Kimberly A Udlis University of Wisconsin Oshkosh College of Nursing 800 Algoma Blvd Oshkosh, WI 54901 USA Telephone: +920 424 2106 E-mail: firstname.lastname@example.org
udlis ka (2011)Journal of Nursing and Healthcare of Chronic Illness3, 130–139 Self-management in chronic illness: concept and dimensional analysis
Aim. To define self-management in chronic illness and explore the concept.
Background. Successful management of chronic illness requires an integrated approach with active involvement of the patient, family and healthcare professional. The term self-management is used extensively within the literature as a method to improve chronic illness outcomes and is recognised as an essential component in the treatment of persons with chronic illness, yet the concept of self-management varies greatly depending on context and perspective. As patient involvement is the essence of self-management, the concept of self-management is in need of further exploration.
Methods. Dimensional analysis provides the optimal approach to analysing the concept of self-management in chronic illness as it seeks to offer an understanding of the concept through its social construction and examines differences across perspectives and contexts.
Conclusions. Antecedents, dimensions and consequences of self-management were identified and a definition and model of self-management was constructed. The salient dimension of adherence to a plan represents the dominance of the healthcare professional’s perspective in the literature. Further research exploring self-management from the patient’s perspective and encompassing all the aspects of the self-management model is necessary to accurately evaluate the consequences of improved quality of life, improved clinical outcomes and reduced healthcare expenditures.
Relevance to clinical practice. Antecedents and dimensions of self-management derived from the chronic illness literature can be used to formulate tailored plans aimed at fostering successful self-management in patients as well as to guide interventions to improve self-management and patient outcomes.
The prevalence of chronic illness is increasing globally. Approximately, 45% of Americans had one chronic illness and 21% had multiple chronic illnesses in the year 2000 with 78% of healthcare expenditures in the United States being dedicated to the treatment of people with chronic illness (Anderson & Horvath 2004, Yach et al. 2004). By 2020, it is projected that nearly 50% of Americans will be living with at least one chronic illness and that these illnesses will be the leading causes of morbidity and mortality in the United States (Anderson & Horvath 2004, Newman et al. 2004). As the traditional provider-directed/patient-compliant approach to chronic illness management failed to produce improved clinical outcomes, alternative approaches were sought (Funnell & Anderson 2004, Koch et al. 2004).
The term self-management is used extensively within the literature as a method to improve chronic illness outcomes. Successful management of chronic illness requires an integrated approach with active involvement of the person, family and healthcare professional. This paradigmatic shift in treatment necessitates a partnering of healthcare professionals with their patients and movement away from the traditional concepts of patient compliance and adherence to a more mutual relationship (Hughes 2003, Holman & Lorig 2004, Newman et al. 2004, Yach et al. 2004, Carryer et al. 2010). Self-management is now recognised as an essential component of the treatment of persons with chronic illness and is endorsed by the National Institute of Health, the National Institute of Nursing Research, the Agency for Healthcare Research and Quality and the American Medical Association (Kass-Bartelmess 2002, National Institute of Nursing Research 2003, American Medical Association 2010).
Although the term self-management is ubiquitous in the chronic illness literature, the application and definition of the concept of self-management varies greatly depending on context and perspective. The rudimentary premise of self-management is that of the person’s involvement in the management of their own illness (Lorig & Holman 2003, Newman et al. 2004). However, the precise meaning of this involvement is not well-explicated in the literature. Furthermore, the objectification of person as patient is widespread in the self-management literature suggesting that self in self-management is becoming lost (Koch et al. 2004).
Self-management does not occur in a vacuum as the person interacts with and is influenced by multiple factors including healthcare professionals, family and society. The person’s chronic illness management setting also varies according to illness aetiology, socioeconomic factors and cultural aspects. As self involvement is the essence of self-management, the concept of self-management itself is in need of further exploration.
Antecedents, dimensions and consequences of self-management were identified through concept analysis consistent with the evolutionary view described by Rodgers (2000). Rather than seeking the essence of a concept and assume that a concept is universal and unchanging, the evolutionary view incorporates the contextual biases of the concepts by exploring the situational, temporal, sociocultural and disciplinary aspects of the concepts (Rodgers 2000).
Dimensional analysis, guided by Caron and Bowers (2000) framework, complements the evolutionary view of concept analysis. ‘A dimensional analysis is based on the assumption that a concept is always defined within a perspective – and may have different meanings depending on whose perspective is reflected and in what context the concept is defined or used’ (Caron & Bowers 2000, p. 293). This provides the optimal approach to analysing the concept of self-management as it seeks to offer an understanding of the concepts through its social construction and examines its differences across perspectives and contexts (Caron & Bowers 2000). Asking the relevant questions of: ‘What are the dimensions of self-management?’, ‘What is the social construction of the concept?’, ‘What are the varying contexts and perspectives that contribute to the definition?’ allows for natural analysis of the meaning of self-management through interpretation of the dimensions of the concept (Morse 1995, Kools et al. 1996).
Analysis of the literature consisted of reviewing articles within several healthcare disciplines including nursing, medicine and psychology. Literature searches were conducted through MEDLINE, CINAHL, ProQuest, PubMed and PsychInfo using the keywords of self-management, chronic illness, chronic disease, compliance and adherence. Articles were limited to the past 10 years, availability in the English language, and were chosen based on relevance and their reflection of varying perspectives and contexts germane to self-management. Articles were deemed relevant if the authors described the methodology for measuring the before mentioned keywords or if the authors used a concept analysis approach to describing the keywords. Forty articles were chosen for review based on these criteria.
The following steps consistent with the evolutionary method of concept analysis were used (Rodgers 2000):
1 Identify the concept.
2 Identify the data collection strategies.
3 Collect the relevant data and identify antecedents, attributes (dimensions) and consequences of the concept.
4 Analyse the data and abstract the major themes/aspects of the above characteristics.
5 Interpret the data and clarify the concept.
6 Identify implications for further development of the concept.
Also, the following questions guided the dimensional analysis of the concept (Caron & Bowers 2000):
1 What are the dimensions of the concept and how are they related to each other?
2 What are the perspectives of the concept in the literature? Who is represented and how, and who is not included?
3 What are the contextual elements that contribute to the use of the concept?
4 What assumptions do the author(s) integrate into the literature?
5 What are the implications of how the concept is constructed and used?
Concept and dimensional analysis
Consistent with the evolutionary method of concept analysis, antecedents, dimensions and consequences were derived from the literature. Each category of data was examined separately and major themes were extracted from the literature. Data were organised and ‘labels were identified to describe the major aspects of the concept’ (Rodgers 2000, p. 95).
The antecedents to self-management derived from the literature were those of information, self-efficacy, support, intention and mutual investment between the patient and healthcare provider.
Self-efficacy refers to a person’s own perception of his or her ability to perform an act. It incorporates the aspects of motivation, ability, desire and resources which influence not only the decision of what conditions to act upon, but also which environments to act within (Ozer & Bandura 1990, DiIorio et al. 1996, Lorig & Holman 2003, Prior & Bond 2004). An individual’s confidence in their abilities to perform health behaviours (i.e. self-manage) will influence their actual performance and adherence of those behaviours (Urmimala et al. 2009). Therefore, a belief in one’s ability to successfully perform health behaviours can directly impact self-management behaviours.
Mutual investment involves the dissolution of the dichotomous patient–doctor relationship and incorporates a partnering of healthcare professionals with the patient. This interaction consists of shared goals and responsibilities between the professional and the patient (Bourbeau 2003, Huffman 2005). Trust and confidence lay the foundation for this collaborative approach to management while a transfer in power roles promotes patient empowerment (Rodwell 1996, Bodenheimer et al. 2002, Koch et al. 2004). Rather than being responsible for their patients, healthcare professionals need to be responsible to their patients (Thorne & Paterson 2001, Funnell & Anderson 2004, p. 124).
Dimensions of self-management
Dimensions are abstract concepts, each being a component of the concept of interest (Kools et al. 1996). Along with identification, dimensional analysis seeks to explore how the dimensions are related to each other (Caron & Bowers 2000). Five dimensions of self-management were extracted from the literature review. Resources, knowledge, adherence to a plan, active participation and informed decision-making formed a hierarchical structure representing the concept of self-management (see Fig. 1).
Resources and knowledge form the base of the self-management structure. Various types of resources need to be accessible to the patient living with a chronic illness. Access to physical, environmental and socioeconomic resources must be readily available to the patient on a daily basis and used effectively to maintain self-management (Prior & Bond 2004, Tanner 2004). Newer, technologically-based resources, including on-line support, telemonitoring and internet interventions, have also become available to better equip patients with the tools to be successful in self-management behaviours (Ghahari et al. 2010, McManus et al. 2010, Stinson et al. 2010, Zheng et al. 2010). The healthcare provider also acts as a resource to the patient, supplying the needed advice, encouragement and guidance as necessary (Fisher et al. 2005, Huffman 2005).
Knowledge represents the application of information and skills necessary to adapt to a chronic illness state (Prior & Bond 2004) and can be acquired through external means or through personal experience and the development of expertise (Paterson & Thorne 2000, Cameron et al. 2010). This acquired knowledge presupposes that the persons have gained an understanding of the information provided to them and have the ability to perform the necessary skills competently (Anarella et al. 2004, Deakin et al. 2005). Devoid of knowledge, patients are unable to actively participate in their care (Newman et al. 2004, Tanner 2004). Although knowledge is necessary, it is not sufficient to achieving self-management.
The culmination of resources, knowledge, adherence to a plan and active participation is informed decision-making. Derived as a summary concept from problem solving, decision-making and patient control, informed decision-making provides patients with the capacity to make optimal choices and employ varying management strategies on a day-to-day basis (Lorig & Holman 2003, Funnell & Anderson 2004). Persons with chronic illnesses are inundated with daily decisions regarding their health and management of illness; ‘What if my left arm aches?’, ‘Should I exercise if I’m feeling tired?’ and ‘What should I do if my blood sugar is low?’ are various examples of common obstacles. Problem-solving techniques provide people with the ability to define and address problems and generate solutions. Decision-making skills are based on the foundations of knowledge, resources and prior experience, which patients gain through adherence to a plan and active participation (Schilling et al. 2002, Lorig & Holman 2003, Koch et al. 2004). Informed decision-making places the person in control of their choices and resultant consequences (Funnell & Anderson 2004).
The consequences of self-management in chronic illness converged into three major themes: (1) improved clinical outcomes, (2) reduced healthcare expenditures and (3) improved quality of life.
Improved clinical outcomes
Improved clinical outcomes are one of the predominate methods for evaluating the success of self-management programs in the chronic illness literature. These clinical outcomes consist of predetermined, evidence-based clinical criteria. Several examples such as haemoglobin A1C levels, patient monitoring of blood sugar levels, medication compliance and adherence to various physician recommendations encompass the category of clinical outcomes (Bourbeau 2003, Anarella et al. 2004, Deakin et al. 2005, Menendez-Jandula et al. 2005).
Reduced healthcare expenditures
The other defining outcomes used extensively in the literature to measure the success of self-management programs are the reduction in healthcare expenditures. Decreased physician visits, hospitalizations, service utilisation, emergency room visits, complication rates as well as other indicators are used to discern a reduction in healthcare costs (Bodenheimer et al. 2002, Bourbeau 2003, Dongbo et al. 2003, Koch et al. 2004, Gately et al. 2007).
Review of the chronic illness literature, consistent with Rodger’s evolutionary concept analysis, resulted in a definition of self-management. This definition is not to be inferred as universal and stagnant, but rather to clarify the concept based on the analysis and provide the foundation for further concept development (Rodgers 2000, p. 97). Self-management may occur when the individual has the resources and knowledge needed to adhere to a mutually agreed upon plan while actively participating in the management of their chronic illness. The culmination of these acquired abilities provides the individual with the capacity to make informed decisions which result in improved quality of life, improved clinical outcomes, improved self-worth and reduced healthcare expenditures. The antecedents necessary to self-management are information, self-efficacy, support, intention and mutual investment between the patient and healthcare provider.
The basic assumption of dimensional analysis is that concepts are defined within perspectives and contexts. Therefore, the dimensions of self-management in chronic illness must be explored and described across multiple perspectives and contexts as well as social constructions to determine presence, salience and relevance (Caron & Bowers 2000).
Self-management from multiple perspectives and contexts
Self-management is dependent upon the environmental contexts surrounding the person with chronic illness (Fisher et al. 2005, p. 1523). Context in the chronic illness literature varies primarily based on the aetiology of illness. Many chronic illnesses employ self-management strategies such as asthma, diabetes, hypertension and arthritis (Warsi et al. 2004, Chodosh et al. 2005). The effects of self-management on oral anticoagulant therapy, epilepsy and age-related macular degeneration are also cited in literature (DiIorio et al. 1996, Anarella et al. 2004, Brody et al. 2005, Menendez-Jandula et al. 2005). Cultural aspects of self-management have been studied in urban settings among minorities, the Chinese, and inner city children (Dongbo et al. 2003, Lipton et al. 2003, Butz et al. 2005). Salient among all these groups is the dimension of adherence to a plan. Implicit assumptions of the person’s desire to make informed decisions regarding management of their chronic illness is an overriding theme, however the success of most self-management programs was determined by improved clinical outcomes.
The definition of self-management varies contextually amongst illness entities. Different objectives for the management of different illnesses give rise to multiple definitions (Newman et al. 2004). Deakin et al. (2005) define self-management as ‘the learned ability to perform an act competently’ (p. 3). Research in self-management of age-related macular degeneration focused on education and enhancement of problem-solving skills. Improvements in quality of life, self-efficacy, mood and function were desired outcomes (Brody et al. 2005). Self-management programs in patients with chronic obstructive pulmonary disease incorporated a comprehensive definition of self-management including patient engagement in health promoting activities, interaction with healthcare providers, adherence to recommendations, monitoring of physical and emotional status, making autonomous decisions and management of self esteem, role function and relationships (Bourbeau 2003). In contrast, self-management in oral anticoagulation therapy assumes that the patient will monitor their own INR and adjust their doses as necessary (Menendez-Jandula et al. 2005).
Koch et al. (2004) discovered three different models of self-management among 24 participants in their study of chronic illness self-management. The predominant model was that of the medical model which uses the concepts of medication compliance and adherence to physician recommendations. Trust and knowledge were important aspects of the medical model, but more so from the patient’s perspective and not the physician’s. The collaborative model applied a joint effort between the patient and provider determining management strategies. The self-agency model was epitomised by patients taking control of their own management. The patients within this model displayed vigilance in their medical management and kept well-informed of new methods and changes to the management of their chronic illness.
Social construction of self-management
Few articles germane to the person’s perspective of self-management were found in the chronic illness literature. Interpretive methodologies provide a rich and strategic process by which to elicit the patient’s meaning and experience of self-management. Control of the disease, becoming experts, the need for knowledge and skills and the importance of context are examples of the vital themes gleaned from the qualitative literature exploring the viewpoint of the patient (Paterson & Thorne 2000, Thorne et al. 2003).
Holman and Lorig (2004) found that few studies examined clinical outcomes based on physician attentiveness to patient concerns adhered to a patient-centred approach. Additionally, they proposed that chronically ill patients rarely, if ever, have their needs addressed or met by the current healthcare system. According to Holman and Lorig, patients want access to information, continuity of care, access and coordination of care, simplified care (better scheduling, billing procedures and wait times) as well as learning the skills and techniques necessary to cope with symptoms and adjust to chronic illness consequences.
Anarella et al. (2004) examined Medicaid recipients and their perceptions of self-management, access and care. Self-management was measured based on behaviours consistent with adherence to a plan and active participation; medication compliance, use of peak flow metres and diaries, medication adjustment based on peak flow readings and preventative behaviours such as avoiding cigarettes. Other measured outcomes consisted of patient education, patient knowledge, access to care, satisfaction with care and medication usage. Interestingly, their conclusions noted that although quality of care, ease of access and provision of quality education by providers were highly rated, medication compliance rates were less than optimal. The researchers concluded that motivating patients through education to improve medication adherence were needed.
In a surveyed sample of patients with chronic illnesses, general practitioners and nurses, general practitioners rated themselves to be providing more self-management support than the patients reported receiving it (Carryer et al. 2010). While general practitioners were viewed a providing sporadic support by the patients, nurses were viewed as being more consistent (Carryer et al. 2010).
The person’s perceptions of their needs must form the foundation for self-management programs. Strengths and self-agency abilities ought to be identified and implemented with the management plan (Koch et al. 2004, Turpin et al. 2004). Along with recognising the person’s potential contributions to illness management, ascertaining how they feel towards their illness and themselves is critical as it will impact self-management therapies (Newman et al. 2004) People cannot not self-manage; each daily decision, each choice reflects a type of self-management strategy. How they manage their chronic illness, not whether they manage their illness, is the core question (Bodenheimer et al. 2002, Lorig & Holman 2003). Yet, the person’s perception of self-management remains elusive. Constructivism is the person’s philosophical way of knowing their reality. As each person constructs their own unique reality, self-management from this perspective will consist of multiple realities. These constructions need to be sought out and identified through interpretive methodologies to gain an understanding of the person’s perspective.
The primary assumption underlying this perspective is that people want to self-manage their chronic illness. This assumption is based on the ideal that people want information regarding their illness and want to manage effectively implying knowledge as the salient dimension. However, without a better understanding of the person’s perspective through an interpretive approach, these assumptions cannot be validated. The person’s perspective of self-management is primarily construed through the perspective of the healthcare provider. This perspective objectifies the person as patient and assumes implicit healthcare provider assumptions of self-management.
Even with the lack of authentic perspectives of the person in self-management, the philosophical inconsistencies between this and the healthcare provider’s perspective are evident. The epistemological stance of the healthcare provider conflicts with the person’s constructivist way of knowing. Until the provider and person with chronic illness can acknowledge and appreciate the unique ways of knowing each brings to the situation, the two perspectives will remain dichotomous and pose a challenge to any future success of self-management programs.
The major role of the family in the self-management of chronic illness is that of support and resource (DiIorio et al. 1996, Schilling et al. 2002, Tanner 2004, Fisher et al. 2005). The amount of positive family support given to people with chronic illness has been positively correlated with adherence to medical treatment (DiMatteo 2004). Chronic illness impacts not only the person, but the family as well, having the potential to disrupt family processes, roles and financial stability (Lipton et al. 2003). With the significant role that family plays in the success of self-management, their perspective would be a great importance, yet their voice is small when specifically examining self-management in the chronic illness literature. The tasks and obligations of the family pertinent to success in self-management are well-articulated and defined; lacking is the family’s viewpoint of their assumed roles in the concept of self-management. Underlying assumptions of the family perspective are the family’s desire for the person to self-manage as well as the family’s desire to participate. The importance of understanding the family’s philosophical perspective is vital to ensuring successful self-management. Should philosophical views of the person and family be incommensurable, the family support and resource necessary for successful self-management is jeopardised.
In addition to the family’s perspective, society’s perspective in self-management also incorporates the dimension of resources (Lorig & Holman 2003, Prior & Bond 2004, Tanner 2004). Society contributes to self-management through providing training, community-based programs and government subsidies (Fisher et al. 2005). The implicit dimension reflected in society’s perspective is that of adherence to a plan with the potential consequence of reduced healthcare expenditures. This pragmatic approach assumes that if people have the necessary resources, they will self-manage successfully. Resource acquisition is grounded in the community and society; its importance in self-management cannot be underestimated (Fisher et al. 2005).
The dominant perspective of self-management in the chronic illness literature is that of the healthcare professional. A number of studies have been published examining various self-management strategies and their effects on clinical outcomes and reduction of healthcare expenditures. The success of self-management is contingent upon marked improvement of predetermined clinical outcomes and a decrease in healthcare utilisation (Bodenheimer et al. 2002, Bourbeau 2003, Dongbo et al. 2003, Warsi et al. 2004, Butz et al. 2005, Menendez-Jandula et al. 2005, Gately et al. 2007). This pragmatic and positivist epistemological approach reflects the social pressures of liability factors, consequence-minded practice and fiscal influences that dictate the healthcare professional’s perspective. Although informed decision-making is structured to be the epitome of self-management, the salient dimensions within the healthcare provider’s perspective are those of adherence to a plan and active participation (Koch et al. 2004).
The conceptual inconsistency inherent in this perspective becomes apparent when the antecedent of mutual investment is ignored while employing the attribute of adherence to a plan. Mutual investment consists of shared goals and identification of problems between the professional and the patient (Bourbeau 2003, Huffman 2005). Through mutual investment, the plan to which a person adheres to is developed through a collaborative approach incorporating the difficulties and concerns important to the patient. Mutuality is lost when self-management success is measured by clinical outcomes, which is predominantly reflective of the healthcare professional’s perspective. Judging adherence to a plan based on clinical outcomes devoid of mutual investment is inconsistent and leads to an inaccurate evaluation of self-management (Bodenheimer et al. 2002).
The healthcare professional’s perspective is based on several assumptions: (1) patients ought to follow their healthcare provider’s directions, (2) the healthcare provider knows what problems need to be addressed regarding the management of the patient’s chronic illness, (3) patients who do not adhere to a plan are non-compliant and (4) without adherence, self-management cannot be achieved. These assumptions greatly restrict the totality of the concept of self-management. While clinical outcomes and healthcare expenditures are desired outcomes and have notable importance, the loss of the self in self-management minimises the holistic potential within this concept.
Relevance to clinical practice
As the prevalence of persons living with chronic illnesses rises, nursing plays a pivotal role in incorporating strategies that promote patient self-worth and improved quality of life. Nursing must also strive to improve clinical outcomes in patients with chronic illness while being mindful of healthcare expenditures. To promote self-management, nurses ought to recognise the limitations of the traditional healthcare professional-directed/patient-compliant approach and foster a more patient-centred, mutually formulated plan of care for their patients. The antecedents and dimensions of self-management derived from the chronic illness literature can be used to formulate tailored plans aimed at fostering successful self-management in persons as well as to guide interventions to improve self-management and improve outcomes.
Several issues may potentially limit the application of these findings. The review of the literature may not reflect the totality of the chronic illness literature pertaining to self-management. This review was restricted to English-language articles within the last 10 years. This may under represent the various dimensions, perspectives and contexts of self-management in the literature. This review also reflects the philosophical and perspective bias of the author. Although all efforts were made to objectively review the literature by abstracting the essence of the articles while remaining true to their uniqueness, author bias cannot be completely omitted.
Self-management is a mature concept in the chronic illness literature, yet its meanings and definitions vary greatly. Concept analysis consistent with Rodger’s evolutionary view provided the method to construct and examine the common uses of self-management and a means to identify and explore its attributes. The additional dimensional analysis allowed for a more comprehensive understanding of self-management by examining meanings across perspectives and contexts. Self-management is a socially constructed concept that varies according to perspectives and contexts. The salient dimension of adherence to a plan was identified across the perspectives of the healthcare professional and society. The patient and family perspectives of self-management in chronic illness require further exploration to expose the prominent dimensions.
The person is central to the concept of self-management; further research is necessary to explore the self in self-management. Interpretive methodologies will provide the needed perspective of the patient within this concept. Support and resources acquired from family is another critical factor in the success of self-management. Further exploration is needed to explicate this perspective to further our understanding of the various meanings of self-management. The integration, understanding and acknowledgement of all perspectives will aid in defining self-management and clarification of the concept.
Further research exploring the model derived from the literature is needed to further develop the concept of self-management and clarify the relationships between self-management and its antecedents and consequences as well as the relationships within the antecedents and consequences. As the dimensions of self-management formed a hierarchal structure, the proposition that its antecedents and consequences may also occur in stages is of relevance for further research as well.
The power dynamic between person and professional reveals two opposing views; the professional who knows what’s best for the patient, and the person who knows what’s best for them. However, the healthcare professional holds the position of authority and controls how knowledge is constructed by measuring the success of self-management programs primarily by improved clinical outcomes and reduced healthcare expenditures (Thorne & Paterson 2001). By doing so, the concept of self-management is reduced to the sole dimension of adherence to a plan, which is essentially compliance. When measuring and judging the success of self-management, healthcare professionals ought to measure the correct concept to beget the correct conclusions.
Knowledge, resources, adherence to a plan, active participation and informed decision-making emerged from the literature review as the dimensions of self-management. These dimensions are dependent upon the antecedents necessary to acquire them (information, self-efficacy, intention, support, and mutual investment). Further research exploring self-management encompassing all the aspects of the self-management model is necessary to accurately evaluate the consequences of improved quality of life, improved clinical outcomes and reduced healthcare expenditures.
Study design, data analysis and manuscript preparation: KAU.