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Running head: THE ROLE OF NURSING IN PATIENT SELF-MANAGEMENT
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THE ROLE OF NURSING IN PATIENT SELF-MANAGEMENT
The Role of Nursing in Patient Self-Management
Ping Xu
KentStateUniversity
Author Guideline
The scholarly journal that I have identified for my paper is: Journal of Clinical Nursing. It is “an international, peer reviewed, scientific journal that seeks to promote the development and exchange of knowledge that is directly relevant to all spheres of nursing and midwifery practice”. Theprimary aim is “to promote a high standard of clinically related scholarship which supports the practice and discipline of nursing”.
The reasons that I choose this journal are: first, the journal publishes papers related to clinical issues in ambulatory care, community care, family care, home, and hospital in the primary and secondary settings; second, the journal also publishes research papers and literature reviews about all aspects of clinical issues including policy, management, education and research related to nursing practice; third, my project targets on nursing role in patient self-management, which is a clinical issue involved in nursing and organizational spheres. It is originated from a pilot study from a hospital, and education of nursing staff is a part of this project. Therefore, I think this journal is appropriate for my manuscript.
There are five manuscript categories as listed in the author guideline: original articles, review articles, research-in-brief, commentaries, and discursive papers. The structure of the manuscript includes title page, abstract, keywords, contributions, main text, and references. The main text of an original article is required to be organized as:introduction, background (literature), methods (design, data collection and analysis), results, discussion, conclusion, and relevance to clinical practice. The details of author guideline are listed at the following website:
Abstract
Aims and Objectives: The purpose of this project is to investigate the role of nursing in patient self-management. The influences of the project on the nursing and organizational spheres are discussed. The roles of the CNS in the nursing and organizational spheres in this process are also investigated.
Background:Patient self-management refers to patient management oftheir own health conditions actively. However, how to engagethe patient into self-management is a challenge for healthcare providers. Nurses have great opportunity to teach patients how to become involved into the self-management of their own health.
Design and Method:The preliminary data were obtained from a pilot study. The barriers of nurses to patient’s self-management are investigated by a survey. A program that targets on how nurses can help patients with chronic conditions to engage into the self-management is developed and presented to the nurses. The evaluation of the program is done by feedback fromboth nurses and patients. The hospital will also compare discharge patient satisfaction scores as a quantitative measurement. The roles of the CNS in this whole process are discussed.
Conclusion: Nurses play an important role in patient self-management, including initiatingand monitoring patient self-management, and evaluating patient. The teaching program developed in this project helps nurses to improve the knowledge of self-management, and to recognize the barriers. The effects of the project on the organizational spheres, such as teaching nursing staff, and providing valuable information for future research program are discussed.
Relevant to clinical practice:With the increasing population with chronic disease, nurses play important roles to help patients to be involved in disease self-management. This project provides valuable information for nurses to help patients with their self-management of their health conditions.
Keyword: Nursing, Self-Management, the Roles of Nursing, the Roles of the CNS
Contribution: Ping Xu, BSN, MS, RN
The Role of Nursingin Patient Self-Management
Introduction
According to World Health Organization (WHO), as a challenge of the 21st century healthcare system, long-term health conditions and chronic illnesses account for more than half of the global disease burden (WHO, 2005). It is estimated that approximately 171 million Americans will have at least one chronic disease and half of them will have more than one health problem by 2030 (Anderson & Horvath, 2004). In addition, people with chronic conditions utilized about 78% of healthcare spending according to the Medical Expenditure Panel Survey (MEPS) in 1998 (Anderson & Horvath, 2004). The increased population with chronic disease requires that the traditional, acute in-patient health care provided by the health care professionals is not the most effective way to manage people with chronic health conditions.
The traditional healthcare system has been based on an acute care model, in which the care is episodic and based on the needs of patients (Scruggs, 2009). In the acute care model, the patient waits to seek for help and advice from medical professionals; and healthcare professionals are the key health care providers for patients, and they are accountable for patients’ health conditions (Scruggs, 2009). The traditional acute care model has been working well for patients with acute injuries and illness, while it does not work as efficient for patients with chronic health conditions (Scruggs, 2009). Patients with chronic health issues need to learn how to manage their chronic health conditions by themselves for the long term purpose. The term self-management is used to describe ways to support patients who have long-term health conditions to manage their own care in the community setting, in which they are actually accountable for their own health (Lau-Walker, 2009).
Background and Problem Description
Self-management refers to behaviors and strategies that an individual takes to maintain or improve his health status (Audulv, Asplund, & Norbergh, 2010). Self-management has been used in different ways for patients to manage their own health. First, it refers to an increase in patients’ general confidence to manage their health conditions, and patients assume that they have the primary role to manage their conditions instead of the healthcare providers, such as physician, nurses, and other members (Jovici, Holroyd-Leduc, & Straus, 2006). On the other hand, it means to increase the individual patient’s confidence to manage specific tasks related to their illness conditions, such as monitoring their symptoms, watching their diet, adjusting their medications based on some criteria, and determining when they should seek medical advice or help (Jovici, et al., 2006). Self-management requires patients to have a good understanding of their health conditions, signs and symptoms, the rationales for the treatments (such as medications and medical equipments), and side effects of the medications, etc. In this process, the nurses working at the acute setting play an important role to help engage patients into the self-care management of their health.
The positive effects ofself-management as an important part of management of patient’s chronic condition have been widely studied in people with different health conditions, such as diabetes, asthma, and congestive heart failure (Ditewig, Blok, Havers, & Veenendaal, 2010; Warsi, Wang, LaValley, Avom, & Solomon, 2004). However, engaging patients into self-management is a challenge for healthcare providers. Clinical nurses have the best chances to work with patients in an acute care setting since they are the major patient care providers from patients’ admission to their discharge. They have the opportunity to initiate the program, and to discuss and evaluate self-management on a daily basis.
At Summa Health System, apilot program called “It’s My Health” was launched by the Transitional Care Committee fromJuly, 2010 to September, 2010. The purposes of the program are:to increase patient and patient’s family to participate in their care and be accountable for their health, and to empower patient and patient’s family to self-manage their health conditions. The program was initiated on three floors, and the data of the pilot program were collected from July to September, 2010. Upon admission, the patient/family will receive a copy of “It My Health” packet from the staff nurse which includes tools to help manage personal health and medications, discharge preparation checklist, medication lists, and an empty space for patient to write down their questions and concerns. The nurse is responsible to introduce patient/family into the program, to review the individualized patient goal on a daily basis, and to reinforce the importance of care after discharge, including schedulingthe follow-up appointment, and bringing the book when they visit their doctors. Besides those duties, nurses are also required to make the follow-up phone calls within 24 to 48 hours after patients discharged. For the follow-up phone call, the nurse will ask patient: the overall experience of the hospital stay and the discharge process, the prescriptions and follow-up appointment, etc.
The preliminary data from the pilot study on one floor has shown: among 93 randomly picked discharged patients between July and August 2010, there were 56 calls completed (60% of called completed while 40% of calls were not completed); among those discharged patients, 28% did not receive the book “It’s My Health”; and almost all the calls were not made within 24-48 hours after patients’ discharge (90%). Some patients do not understand the purpose of the medications that they were on, and some of them had problems obtaining the medications. These all mightbecome the barriers to successful self-management for patient. The question that we want to ask is how nurses can engage patient into this self-management regimen successfully? What are the barriers for nurses to help patient into the self-management regimen? This project is developed based on those questions, and it aims to increase nurse’s knowledge of self-management, and help nurse to understand the importance of patient self-management, and increase their compliance in the future study.
Self-management is developed according to Bandura’s theory of self-efficacy(1977). Self-efficacy is defined as “the belief that one can or cannot successfully execute the behavior required to produce a specific outcome” (Lau-Walker, 2009, p. 290); and it has been recognized as a critical concept in the management of chronic disease for a long time (Ory & Defriese, 1998). With the increasing number of people with chronic disease, self-management and the need to support self-management become more important (Albert, Musa, Kwoh, & Silverman, 2008). For patient with chronic disease, self-management plays a key role to increase patient’s involvement and control in their health conditions and to improve their overall well-being (Bourbeau, 2009).
Studies about the population with different health conditions have shown that self-management can help patients to manage their health successfully/appropriately. For example, a study about self-management of patient with osteoarthritis done by Albert, et al. (2008) has shown that the report of painwas significantly less in both white and African-Americans who practice optimal self-management. For people with chronic obstructive pulmonary disease (COPD), self-management helps patients adapt to COPD-related changes and maintain healthy behaviors as the disease progresses through different stages and complications (Bourbeau, 2009). Studies have been also shown that self-management program decreased the rate of hospital admission and health care utilization for patients with COPD (Adams, Smith, Allan, Anzueto, Pugh, & Cornell, 2007).
Nurses are the primary health care provider at the acute care settings. They work with patients from admission to discharge. They provide the 24-hour patient care to patients during their hospital stay. Therefore, they have the great opportunity to help patient to start the self-management program, specifically for patients with chronic health conditions. Study of self-management for vascular risk has shown thatin the nursing led self-management program, the nursing interventions based on self-management can provide a new and promising approach to reduce vascular risks for the patients (Sol, van der Bijl, Banga, Visseren, 2005). In order to promote patient’s self-management for a particular long-term health condition, it is important to provide clear, precise, and specific knowledge and competency to help them manage their specific conditions (Lau-Walker, 2009). Therefore, the assessment of patient’s general health, and knowingtheir needs,are the first step to help patients to get involved into self-management program for their health condition. During this process, patients will undergo a transition from the care management by the health care providers to management by themselves (Bourbeau, 2009). How the nursing staff helps patients to go through the shift is important for the efficiency of the self-management regimen. Wagner, et al. (1996) identify four essential factors for a successful self-management program: (1) In order to enhance patient’s participation, a cooperative problem definition needed to be developed by both patient and providers; (2) the realistic and personalized goals needed to be set and patient is willing to change and ready for self-efficacy; (3) In order to support behavioral change, exercise options and interventions are needed to be set to deal with the emotional demands of chronic health conditions; (4) An active and sustained follow-up by the provider should be initiated. Based on those factors, nurses can develop the personalized health care plans for patients with chronic health conditions to help them to engage in the self-management program.
Method
The clinical project is designed and carried out by the CNS student. As previous description about the current problem, we can see that there are barriers existing in the nursing staff from the results of the pilot study. Therefore, to find out those barriers is the first step of this project. In this project, the teaching back technique is emphasized in the patient’s self-management. Teaching back is recommended to enhance communication and confirm understanding, and increase healthcare outcome (Kripalani, & Weiss, 2006).
This project is carried out in three steps. First, since the data have shown that nurses have not done a satisfactory job to introduce patients into the self-management program – “It’s my health”, it is necessary to assess nurses’ views about the concept of self-management, and the barriers to help patient engage into the self-management program. A survey was developed to offer to the nurses who have been involved in “It’s my health” program on the three pilot floors to investigate their views of the program. Based on their response, the common stated barriers are obtained from the results of the survey. Second, based on the results of the survey, a program aimed at helping nurses to engage patients into the self-management regimen was developed for the nurses. Third, the program is presented to the nursing staff.
The education program was developed according to the results of the nursing survey. The content of the teaching program included: the importance of self-management (what self-management is and why self-management); the role of nursing in patient self-management; the survey responses; and how the nursing staff can support the patient with self-management, such as using motivational interview and teaching back techniques. The teaching program used PowerPoint presentation and video clips to deliver to the audience. The evaluation of the teaching program was done at the end of the presentation.
The previous studies have shown that patients involved in self-management have the lower admission ratesand reduced use of healthcare resources when compared to the patients who were not engaged in the self-management program (Adams, et al., 2007). One of the indirect long term evaluations for this program is to check readmission rate of patients who have been involved in the self-management in the period ofsix month and a year, and to compare the readmission rate with patients who were not involved in the program.
The hospital has decided to establish “It’s my health” program as a formal research project; and it will start to carry out hospital wide next year. This project can provide the valuable information for the principal investigators. For example, almost all the nurses who did the survey stated that time was the number one barrier to prevent them from making follow-up calls for patient. Before the research project is launched formally, the administration and/or the principal investigators should take it into consideration. They can appoint some designated nurses to help with the follow-up calls instead of just assigning to bedside nurses. On the other hand, the principal investigators can adapt the teaching program developed in this project to present to the nursing staff to improve their knowledge of patient self-management. Since this teaching project is developed by the CNS student, it costs nothing. Therefore, the organization will benefit from this project from financial aspect.
Application of Project to the ANA Scope and Standards and CNS Competence