Implementation of a self-management support approach (WISE) across a health system: a process evaluation explaining what did and did not work for organisations, clinicians and patients

Implementation Science

Joanne Protheroe¹  Rebecca Morris²  Victoria Lee²  Caroline Gardner²  Robert Bowen²  Thomas Blakeman²  Carolyn Chew-Graham¹  Anne Rogers³  Anne Kennedy³ 

[1] Keele University, Staffordshire ST5 5BG, UK;University of Manchester, Manchester M13 9PL, UK;NIHR CLAHRC Wessex, University of Southampton, Southampton SO17 1BJ, UK

关键词: Primary care;    Long-term conditions;    Self-management support;    Normalisation Process Theory;    Process evaluation;   

Others  :  1146272
DOI  :  10.1186/s13012-014-0129-5

 received in 2013-11-06, accepted in 2014-09-18,  发布年份 2014

【 摘 要 】

Background

Implementation of long-term condition management interventions rests on the notion of whole systems re-design, where incorporating wider elements of health care systems are integral to embedding effective and integrated solutions. However, most self-management support (SMS) evaluations still focus on particular elements or outcomes of a sub-system. A randomised controlled trial of a SMS intervention (WISE¿Whole System Informing Self-management Engagement) implemented in primary care showed no effect on patient-level outcomes. This paper reports on a parallel process evaluation to ascertain influences affecting WISE implementation at patient, clinical and organisational levels. Normalisation Process Theory (NPT) provided a sensitising background and analytical framework.

Methods

A multi-method approach using surveys and interviews with organisational stakeholders, practice staff and trial participants about impact of training and use of tools developed for WISE. Analysis was sensitised by NPT (coherence, cognitive participation, collective action and reflective monitoring). The aim was to identify what worked and what did not work for who and in what context.

Results

Interviews with organisation stakeholders emphasised top-down initiation of WISE by managers who supported innovation in self-management. Staff from 31 practices indicated engagement with training but patchy adoption of WISE tools; SMS was neither prioritised by practices nor fitted with a biomedically focussed ethos, so little effort was invested in WISE techniques. Interviews with 24 patients indicated no awareness of any changes following the training of practice staff; furthermore, they did not view primary care as an appropriate place for SMS.

Conclusion

The results contribute to understanding why SMS is not routinely adopted and implemented in primary care. WISE was not embedded because of the perceived lack of relevance and fit to the ethos and existing work. Enacting SMS within primary care practice was not viewed as a legitimate activity or a professional priority. There was failure to, in principle, engage with and identify patients¿ support needs. Policy presumptions concerning SMS appear to be misplaced. Implementation of SMS within the health service does not currently account for patient circumstances. Primary care priorities and support for SMS could be enhanced if they link to patients¿ broader systems of implementation networks and resources.

【 授权许可】

   
2014 Kennedy et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]Department of Health: Self care¿a real choice: self care support¿a practical option.Gateway Ref 2005, 4401.
• [2]Schaefer J, Miller D, Goldstein M, Simmons L: Partnering in Self-Management Support: A Toolkit for Clinicians. Institute for Healthcare Improvement, Cambridge, MA; 2009.
• [3]Kennedy A, Rogers A, Gately C: Assessing the introduction of the expert patients programme into the NHS: a realistic evaluation of recruitment to a national lay-led self-care initiative. Prim Health Care Res Dev 2005, 6:137-148.
• [4]Kennedy A, Reeves D, Bower P, Lee V, Middleton E, Richardson G, Gardner C, Gately C, Rogers A: The effectiveness and cost effectiveness of a national lay-led self care support programme for patients with long-term conditions: a pragmatic randomised controlled trial. J Epidemiol Community Health 2007, 61:254-261.
• [5]Truglio J, Graziano M, Vedanthan R, Hahn S, Rios C, Hendel-Paterson B, Ripp J: Global health and primary care: increasing burden of chronic diseases and need for integrated training. Mt Sinai J Med 2012, 79:464-474.
• [6]Royal College of General Practitioners: Care planning improving the lives of people with long term conditions. In Clinical Innovation and Research Centre. 2011.
• [7]Sunaert P, Vandekerckhove M, Bastiaens H, Feyen L, Vanden Bussche P, De Maeseneer J, De Sutter A, Willems S: Why do GPs hesitate to refer diabetes patients to a self-management education program: a qualitative study. BMC Fam Pract 2011, 12:94. BioMed Central Full Text
• [8]Dennis SM, Zwar N, Griffiths R, Roland M, Hasan I, Davies GP, Harris M: Chronic disease management in primary care: from evidence to policy. Med J Aust 2008, 188:S53-S56.
• [9]Tricco AC, Ivers NM, Grimshaw JM, Moher D, Turner L, Galipeau J, Halperin I, Vachon B, Ramsay T, Manns B, Tonelli M, Shojania K: Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis. Lancet 1916, 379:2252-2261.
• [10]Chew-Graham C, Hunter C, Langer S, Stenhoff A, Drinkwater J, Guthrie E, Salmon P: How QOF is shaping primary care review consultations: a longitudinal qualitative study. BMC Fam Pract 2013, 14:103. BioMed Central Full Text
• [11]The NHS Improvement Plan: Putting People at the Heart of Public Services. The Stationery Office, London; 2004.
• [12]Doran T, Kontopantelis E, Valderas JM, Campbell S, Roland M, Salisbury C, Reeves D: Effect of financial incentives on incentivised and non-incentivised clinical activities: longitudinal analysis of data from the UK Quality and Outcomes Framework. Br Med J 2011, 342:d3590.
• [13]Lee V, Kennedy A, Rogers A: Implementing and managing self management skills training within primary care organisations: a national survey of the expert patients programme within its pilot phase. Implement Sci 2006, 1:1-6. BioMed Central Full Text
• [14]Rogers A: Advancing the expert patient. Prim Health Care Res Dev 2009, 10:167-176.
• [15]Macdonald W, Rogers A, Blakeman T, Bower P: Practice nurses and the facilitation of self-management in primary care. J Adv Nurs 2008, 62:191-199.
• [16]Gray C, Hunt K, Lorimer K, Anderson A, Benzeval M, Wyke S: Words matter: a qualitative investigation of which weight status terms are acceptable and motivate weight loss when used by health professionals. BMC Public Health 2011, 11:513. BioMed Central Full Text
• [17]Proctor EK, Powell BJ, McMillen J: Implementation strategies: recommendations for specifying and reporting. Implement Sci 2013, 8:139. BioMed Central Full Text
• [18]Kennedy A, Robinson A, Rogers A: Incorporating patients¿ views and experiences of life with IBS in the development of an evidence based self-help guidebook. Patient Educ Couns 2003, 50:303-310.
• [19]Kennedy AP, Rogers A: Improving patient involvement in chronic disease management: the views of patients, GPs and specialists on a guidebook for ulcerative colitis. Patient Educ Couns 2002, 47:257-263.
• [20]Kennedy A, Rogers A, Bower P: Support for self care for patients with chronic disease. BMJ 2007, 335:968-970.
• [21]Grant A, Treweek S, Dreischulte T, Foy R, Guthrie B: Process evaluations for cluster-randomised trials of complex interventions: a proposed framework for design and reporting. Trials 2013, 14:15. BioMed Central Full Text
• [22]Bower P, Kennedy A, Reeves D, Rogers A, Blakeman T, Chew-Graham C, Bowen R, Eden M, Hann M, Lee V, Morris R, Protheroe J, Richardson G, Sanders C, Swallow A, Thompson D: A cluster randomised controlled trial of the clinical and cost-effectiveness of a `whole systems¿ model of self-management support for the management of long-term conditions in primary care: trial protocol. In Implementation Sci 2012, 7:7. BioMed Central Full Text
• [23]Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC: Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science.Implement Sci 2009, 4.
• [24]Kennedy A, Bower P, Reeves D, Blakeman T, Bowen R, Chew-Graham C, Eden M, Fullwood C, Gaffney H, Gardner C, Lee V, Morris R, Protheroe J, Richardson G, Sanders C, Swallow A, Thompson D, Rogers A: Implementation of self management support for long term conditions in routine primary care settings: cluster randomised controlled trial.Br Med J 2013, 346.
• [25]Kennedy A, Chew-Graham C, Blakeman T, Bowen A, Gardner C, Protheroe J, Rogers A, Gask L: Delivering the WISE (Whole Systems Informing Self-Management Engagement) training package in primary care: learning from formative evaluation. Implement Sci 2010, 5:7. BioMed Central Full Text
• [26]Protheroe J, Blakeman T, Bower P, Chew-Graham C, Kennedy A: An intervention to promote patient participation and self-management in long term conditions: development and feasibility testing. BMC Health Serv Res 2010, 10:206. BioMed Central Full Text
• [27]Bodenheimer T, Wagner EH, Grumbach K: Improving primary care for patients with chronic illness. JAMA 2002, 288:1775-1779.
• [28]Charles C, Gafni A, Whelan T, O'Brien MA: Treatment decision aids: conceptual issues and future directions. Health Expect 2005, 8:114-125.
• [29]Haywood K, Marshall S, Fitzpatrick R: Patient participation in the consultation process: a structured review of intervention strategies. Patient Educ Couns 2006, 63:12-23.
• [30]Blickem C, Bower P, Protheroe J, Kennedy A, Vassilev I, Sanders C, Kirk S, Chew-Graham C, Rogers A: The role of information in supporting self-care in vascular conditions: a conceptual and empirical review. Health Soc Care Community 2011, 19:449-459.
• [31]Kennedy A, Gask L, Rogers A: Training professionals to engage with and promote self-management. Health Educ Res 2005, 20:567-578.
• [32]Kennedy AP, Robinson A, Hann M, Thompson DG, Wilkin D: A cluster-randomised controlled trial of a patient-centred guidebook for patients with ulcerative colitis: effect on knowledge, anxiety and quality of life. Health Soc Care Community 2003, 11:64-72.
• [33]Kennedy AP, Nelson E, Reeves D, Richardson G, Robinson A, Rogers A, Sculpher M, Thompson D: A randomised controlled trial to assess effectiveness and cost of a patient orientated self-management approach to chronic inflammatory bowel disease. Gut 2004, 53:1639-1645.
• [34]Morriss R, Dowrick C, Salmon P, Peters S, Dunn G, Rogers A, Lewis B, Charles-Jones H, Hogg J, Clifford R, Rigby C, Gask L: Cluster randomised controlled trial of training practices in reattribution for medically unexplained symptoms. Br J Psychiatry 2007, 191:536-542.
• [35]Protheroe J, Rogers A, Kennedy A, Macdonald W, Lee V: Promoting patient engagement with self-management support information: a qualitative meta-synthesis of processes influencing uptake. Implement Sci 2008, 3:44. BioMed Central Full Text
• [36]Robinson A, Lee V, Kennedy A, Middleton E, Rogers A, Thompson DG, Reeves D: A randomised controlled trial of self-help interventions in patients with a primary care diagnosis of IBS. Gut 2006, 55:643-648.
• [37]Sikorski C, Luppa M, Konig HH, van den Bussche H, Riedel-Heller S: Does GP training in depression care affect patient outcome? - A systematic review and meta-analysis. BMC Health Serv Res 2012, 12:10. BioMed Central Full Text
• [38]Thompson C, Kinmonth AL, Stevens L, Peveler RC, Stevens A, Ostler KJ, Pickering R, Baker N, Henson A, Preece J, Cooper D, Campbell M: Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire depression project randomised controlled trial. Lancet 2000, 355:185-191.
• [39]Wensing M, van der Weijden T, Grol R: Implementing guidelines and innovations in general practice: which interventions are effective? Br J Gen Pract 1998, 48:991-997.
• [40]Oakley A, Strange V, Bonell C, Allen E, Stephenson J: Process evaluation in randomised controlled trials of complex interventions. Br Med J 2006, 332:413-416.
• [41]May C, Finch T: Implementation, embedding, and integration: an outline of normalization process theory. Sociology 2009, 43:535-554.
• [42]MacFarlane A, O'Reilly-de Brun M: Using a theory-driven conceptual framework in qualitative health research. Qual Health Res 2012, 22:607-618.
• [43]Ong BN, Morden A, Brooks L, Porcheret M, Edwards JJ, Sanders T, Jinks C, Dziedzic K: Changing policy and practice: making sense of national guidelines for osteoarthritis. Soc Sci Med 2014, 106:101-109.
• [44]Lloyd A, Joseph-Williams N, Edwards A, Rix A, Elwyn G: Patchy `coherence¿: using normalization process theory to evaluate a multi-faceted shared decision making implementation program (MAGIC). Implement Sci 2013, 8:102. BioMed Central Full Text
• [45]Freeman AC, Sweeney K: Why general practitioners do not implement evidence: qualitative study. BMJ 2001, 323:1100.
• [46]Sheaff R, Pilgrim D: Can learning organizations survive in the newer NHS? Implement Sci 2006, 1:27. BioMed Central Full Text
• [47]Harkness EF, Harrington V, Hinder S, O'Brien SJ, Thompson DG, Beech P, Chew-Graham C: GP perspectives of irritable bowel syndrome - an accepted illness, but management deviates from guidelines: a qualitative study.BMC Fam Pract 2013, 14.
• [48]Lester HE, Hannon KL, Campbell SM: Identifying unintended consequences of quality indicators: a qualitative study. BMJ Qual Saf 2011, 20:1057-1061.
• [49]Rogers A, Lee V, Kennedy A: Continuity and change? Exploring reactions to a guided self-management intervention in a randomised controlled trial for IBS with reference to prior experience of managing a long term condition.Trials 2007, 8. doi:10.1186/1745-6215-8-6.
• [50]Vassilev I, Rogers A, Blickem C, Brooks H, Kapadia D, Kennedy A, Sanders C, Kirk S, Reeves D: Social networks, the `work¿ and work force of chronic illness self-management: a survey analysis of personal communities. PLoS One 2013, 8:e59723.
• [51]Blickem C, Kennedy A, Vassilev I, Morris R, Jariwala P, Blakeman T, Rogers A: Linking people with long-term health conditions to healthy community activities: development of Patient-Led Assessment for Network Support (PLANS). Health Expect 2013, 16(3):e48-e59. doi:10.1111/hex.12088. Epub 2013 Jun 3
• [52]Croker JE, Swancutt DR, Roberts MJ, Abel GA, Roland M, Campbell JL: Factors affecting patients trust and confidence in GPs: evidence from the English national GP patient survey.BMJ Open 2013, 3.
• [53]Rogers A, Kennedy A, Nelson E, Robinson A: Uncovering the limits of patient centredness: a qualitative investigation of implementing a self-management trial for chronic illness. Qual Health Res 2005, 15:224-239.
• [54]Clarke D, Godfrey M, Hawkins R, Sadler E, Harding G, Forster A, McKevitt C, Dickerson J, Farrin A: Implementing a training intervention to support caregivers after stroke: a process evaluation examining the initiation and embedding of programme change. Implement Sci 2013, 8:96. BioMed Central Full Text
• [55]Gask L, Ludman E, Schaefer J: Qualitative study of an intervention for depression among patients with diabetes: how can we optimize patient¿professional interaction? Chronic Illn 2006, 2:231-242.
• [56]Gask L, Usherwood T, Thompson H, Williams B: Evaluation of a training package in the assessment and management of depression in primary care. Med Educ 1998, 32:190-198.
• [57]Gask L: Small group interactive techniques utilizing video feedback. Int J Psychiatr Med 1998, 28:97-113.
• [58]Hull S, Chowdhury TA, Mathur R, Robson J: Improving outcomes for patients with type 2 diabetes using general practice networks: a quality improvement project in east London. BMJ Qual Saf 2014, 23:171-176.
• [59]Lemak CH, Cohen GR, Erb N: Engaging primary care physicians in quality improvement: lessons from a payer-provider partnership. J Healthc Manag 2013, 58:429-443.
• [60]Schein EH: Organization Culture and Leadership. John Wiley and Sons, San Francisco; 2010.
• [61]Ivers N, Sales A, Colquhoun H, Michie S, Foy R, Francis J, Grimshaw J: No more `business as usual¿ with audit and feedback interventions: towards an agenda for a reinvigorated intervention. Implement Sci 2014, 9:14. BioMed Central Full Text
• [62]Vassilev I, Rogers A, Kennedy A, Koetsenruijter J: The influence of social networks on self-management support: a metasynthesis. BMC Public Health 2014, 14(1):719. BioMed Central Full Text