 1987). A coding framework was devised by W. M. by analysing the first interview; this was then compared and contrasted with the second interview. Any additional or modified codes were incorporated into the framework. This process was replicated with all transcripts. The interviews were also read and analysed by A. R. and the coding framework was agreed following discussion between W. M. and A. R. Emergent themes and sub-themes were then agreed between the authors.

The emergent categories and themes resonated with Kelly’s ‘personal construct’ theory (Kelly 1991) and with the ‘trajectory model’ (Corbin & Strauss 1992). These theoretical ideas informed further analysis of the empirical data. For example, early analysis of open codes revealed the categories or ‘personal constructs’ that the practice nurses used in their work which was followed up in later interviews.

Approaches to working with patients differed according to whether they were newly diagnosed or had been living with a chronic condition for some time. The ‘trajectory model’ (Corbin & Strauss 1992) emphasizes stages of an ‘illness career’ and the varying impact on patients’ everyday lives. Primacy is given to patients’ perceptions about what is happening to them in terms of predicting the trajectory, and therefore the management, of their condition. They argue for nursing work to be based on the experiences of individuals with chronic illness to provide the integration that is needed to guide practice (Corbin & Strauss 1992).

Personal construct theory (Kelly 1991) centres on the notion that people create dimensions of meaning, or ‘personal constructs’, which they use to make sense of experiences and anticipate the future. Individuals are viewed as continually constructing and testing realities in the same way scientists do with theories. Constructs are developed and then tested by engaging in behaviours that evaluate expectations and improve understandings of reality. This theory has also been used to explain the way in which other professionals encounter ‘new’ work (Nicholls 2005).

Rigour

Our methodological approach helped to ensure the credibility of the findings. Two researchers analysed all the data and any disconfirming or deviant responses were taken into account. The data were also compared between and within cases. Other efforts to enhance the trustworthiness of the study included note-taking and extensive discussions about coding with colleagues.

Ethical considerations

A Multi-Centre Research Ethics Committee approved the study. The informants were guaranteed confidentiality and were told that participation was voluntary and they were free to withdraw at any time. They were also told that if they had any concerns they could ask for any data collected to be excluded from analysis but none of the participants asked for this to be performed. Consent forms were signed.

Findings

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. What this paper adds
  5. Introduction
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Acknowledgements
  11. Author contributions
  12. References

The themes and sub-themes which emerged from the nurses’ accounts reflect the process of supporting self-care with their patients over time:

  • Early stages: ‘making sense of the patient and the condition’:
    •  categorization of patients;
    •  diagnosis as an initial point for developing a working relationship with patients; and
    •  patient education.
  • Intermediate stages: ‘ways of working with patients’:
    •  breaking the task down;
    •  cognitive restructuring and addressing dissonance;
    •  modelling how to behave;
    •  encouragement;
    •  listening;
    •  involving carers; and
    •  referral as a resolution to becoming ‘stuck’.
  • Later stages: engaging and managing people in the longer term:
    •  ‘in for the long haul’.

Early stages: ‘making sense of the patient and the condition’

Categorization of patients

Most interviewees described how they organized their initial impression of patients into categories early in the relationship – usually in the first consultation – concerning how well they thought a patient was going to cope with their illness in the future. Such assumptions about patients were used to make encounters more predictable:

Some just can’t take it on board at all…others grasp the nettle very quickly…you can normally tell with people when you first meet them…you can categorize them as to how well you think they’re going to do.

There was general agreement that ways of working were based on judgements about whether a patient was active or passive and whether they were likely to be a ‘good’ or ‘bad’ self-manager:

The questions that a person asks you back give you an insight…rather than just sitting there and nodding.

If somebody’s very, very interested and wants information I know they’re going to be compliant.

Other patients whom nurses identified as ‘good’ self-managers were those who in paid employment or active in other ways, had good social and familial networks, were viewed as intellectually able or self-confident, and who demonstrated an interest in their illness by asking questions, read and digested information and sought knowledge from other sources:

I think some of it comes down to intellect…I am not an elitist…I have no preference who I see. The ones that [have]…an active life and job.

Somebody who’s quite self-confident, believes they can be well, not fatalistic…got outside interests…maybe family, church groups or some sort of social life.

Categorization seemed to serve the function of setting boundaries for the way in which nurses worked with patients. There was variation and flexibility in the constructs and the degree to which they were deployed as ‘working models’ for predicting patient behaviour:

Sometimes you can be wrong…‘cos the ones you think perhaps won’t sometimes do [well] and those who you think will sometimes don’t so…it’s hard, really, to assume.

Diagnosis as an initial point for developing a working relationship with patients

Patients being diagnosed with a long-term condition appeared to be an anchor point for initiating a positive working relationship. Interviewees described the focused work they carried out with patients (tests and information giving, etc.), which suggested a degree of confidence and security about their role at this point in a person’s illness career. The recognized difficulties associated with diagnosis resonate with the notion of biographical disruption (Bury 1982, 1991), which has been used to describe how the onset of a chronic illness undermines the ‘taken-for-granted’ aspects of everyday life, brings to the fore the recognition of pain and suffering associated with disease, and contributes to the impact of managing symptoms. Nurses’ accounts demonstrated an appreciation of the way conditions presented different challenges, and the importance of understanding a patient’s own perspective:

The first thing to find out…what does that mean to them…sometimes they think it’s the end, its so overwhelming…to have a new diagnosis…they’re very worried and frightened. But if you say, ‘There is life after this heart attack’, or There is life after this diagnosis of diabetes, you will learn to manage it.

To some people it’s a big shock that they’ve received a diagnosis. Then all of a sudden they’re expected to change a way that they’ve lived for years…to be successful…it has to be gradual – I don’t think you can be bullied into immediate lifestyle changes.

In the initial stages of illness, nurses recognized the sense of loss patients experienced:

That’s fine. I always have a box of tissues handy because people do cry…‘If I’ve lost me health, what have I got left? Now I’m retired I’ve got no work’. It’s a big thing for a lot of people…a period of mourning.

Interviewees intimated greatest confidence in their ability to help patients in the early stages of illness to understand their condition. This is a time when patients may be more likely to seek advice about symptom management (Locker 1983). In the early period of a condition, practical management may be more uncertain for patients as they learn to manage their symptoms, and they may rely more on healthcare professional input (Bury 1991). Learning to live with a chronic disease is widely recognized as challenging (Thorne et al. 2000, Thorsteinsson 2002, Gregory 2005). Participants’ accounts suggested that early categorization of patients at the time of diagnosis is of less value, and becomes more complex as the relationship develops. Thus, contact with formal services through CDM clinics may become less important to patients than the management of illness in their everyday lives.

Patient education

Patient education was seen as a vital component of CDM in the early stages of a condition, and nurses viewed giving appropriate amounts of information and using visual modes of delivery as essential:

I’ll start off showing them. ‘What’s cholesterol?’ So I always draw, ‘That’s your artery. See…that’s how narrow it’s going to be. (If it) carries on, you’ll have a heart attack’. ‘What now?’...‘No, but if you carry on…we are preventing something’…They seem to grasp more visual things, I think.

If nurses considered that patients were well-informed and concordant, they felt more confident about relinquishing control. In contrast, if they believed that they had imparted enough education but the patient continued to ignore advice, they would be more likely to view this in the context of patient choice and responsibility. This resonates with the argument that when treatment fails a doctor is more likely to see the problem residing in the patient than the therapy (Balint et al. 1969) or in lack of patient control (Ogden et al. 2001):

Education is paramount as long as we’ve imparted...all the knowledge we have…the choice is definitely up to them…I see my role as overseer of their care…we don’t have [paternalistic] medicine anymore – it’s very much their disease and we’re only here to help them manage it, and empowerment is everything.

There is evidence that some professionals maintain the role of expert even when a patient demonstrates quite sophisticated self-care decision-making, modifies their behaviour to improve their quality of life (Thorne et al. 2000), or uses strategic non-compliance (Pound et al. 2005). There were examples in this study of nurses persisting in giving information even when patients made it clear that this would not have any effect on the targeted behaviour. However, the findings also seemed to indicate that as time went on and information-giving and bio-medical measures might become less important to patients than day to day self-care, nurses had to draw on a wider range of techniques, as described below.

Intermediate stages: ‘ways of working with patients’

In the absence of specific education and skills in CDM, nurses tended to rely on their own idiosyncratic methods, which appeared to have developed through ongoing contact with patients and then been incorporated into everyday working practices. They acknowledged the complicated influences which influenced patients’ ability to self-manage:

Most patients…they’re multifaceted…there’s an awful lot going on…you’re a bit of a social worker as well.

The reason that some have become overweight is because they’ve lost their husband. There are other factors…they’ve sat at home for six months because they’ve been miserable and…just eaten…they need that motivating factor.

When asked to give examples of patients whose management was problematic, the nurses described a range of strategies on which they called.

Breaking the task down

With patients who were newly diagnosed, nurses tended to give limited amounts of information at any one time. Frequent appointments following diagnosis allowed them to influence patients’ knowledge slowly. They took account of the style and language they used in delivering information and tried to tailor these to individuals.

In order to further support patients, they tried to break tasks down into manageable ‘chunks’. Most nurses said that they would try to agree realistic goals which took into account a patient’s lifestyle. In the case of smoking they would urge cutting down, particularly if they knew the patient was having difficulties in their personal lives:

‘Can we, if you can’t manage to do everything all at once, can we just take a little bit and do this…first, then see how you go? Maybe just alter your diet by one meal a day? Can we just do something with your breakfast or your bedtime or whatever…?’ Try and work little steps if they’re not gonna be able to do the whole thing at once.

Cognitive restructuring and addressing dissonance

Cognitive restructuring is defined as focusing on thoughts (beliefs, expectations, etc.) and offering suggestions about changes to the way the patient thinks in order to modify behaviour (Beck 1976). Dissonance refers to the effect of holding two opposing beliefs at one time. Although nurses were unaware of these psychological terms – or at least did not refer to them explicitly – they gave examples of the use of these techniques:

‘I’ve got to this age and I’ve smoked all my life and what is the point of me giving up?’– they talk themselves into that. You know, ‘I haven’t much longer on this earth’, is something they all say…‘But…you’re quite willing to come in and take a preventative measure...you come in and have all the flu jabs…you think, ‘Oh well, I need to have that’. And yet when it comes down to the smoking side of things, you’re saying, ‘Well I’m too old’. But you’re hoping by having the (influenza vaccination) you’re not going to have pneumonia. And you’re going to live another year. So you’re contradicting yourself, aren’t you?

Modelling how to behave

Modelling ‘good’ behaviour which patients were encouraged to emulate was one of the ways in which some nurses considered that they were encouraging self-management. It was clear that a number of interviewees found it relatively easy to maintain a healthy lifestyle (through exercise and diet) and felt that, through their example, patients should also be able to adopt healthy behaviours:

I watch what I eat, I try to exercise…if I carried on eating like they eat (patients) I would be a little round pudding.

Encouragement

Motivation was a word that recurred through all the narratives, although nurses found it difficult to describe how they would, in practice, improve patient motivation apart from reinforcing the abilities to make the necessary changes:

They need someone who is going to say to them, ‘Look you can do this’. Most people are very, very good at making excuses for reasons why they can’t.

Listening

Listening to patients was seen as important and there was recognition that nurses had more time than GPs for this. Some recognized that allowing patients to talk could reduce the need for additional appointments:

But the asthmatics and the diabetics particularly, they’ll often say, ‘The doctor never has time. I can’t really talk to him’. They always come…to us. It’s, ‘Well he doesn’t have time, doesn’t listen.…sometimes we get a prescription and be sent on our way, we’re quite happy, if we’re told why this is happening and it might not happen and that might not happen. It might stop, it might not stop, that’s fine’...if you spend a bit more time, sometimes you’re preventing more appointments.

When patients were unhappy as a consequence of life events, nurses felt ill-equipped to do anything other than listen. This led to tension between the need to collect biomedical information to meet the needs of the new GP contract (Department of Health 2004a) and their perceptions of patients’ need to talk about their difficulties:

It makes you realize that (sigh) you’ve got to give patients a chance to say how I feel today. I think we’re not always very good at that, nurses, doctors, carers. Generally I think we are a bit on the poor side – we might eventually say…you know, we might stop and look and think, ‘Oh god, you know, they don’t look well today’ (laugh)…not nastily now, but purely because you’ve got a ten minute slot, you’ve got their bloods to take, you’ve got to get them weighed, all the forms filled in, all in that same time and you’re thinking ‘Ohhh’.

The length of time that nurses were allocated for CDM varied, and those with shorter consultations found this particularly problematic.

Involving carers

In practices with relatively stable populations, nurses talked about the value of involving family, friends or carers in encouraging self-care. Recognition was given to the way in which self-care behaviours were likely to extend beyond individuals’ internal motivations or willingness to make behavioural changes. Consultations were described where family members were encouraged to support the person with a long-term condition, particularly in relation to diet and exercise. However, it was noted that some patients found this unhelpful, with its undertones of surveillance:

I usually get their wives or husbands to come in and they’ll say, ‘Whatever he says, he’s not doing what he should…it’s all very well him saying that I’m cooking…but it’s him that hides the chocolate papers under the cushions’…they’ll tell because they know me, and it’s not gonna be horrible because I don’t shout at anybody or get stroppy.

Referral as a resolution to becoming ‘stuck’

As a last resort, nurses would consider referring patients they were concerned about to GPs, other nurses or to secondary care. They generally expressed reluctance to do this but acknowledged that there were times when they ran out of options. There was also evidence that nurses wanted to share responsibility for patients when behaviours were a risk to health:

I’d refer them on. If I felt that I’d done my best and they’ve been through all the avenues that I can…think of…I’d refer a diabetic on to a diabetic specialist nurse.

However, referring patients on to other care professionals was not always seen as helpful, except when negotiating with the patient to improve concordance:

It’s very difficult, compliance, it’s probably a small percentage of people who are non-compliant…it’s very difficult. Some people are just not motivated at all and even with extra education and trying to have more input it is very, very difficult. Sometimes the more people you try and get involved, the harder it becomes. They lose focus somehow – so if you’ve got a diabetic maybe who was non-compliant with their medication, to then refer them to the hospital when they don’t want that anyway…you have to try and barter with them and say, ‘Unless you come to me, then we are going to have to refer you on.

Ultimately, however, nurses had to continue to work on a long-term basis with patients with chronic illnesses, were often reluctant to refer on, and at best saw it as an interim strategy.

Later stages: engaging and managing people in the longer term

In for the long haul

Nurses had a keen appreciation that they were on a long ‘journey’ with patients with chronic illnesses, and there were times when they found this difficult, particularly if they felt that a patient was not making progress. The tendency to categorize patients as ‘good’ or ‘bad’ self-managers might have played a part in the frustration some expressed.

Their comments illustrated some of the complexities of delivering CDM in primary care and the ways in which professionals can create long-term partnerships in which they guide patients over several years towards skill development (Cumbie et al. 2004). At times discrepancies between what nurses thought patients ought to be doing and how patients viewed themselves gave rise to frustration:

You will get some people that will not take that on board and many a time we roll our eyes in the diabetic clinic. This – chap will come in and say, ‘I eat like a bird. I honestly eat like a bird’. Well, if you’re eating like a bird, what type of bird are we looking at? An emu? You know, because it certainly isn’t a sparrow.

When patients did not carry out the suggested lifestyle changes there were indications that nurses resorted to reliance on didactic information-giving, even when the patient made it clear they were making informed choices about their behaviours. It would seem from the following excerpt that this did not always achieve the desired outcome.

(With) some people, you can bang your head against that brick wall until you’ve knocked yourself out. Some people will come up with excuse after excuse…‘I don’t want to know about smoking cessation, I’m happy to smoke…that’s my choice and just back off’…You just keep whittling away…every time they come in, you do it again. They say, ‘I know what you’re going to tell me – I can recite it backwards’.…‘Well, I’ll say it again’.

Discussion

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. What this paper adds
  5. Introduction
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Acknowledgements
  11. Author contributions
  12. References

Previous literature suggests that nurses communicate considerably more with patients about behaviours such as smoking, diet and alcohol than do doctors and patients are more likely to discuss behaviour change with nurses (Pill et al. 1998). However, whilst there are indications that healthcare professionals welcome a central role in promoting self-management, the notion of self-care support within healthcare services is still relatively new and under-developed (Kennedy et al. 2005). In this study, the way in which nurses tried to enable patients to self-manage was found to be based on a combination of their personal constructs of patients, their understanding of the stage of the patients’ illness career, and the impact of the biographical and social dimensions of chronic illness. Some interviewees reported changes in the way in which they approached patients with long-term conditions over time, because experience with the patient required alteration of their personal constructs. Accounts – particularly of early engagement with people with a long-term condition – resonated with elements of patients’ struggles described in the trajectory framework formulated by Corbin & Strauss (1992). Our participants seemed to understand and take into account the disruption, grief and biographical impact that diagnosis of a chronic illness can bring (Bury 1982, 1991, Corbin & Strauss 1992).

Nurses appeared more confident in dealing with patients in the early stages of the illness trajectory, particularly around the time of diagnosis. The dichotomous use of personal constructs of ‘good’ and ‘bad’ self-managers provided an anticipatory model for future behaviours. However, as relationships with patients developed and became more complex, nurses seemed to lack other resources to call on to encourage effective self-care beyond strategies developed on the basis of personal experience and reliance on intuitive ways of working. Although they demonstrated understanding of the challenges their patients faced, they found it difficult to articulate strategies they used beyond these ‘common-sense’ methods. In the absence of formal education in psychological techniques to encourage behavioural change, they relied on repeated information-giving, improvized role modelling and patient education.

Our participants were expected to work with patients over a long period and manage feelings of frustration if a patient was ‘stuck’. Working in a context which is increasingly driven by targets, achieving outcomes for CDM which attract financial rewards, and where the time available to address complex aspects of care may be diminishing may mean that the requirement to measure biomedical parameters take precedence over the need to understand complex patient needs. The demands of the GP contract may militate against moves to establish an ethos of concordance rather than compliance (Royal Pharmaceutical Society of Great Britain 1997), where patient and healthcare professional work together to agree a treatment regime (Dukes Hess 1996) and a patient’s refusal of treatment is not necessarily seen as negative (Connect 2000). Strategic non-compliance, for example, has been identified as a necessary component of achieving a sense of balance, control and well-being in lay experiences of chronic illness (Campbell et al. 2007) and might act as point of negotiation and continuing dialogue.

Study limitations

This study was limited to nurses’ accounts of their work, and future research might employ interviews with patients and observation of CDM to address the question of what nurses actually do and how this fits with the principles underlying theories of self-management in chronic illness. Further, the transferability of the findings is limited because the study was conducted in only two PCTs in northern England.

Conclusion

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. What this paper adds
  5. Introduction
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Acknowledgements
  11. Author contributions
  12. References

The findings have implications for considering the delivery of CDM in primary care and the ways in which professionals can create long-term partnerships in which they support patients’ own efforts at self-management and work with them over several years. A necessary part of this process would be giving nurses the ability to relinquish control on occasions to minimize the frustration both they and patients experience. Training in self-management skills (e.g. cognitive behavioural therapy) could give nurses the resources to work effectively in supporting patients suffering from long-term conditions to undertake self-management. In developing such training, it might be helpful to audit nurses’ existing skills and use these as the starting point for developing theory-driven strategies and techniques for encouraging self-care. Nurses could be enabled to be more reflective about a patient’s position on the illness trajectory and to use this as a basis for discussion and negotiation, instead of feeling that they had constantly to make progress by resorting to strategies that had failed in the past. This could allow both patient and nurse time to consider how they might best overcome obstacles to patient engagement with self-management. While our data indicate the need for additional training and support, it is also necessary to acknowledge and build on the existing commonsense knowledge and skills that nurses have built up over time in their day-to-day work with patients in CDM clinics.

Acknowledgements

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. What this paper adds
  5. Introduction
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Acknowledgements
  11. Author contributions
  12. References

We would like to thank the practice nurses who gave so generously of their time. Thanks are also due to Carolyn Chew-Graham for her insights.

Author contributions

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. What this paper adds
  5. Introduction
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Acknowledgements
  11. Author contributions
  12. References

WM and TB were responsible for the study conception and design and the WM, AR, WM, AR, TB and PB drafting of the manuscript. WM performed the data collection. WM, AR, TB and PB performed the data analysis. WM, AR, TB and PB made critical revisions to the paper for important intellectual content.

References

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. What this paper adds
  5. Introduction
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Acknowledgements
  11. Author contributions
  12. References
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