Globally, health care systems are being affected by the rapid, dynamic changes in advancements in biomedical science, newer technologies, the expansion of informatics, and the ability to meet the needs of the diverse populations (Centers for Disease Control and Prevention [CDC], 2014; Stanley, 2010). Meanwhile, evidence is mounting on the concerns of millions coping with chronic illnesses. In 2010, the National Institutes of Health indicated that 133 million adults have at least one chronic disease. Ryan and Sawin (2009) estimated “half of all Americans are managing a serious chronic health condition at home” (p. 217). Therefore, a major concern for nurses, patient educators, and program developers is determining what the best practices are for teaching self-management to people with chronic disease.
In the United States and globally, patient education and the task of teaching self-management to patients and families became an even more critical part of nursing's role for delivery of safe, quality care (American Association of Colleges of Nursing, 2008; Ghorbani, Soleimani, Zeinali, & Davaji, 2014; Kennedy et al., 2014; Masters, 2005). Prior research evidence indicates that the challenges facing nurse educators and health professionals are to learn and tailor the educational methods for patients and families, to develop or design strategies and interventions to help the patients and families self-manage the illness, and to identify supportive techniques for patients and families in order to sustain the lessons learned (Coulter et al., 2015; Institute for Healthcare Improvement, 2015; The Joint Commission, 2014; National Heart, Lung, and Blood Institute, 2013; Qualis Health, 2013; Ryan & Sawin, 2009; Waldrop-Valvede, 2015). The practice theory of self-management relates to the processes, the interventions, and the outcomes of the interventions (Moore et al., 2016; National Institute of Nursing Research [NINR], 2014; Ryan & Sawin, 2009). An example from one research study on self-management noted “that similar strategies can be effective across different types of chronic illnesses” (Schulman-Green et al., 2012, p. 137). However, literature indicates there is little current knowledge on interventional strategies that work best for adults across the three chronic illnesses of heart failure (HF), chronic obstructive pulmonary disease (COPD), and diabetes type 2 (DM2) (NINR, 2014). In addition, further study is needed as to why some adults are less successful in self-managing their chronic illness (NINR, 2011). Therefore, this integrative review of research focuses on the three major chronic conditions of HF, COPD, and DM2. The goal of this study is to identify program strategies and interventions that nursing may use to provide effective self-management programs and intervention for patients and families with chronic disease (NINR, 2014).
Background and Significance
In 1993, the landmark Diabetes Control and Complications Trial published its report that clearly demonstrated that more active self-management can delay the onset and progression of long-term complications of diabetes (Lasker, 1993). By 2004, the Institute of Medicine and the Joint Commission introduced National Patient Safety goals; in 2008, the Agency for Healthcare Research & Quality started to identify Inpatient Quality Indicators. In 2012, Sherwood and Barnsteiner described competencies for nurses to develop to improve health care quality and safety (Sherwood & Barnsteiner, 2012). By 2013, The Center for Medicare and Medicaid Services indicated quality of care, safety concerns, and cost will continue to be challenges well into the 21st century (Center for Medicare and Medicaid Services, 2013). This shift in focus on safety created greater efforts by nurse educators to help patients and families to improve their quality of life through self-management and thus avoid hospital admissions and multiple readmissions. As nursing practices adapt and change to meet the needs of society, nursing has a responsibility to incorporate the new technologies and to use research evidence in their practice (American Association of Colleges of Nursing, 2017; American Nurses Association, 2003).
The nursing literature on self-management in chronic illness indicates there are distinct features when assisting patients and families to learn the knowledge and skills to self-manage their disease (Edelman, Kudzma, & Mandle, 2014; Elwood, 2015; Grady & Gough, 2014; Lorig & Holman, 2003; Ryan & Sawin, 2009). The NINR indicated that self-management is a science, and they are investigating supportive strategies for people with chronic illness (NINR, 2014). A shift has occurred in most chronic care programs now that research has reported evidence on the scope and complexity of chronic disease self-management, especially with the expected increase of people living longer with chronic illnesses (Grady & Gough, 2014). A key point learned from previous research on adults with chronic illnesses is the need to individualize the plan in collaboration with the patients and families (The Joint Commission, 2014; Lorig & Holman, 2003; McCloskey & Huss, 2015; Qualis Health, 2013).
Currently, self-management supportive programs use a wide range of teaching–learning strategies based on common adult learning theories and philosophies, as well as psychosocial, behavioral theories (Bandura, 1977; Candela, 2012; Institute for Healthcare Improvement, 2015; Knowles, 1990). In most of the studies, the interventions and strategies used were of various types; the supplies and equipment ranged from pretested print media to virtual and electronic media (Chiauzzi, Rodarte, & DasMahapatra, 2015; de Jong, Gurol-Urganci, Vodopivec-Jamsek, Car, & Atun, 2012; Graves, Ford, & Mooney, 2013; Marek et al., 2013). The earlier interventional studies reported length of the program and contact time for self-management ranged from months to years. Therefore, baseline and time period data were collected using a number of tests or measurement scales, appropriate to the specific chronic illness (Barth, Jacob, Daha, & Critchley, 2015; Brady et al., 2013). Although all types of teaching–learning techniques and specialized supplies and equipment are available, little is known about which program structures and teaching–learning methods are most effective across the three chronic illnesses of HF, COPD, and DM2. This study aims to add to and update the knowledge on the use of the science of self-management across those three chronic illnesses.
The purpose of this study was to identify the best practices for self-management programs and interventions across the chronic illnesses of HF, COPD, and DM2, and to identify the major barriers to achieving self-management goals. The Donabedian (2005) quality framework of structure, process, and outcome was used in this study. In the Donabedian (2005) framework, the structure is the physical organizational characteristics where health care occurs; the process is on the care delivered in the form of services or treatments; the outcome is the effect of the care on the patient's status. For this study, the term strategies represented the structures and processes of the program, and the term interventions represented the method or approaches used in the teaching–learning processes. The outcome relates to the identification of the best self-management strategies and interventions across the three chronic illnesses.
The three research questions are:
- What are the best self-management strategies and interventions for adults with HF, COPD, and DM2?
- Which are the best self-management strategies and interventions common among the three chronic conditions of HF, COPD, and DM2?
- In all studies reviewed, what were the barriers to successful self-management?
The research design for this study was an integrative review of research using 36 research studies that met the inclusion criteria and were of the highest level of evidence in quantitative and qualitative studies (Grove, Gray, & Burns, 2015). The analysis and synthesis of these 36 studies accounted for 786 individual studies and provided current findings on self-management from a total of 105,863 participants (HF, n = 47,911; COPD, n = 13,642; DM2, n = 44,310).
Sources and Search Terms. The databases used for all three chronic illnesses were the Cumulative Index of Nursing and Allied Health Literature (CINAHL®), Cochrane Collection (systematic reviews, meta-analyses, EMBASE™, and MEDLINE®), EBSCOhost/Academic Search™ Complete and Academic OneFile, ERIC™, and OVID®. Other sources for the HF topic included hand searches in libraries, the websites of publishers such as Wiley and Elsevier, Heart Failure Society of America, online nursing and specialty heart journals, American Heart Association, NINR, and government websites. Additional sources for DM2 included PubMed® and PsycINFO®. The literature search inclusion criteria were published from 2008 to 2017, as the volume of nursing research literature on self-management and interventions started to be noted around 2008; published and available in the English language; focused on self-management on adults with HF, COPD, and DM 2 chronic illnesses; primary residence living at home and/or attending primary care settings; and all genders and/or ethnicities. The exclusion criteria were studies with psychiatric or mentally challenged participants and substance abuse categories. Key search terms for all three chronic illnesses were the name of the illness with terms such as self-management, self-care, patient education, and self-management interventions.
Criteria and Evaluation. Each researcher assumed responsibility for one of the three chronic illnesses and individually conducted the literature search for their topic. An informal guide sheet that listed the inclusion criteria was used by the researchers to support them during their search of the literature. Once each researcher selected the articles deemed to have met the inclusion criteria, they developed a literature matrix. For the evaluation process, a Quality Assessment Scoring Guide, similar to the Downs and Black Checklist (1998), was developed to evaluate seven key factors for including the article. The quality of each selected article was assessed for inclusion criteria, as well as demographic information, sample type and size, and the method or explanation of how the reliability and validity of those articles were met. The outcomes and limitations expressed by the authors of the articles were also noted.
Data Analysis, Reduction, and Extraction
Critical to this analysis was the need for research studies that identified the strategies (program structures and processes) and interventions (teaching–learning methods) with the emphasis on self-management by adults, living in the community with a chronic illness of HF, or COPD, or DM 2. The literature search identified a total of 7,167 articles using the search terms for all three topics. After reading and evaluating the articles' abstracts, 2,113 articles remained; after another cycle of review by fully reading the articles and evaluating them, a set of 116 articles were identified as potential for inclusion; however, from the further evaluation of the 116 articles, another 80 articles were excluded. The remaining 36 articles fit the study variables for this integrative review, the inclusion criteria, and a Quality Assessment score that demonstrated sufficient quality. During this reduction and extraction process, articles that were excluded were because self-management was not described; subject matter focused on only medications, surgical, or medical interventions; and they did not meet the required study variables for HF, DM2, or COPD adult, chronic illness status.
Using the 7-point Quality Assessment Score Guide and the literature matrix, each researcher independently scored the articles based on established criteria. Then, the researchers met and presented their selected articles; articles that needed further discussion were reviewed by all three researchers and a final score was applied. As a result of this evaluation process, the group mean score was 6.4 points on a scale of 0 to 7. The total number of articles included in this review was 36 (HF, n = 13; COPD, n = 10; DM2, n = 13; Figure.)
Data extraction: heart failure (HF), chronic obstructive pulmonary disease (COPD), and diabetes mellitus 2 (DM2) studies.
Synthesis of Studies on HF, COPD, and DM2
Thirteen HF research articles met the requirements in design, strategies, and interventions. These 13 HF articles accounted for 318 individual studies, with 47,911 participants. Within the 13 HF articles, the individual studies' sample sizes ranged from nine to 47 studies. Ten COPD research articles met the design, strategies, and interventions criteria. The 10 articles accounted for 154 individual studies with 13,642 participants. The samples sizes in the individual studies ranged from four to 64 participants. For the 13 DM2 research articles that met the inclusion criteria for design, strategies, and interventions, there were 314 individual studies with 44,310 participants. The sample sizes in the individual studies ranged from nine to 77 participants.
Demographics. For the HF and COPD articles, all 23 articles showed the male gender dominated; of the 13 DM2 articles, only seven articles (53.8%) reported gender, and females slightly dominated in those articles. In reporting on the age of participants, the majority of the participants in the 36 articles were 40 years and older. The reported ethnicity/race of the majority of participants in all the articles was White. In summary, women and other ethnic groups were underrepresented in these studies (Figure).
Self-Management Strategies. The self-management strategies included the program structures and processes reported in the 36 articles. The articles varied based on the aim or purpose of the studies and the study design—quantitative, qualitative, or mixed methods. Within the 36 articles reviewed, 27 (75%) were interventional designs, two (5.6%) were correlational designs, and seven (19.4%) were descriptive designs. Of the 786 individual studies identified in the 36 articles, the home or clinic setting was reported as the most frequent location where participants were engaged with the researchers (n = 664, 84.5%).
The program processes used in the individual studies varied, but the most frequent program approaches were the use of a multidiscipline/team effort, group sessions or focus groups, and one-to-one with a health care provider augmented with print material or electronic devices. Thirty-five articles (97.2%) reported on the individual studies' assessment or measurement of the participants' knowledge about their chronic illness (HF, COPD, or DM2), self-management skills, and attitude or behaviors related to their illness. The major knowledge and skills areas reported in the individual studies were symptom management; physical activity and endurance; and medication, diet, weight, and fluid management. The major attitude or behavior areas reported were coping with the stress, depression, and fatigue; self-efficacy; and quality of life and the interpersonal and social support (Table A; available in the online version of this article).
Self-Management Interventions. The self-management interventions are the teaching–learning methods used in the 36 research articles (Table A). The most frequently reported teaching–learning methods that reported the most favorable outcomes were educational sessions with a health care provider used in combination with some form of telehealth technology, such as structured telephone support, telemonitoring, Web-based modules, and telephone or mobile telephone or texting contacts. The use of a personalized action plan was frequently supportive and effective in those studies that used the action plan in combination with technology and/or personal contact. The use of motivational interviewing to improve self-efficacy was noted in a few studies to have success for that particular need.
Strategies and Interventions Common Across HF, COPD, and DM2. Using the two categories of program structures and processes and interventions, the researchers analyzed and compared the findings from each of the three chronic conditions. The most common element for program structures and processes was sufficient time: time to teach–learn; contact time with health care professionals to absorb and understand the knowledge and skills; and time needed to develop self-efficacy to cope with a chronic illness. The most common intervention was the teach–learn method of combining individualize plans with contact with health care provider—directly or electronically (Table).
Best Self-Management Strategies and Interventions Common in Heart Failure, Chronic Obstructive Pulmonary Disease, and Diabetes Mellitus Type 2
Barriers to Self-Management
In examining the barriers on the participants' lack of success in self-management, there appears to be some common factors across the three chronic illnesses. Separating out the analysis of barriers noted in the individual studies within the 36 articles provides knowledge of the areas in need of improvement in self-management practices. The three most frequent barriers reported in some of the 36 articles were duration of support (n = 17), psychosocial or psychological (n = 16), and disease-related physical limitations (n = 11). These data support the findings of the three separate conclusions drawn for HF, COPD, and DM2 on strategies and interventions that are most successful—i.e., duration of support; individualized training plans; use of multiple methods including technological; adapting knowledge, skills, and attitude training to individuals with these chronic illnesses; and recognizing the physical and psychosocial needs are critical to overcome the barriers.
For this integrative review of research, the three researchers analyzed the data reported in the 786 primary research studies within those articles. The three researchers manually calculated the demographic data for this integrative review and found it difficult to gather specific demographic information on age, gender, and ethnicity/race because these often were not identified in the primary studies. Although meeting the inclusion criteria for this study, the specifics on type and duration of the interventions was sketchy in the primary research study and therefore not fully detailed when synthesized for the articles included in this integrative review of research.
Program Structures and Processes
The outcome of this integrative review of research was to identify the program structures and processes that were most effective in improving self-management. Nurse educators, patient educators, and program developers should consider the following best practices that were identified in this study:
- Provide sufficient time for patients and families to gain the knowledge, skills, and attitude to begin to self-manage the chronic illness.
- Provide sufficient contact time at the point of care with nurses and other health care professionals to support and maintain the knowledge and skills.
- Provide follow-up time to develop the confidence and self-efficacy to cope with a lifelong illness.
Based on the findings from the barriers to self-management for the three chronic illnesses, the follow-up time may need to be adjusted to meet the individual needs of the patient—general cognitive status, physical limitations, age, gender, and culture. The most effective duration of support time was at least 6 months. Therefore, the common practice of the nurse performing one or two telephone calls postdischarge may satisfy as episodic support, but when working with a patient with chronic illness, evidence indicates program support needs to be longer postdischarge.
Intervention—Teaching and Learning Methods
Time is money in any business today and given the cost of health care, the time spent educating patients and families is often rushed, incidental, or episodic. Analysis and synthesis of the 36 studies indicated the least effective teaching–learning methods were the use of handouts only. Therefore, the findings from this study as to the best practices on teaching and learning methods may be helpful in optimizing contact time with patients and families who have a chronic illness. This study's findings indicate that a combination of direct contact and the use of technological devices such as intermittent, structured telephone support, telemonitoring, e-monitoring, and creative use of cellphones and computers are the best teaching and learning methods. Although the findings on barriers to self-management indicate physical limitations, such as pain and mobility, and psychosocial distress, such as depression and fatigue, the use of electronics can be used creatively to reinforce knowledge and skills that in turn can boost self-efficacy. A major finding from this study offers implications for the nurses' role, be it as nurse educators, program developers, or patient educators. Findings indicated the best practice evidence is to use personalized action plans with supportive technology. The following are examples of three of the effective technologies and how they were used.
Web-based interventions used websites developed specifically for a chosen audience. According to Connolly et al. (2013), one study “incorporated stage-based personalized sections on goal setting, a question and answer board and individualized physical activity prescription” (p. 1423). Another study used “web-based diabetes tracker…to monitor clinical outcomes” with the tracker “interfaced with medical records, and automated telephone reminder system” (p. 1477).
Telemonitoring (as cited in Inglis et al., 2011) consisted of people being contacted by telephone once per week for 12 months. In this single study, the researchers collected data on symptoms and adherence to treatment “as well as BP, HR, weight and 24[-hour] urine output collected on the previous day. A weekly [electrocardiogram] transmission was also obtained” (Inglis et al., 2011, p. 58). Another study used “a MOTIVA system,” which was described as “a TV-channel providing educational material, reminders of medication, health related surveys and motivational messages” (p. 59).
Structured telephone support was described in one study's approach wherein a monthly telephone call provided support for more than 8 months. The nurse telephone call involved a “heart failure specialist nurse to assess for symptoms and current medication” (Inglis et al., 2011, p. 65). In another study, the researchers used a “standardized telephonic physician directed nurse-managed case management, involving CHF lifestyle education and medication management” (Inglis et al., 2011, p. 69). Contact was weekly for 6 weeks, biweekly for 8 weeks, and then monthly and bimonthly for a 12-month period.
Nurses around the world bear a major share of the responsibility for self-management education. For patients and families coping with chronic illness, research evidence from this study identified program processes and teaching–learning methods that have implications of best practices for nurse educators, patient educators, and program developers to consider:
- Program structures and processes should be individualized, with frequent contact from health care professionals for at least 6 months in duration to focus support on knowledge, skill training, and attitude.
- Teaching–learning methods are most effective using a collaborative, team approach using the latest technology incorporated into a sustainable program strategy.
Nurse educators, patient educators, and program developers of self-management programs will need to teach and support creative use of technology that protects patient and family privacy and teach nurses how to individualize the teaching time and content for patients' and families' self-management.
Research is needed on how to balance the amount of personalized, face-to-face contact time (i.e., real-time) with the virtual technologies that are being used. Communications that allow for dialogue, two-way communications, have been identified as being more effective in demonstrating support and transfer of knowledge (Balzer Riley, 2008). So, with all the fast-evolving technological devices, efforts to provide real-time contact will become critical to self-management programs.
This study identified the optimal duration of time for support was more than 6 months. What is not known is what time intervals are most supportive. For example, does a once per week call for a particular period of time work best? Should every program developed have to provide at least 6 months of support of some type (e.g., face-to-face, or will virtual technological use be as effective)?
- Agency for Healthcare Research and Quality. (2013). The national healthcare quality report. Rockville, MD: Department of Health & Human Services. Retrieved from http://www.ahrq.gov/qual/qrdr12.htm
- American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Washington, DC: Author.
- American Association of Colleges of Nursing. (2017). Fact sheet: The impact of education on nursing practice. Washington, DC: Author.
- American Nurses Association. (2003). Nursing's social policy statement (2nd ed.). Silver Springs, MD: Author.
- Balzer Riley, J. (2008). Communications in nursing (6th ed.). St. Louis, MO: Elsevier.
- Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84, 191–215. doi:10.1037/0033-295X.84.2.191 [CrossRef]
- Baptista, D.R., Wiens, A., Pontarolo, R., Regis, L., Reis, W.C.T. & Correr, C.J. (2016). The chronic care model for type 2 diabetes: A systematic review. Diabetology & Metabolic Syndrome, 8, 1–7 http://doi.org/10.1186/s13098-015-0119-z doi:10.1186/s13098-015-0119-z [CrossRef]
- Barnason, S., Zimmerman, L. & Young, L. (2011). An integrative review of interventions promoting self-care of patients with heart failure. Journal of Clinical Nursing, 21, 448–475. doi:10.1111/j.1365-2702.2011.03907.x [CrossRef]
- Barth, J., Jacob, T., Daha, I. & Critchley, J.A. (2015). Psychosocial interventions for smoking cessation in patients with coronary heart disease. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD006886.pub2 [CrossRef]
- Bentsen, S.B., Langeland, E. & Holm, A.L. (2012). Evaluation of self-management interventions for chronic obstructive pulmonary disease. Journal of Nursing Management, 20, 802–813. doi:10.1111/j.1365-2834.2012.01469.x [CrossRef]
- Bonner, T., Foster, M. & Spears-Lanoix, E. (2016). Type 2 diabetes-related foot care knowledge and foot self-care practice interventions in the United States: A systematic review of the literature. Diabetic Foot & Ankle, 7. http://doi.org/10.3402/dfa.v7.29758 doi:10.3402/dfa.v7.29758 [CrossRef]
- Boren, S.A., Wakefield, B.J., Gunlock, T.L. & Wakefield, D.S. (2009). Heart failure self-management education: A systematic review of the evidence. International Journal of Evidence-Based Healthcare, 7, 159–168. doi:10.1111/j.1744-1609.2009.00134.x [CrossRef]
- Brady, T.J., Murphy, L., O'Colmain, B.J., Beauchesne, D., Daniels, B., Greenberg, M. & Chervin, D. (2013). A meta-analysis of health status, health behaviors, and health care utilization outcomes of the chronic disease self-management program. Preventing Chronic Disease, 10. http://dx.doi.org/10.5888/pcd10.120112 doi:10.5888/pcd10.120112 [CrossRef]
- Brunton, L., Bower, P. & Sanders, C. (2015). The contradictions of telehealth user experience in chronic obstructive pulmonary disease (COPD): A qualitative meta-synthesis. PLoS ONE, 10(10), 1–22. doi:10.1371/journal.pone.0139561 [CrossRef]
- Bryant, J., McDonald, V.M., Boyes, A., Sanson-Fisher, R., Paul, C. & Melville, J. (2013). Improving medication adherence in chronic obstructive pulmonary disease: A systematic review. Respiratory Research, 14, 109. doi:10.1186/1465-9921-14-109 [CrossRef]
- Candela, L. (2012). From teaching to learning: Theoretical foundations. In Billings, D. & Halstead, J. (Eds.), Teaching in nursing (4th ed., pp. 202–238). St. Louis, MO: Elsevier.
- Centers for Disease Control and Prevention. (2015). Diabetes report card 2014. Retrieved from https://www.cdc.gov/diabetes/library/reportcard.html
- Chiauzzi, E., Rodarte, C. & DasMahapatra, P. (2015). Patient-centered activity monitoring in the self-management of chronic health conditions. BMC Medicine, 13, 1–6. doi:10.1186/s12916-015-0319-2 [CrossRef]
- Connelly, J., Kirk, A., Masthoff, J. & MacRury, S. (2013). The use of technology to promote physical activity in type 2 diabetes management: A systematic review. Diabetic Medicine, 30, 1420–1432. doi:10.1111/dme.12289 [CrossRef]
- Coulter, A., Entwistle, V.A., Eccles, A., Ryan, S., Shepperd, S. & Perera, R. (2015). Personalized care planning for adults with chronic or long-term health conditions. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD010523.pub2 [CrossRef]
- Currie, K., Rideout, A., Lindsay, G. & Harkness, K. (2015). The association between mild cognitive impairment and self-care in adults with chronic heart failure. Journal of Cardiovascular Nursing, 30, 382–393. doi:10.1097/JCN.0000000000000173 [CrossRef]
- de Jongh, T., Gurol-Urganci, I., Vodopivec-Jamsek, V., Car, J. & Atun, R. (2012). Mobile phone messaging for facilitating self-management of long-term illness. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD007459.pub2 [CrossRef]
- Donabedian, A. (2005). Evaluating the quality of medical care. The Milbank Quarterly, 83, 691–729. doi:10.1111/j.1468-0009.2005.00397.x [CrossRef]
- Downs, S.H. & Black, N. (1998). The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. Journal of Epidemiology and Community Health, 52, 377–384. doi:10.1136/jech.52.6.377 [CrossRef]
- Edelman, C.L., Kudzma, E.C. & Mandle, C.L. (2014). Health promotion throughout the life span (8th ed.). St. Louis, MO: Elsevier.
- Elwood, W. (2015, September9). Self, others, and chronic conditions: An opportunity to understand the sociobehavioral underpinnings of the healthiest-possible life [Blog post]. Retrieved November 1, 2017, from http://oppnet.nih.gov/
- Falk, H., Ekman, I., Anderson, R., Fu, M. & Granger, B. (2013). Older patients' experiences of heart failure: An integrative literature review. Journal of Nursing Scholarship, 45, 247–255. doi:10.1111/jnu.12025 [CrossRef]
- Feltner, C., Jones, C.D., Cené, C.W., Zheng, Z.J., Sueta, C.A., Coker-Schwimmer, E.J. & Jonas, D.E. (2014). Transitional care interventions to prevent readmissions for persons with heart failure: A systematic review and meta-analysis. Annals of Internal Medicine, 160, 774–784. doi:10.7326/M14-0083 [CrossRef]
- Ghorbani, R., Soleimani, M., Zeinali, MR. & Davaji, M. (2014). Iranian nurses and nursing students' attitudes on barriers and facilitators to patient education: A survey study. Nurse Education in Practice, 14, 551–556. doi:10.1016/j.nepr.2014.06.003 [CrossRef]
- Grady, P.A. & Gough, L.L. (2014). Self-management: A comprehensive approach to management of chronic conditions. American Journal of Public Health, 104(8), e25–e31. doi:10.2105/AJPH.2014.302041 [CrossRef]
- Graven, L. & Grant, J. (2014). Social support and self-care behavior in individuals with heart failure: An integrative review. International Journal of Nursing Studies, 51, 320–333. http://dx.doi.org/10.1016/j.ijnurstu.2013.06.013 doi:10.1016/j.ijnurstu.2013.06.013 [CrossRef]
- Graves, B.A., Ford, C.D. & Mooney, K.D. (2013). Telehealth technologies for heart failure disease management in rural areas: An integrative research review. Online Journal of Rural Nursing and Health Care, 13, 56–83.
- Grove, S.K., Gray, J.R. & Burns, N. (2015). Understanding nursing research: Building an evidence-based practice (6th ed.). St. Louis, MO: Elsevier.
- Harrison, S.L., Janaudis-Ferreira, T., Brooks, D., Desveaux, L. & Goldstein, R.S. (2015). Self-management following an acute exacerbation of COPD: A systematic review. Chest, 147, 646–661. doi:10.1378/chest.14-1658 [CrossRef]
- Hopp, F.P., Thornton, N. & Martin, L. (2010). The lived experience of heart failure at the end of life: A systematic literature review. Health & Social Work, 35, 109–117. doi:10.1093/hsw/35.2.109 [CrossRef]
- Huang, Z., Tao, H., Meng, Q. & Jing, L. (2015). Management of endocrine disease effects of telecare intervention on glycemic control in type 2 diabetes: A systematic review and meta-analysis of randomized controlled trials. European Journal of Endocrinology, 172(3), R93–R101. doi:10.1530/EJE-14-0441 [CrossRef]
- Hunt, C.W. (2015). Technology and diabetes self-management: An integrative review. World Journal of Diabetes, 6, 225–233. http://dx.doi.org/10.4239/wjd.v6.i2.225 doi:10.4239/wjd.v6.i2.225 [CrossRef]
- Inglis, S.C., Clark, R.A., McAlister, F.A., Ball, J., Lewinter, C., Cullington, D. & Cleland, J.G. (2011). Structured telephone support or telemonitoring programmes for patients with chronic heart failure. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD007228.pub2 [CrossRef]
- Institute for Healthcare Improvement. (2015). The model for improvement: Part 1 & part 2 [Video transcript]. Retrieved August 1, 2018, from http://www.ihi.org/education/ihiOpenSchool/AudioandVisual
- Institute of Medicine. (2012). Living well with chronic illness: A call for public health action. Washington, DC: The National Academies Press. Retrieved November 1, 2017, from http://www.iom.nationalacademies.org/reports/2012/living-well
- The Joint Commission (2014). Self-management goals made simple [Pre-conference presentation on Primary Care Medical Home by Linda M. Jordan, Field Representative]. Retrieved November 1, 2017, from http://www.jointcommission.org/assets/1/18/presentation_Primary/care/medical/home
- Kennedy, A., Rogers, A., Bowen, R., Lee, V., Blakeman, T., Gardner, C. & Chew-Graham, C. (2014). Implementing, embedding and integrating self-management support tools for people with long-term conditions in primary care nursing: A qualitative study. International Journal of Nursing Studies, 51, 1103–1113. doi:10.1016/j.ijnurstu.2013.11.008 [CrossRef]
- Klein, H.A., Jackson, S.M., Street, K., Whitacre, J.C. & Klein, G. (2013). Diabetes self-management education: Miles to go. Nursing Research and Practice, 2013, 1–15. doi: http://doi.org/10.1155/2013/581012 doi:10.1155/2013/581012 [CrossRef]
- Knowles, M.S. (1990). The adult learner: A neglected species (4th ed.). Houston, TX: Gulf Publishing Company.
- Lasker, R.D. (1993). The diabetes control and complications trial: Implications for policy and practice. New England Journal of Medicine, 329, 1035–1036. doi:10.1056/NEJM199309303291410 [CrossRef]
- Liddy, C., Blazkho, V. & Mill, K. (2014). Challenges of self-management when living with multiple chronic conditions: Systematic review of the qualitative literature. Canadian Family Physician, 60, 1123–1133.
- Lorig, K.R. & Holman, H.R. (2003). Self-management education: History, definition, outcomes, and mechanisms. Annals of Behavioral Medicine, 26, 1–7. doi:10.1207/S15324796ABM2601_01 [CrossRef]
- Marek, K.D., Stetzer, F., Ryan, P.A., Bub, L.D., Adams, S.J., Schlidt, A. & O'Brien, A.M. (2013). Nurse care coordination and technology effects on health status of frail elderly via enhanced self-management of medication: Randomized clinical trial to test efficacy. Nursing Research, 62, 269–278. doi:10.1097/NNR.0b013e318298aa55 [CrossRef]
- Masters, K. (2005). Role development in professional nursing practice. Sudbury, MA: Jones & Bartlett.
- McCarthy, B., Casey, D., Devane, D., Murphy, K., Murphy, E. & Lacasse, Y. (2015). Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews. http://dx.doi.org/10.1002/14651858.CD003793.pub3 doi:10.1002/14651858.CD003793.pub3 [CrossRef]
- McCloskey, D.J. & Huss, K. (2015). Role of self-management and nursing science in understanding the effects of basic socio behavioral processes and mechanisms underlying health [Blog post]. Retrieved November 1, 2017, from http://oppnet.nih.gov/
- Moore, S.M., Schiffman, R., Waldrop-Valverde, D., Redeker, N.S., McCloskey, D.J., Kim, M.T & Grady, P. (2016). Recommendations of common data elements to advance the science of self-management of chronic conditions. Journal of Nursing Scholarship, 48, 437–447. doi:10.1111/jnu.12233 [CrossRef]
- National Heart, Lung, and Blood Institute. (2013). Lifestyle interventions to reduce cardiovascular, lifestyle work group. Washington, DC: U.S. Department of Health & Human Services. Retrieved November 1, 2017, from http://www.nhlbi.nih.gov/guidelines
- National Institutes of Health. (2010, October). Fact sheet: Self-management. Washington, DC: U.S. Department of Health and Human Services. Retrieved from http://www.report.nih.gov/nihfactsheets/Pdfs/Self-Management(NINR).pdf
- National Institute of Nursing Research. (2011). Implementing NINR's 2011 strategic plan: Key themes. Retrieved from http://www.ninr.nih.gov/keythemes
- National Institute of Nursing Research. (2014). Self-management: Improving quality of life for individuals with chronic illness. Retrieved from http://ninr.nih.gov/newsandinformation/iq/self-management-workshop
- Niemczewski, J.B. (2013). Improving an outpatient diabetes program telephone follow-up process: Evaluating its impact on glycosylated hemoglobin levels [Capstone project]. Retrieved from Graduate Theses, Dissertations, and Capstones.
- Pal, K., Eastwood, S.V., Michie, S., Farmer, A.J., Barnard, M.L., Peacock, R. & Murray, E. (2013). Computer-based diabetes self-management interventions for adults with type 2 diabetes mellitus. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD008776.pub2 [CrossRef]
- Puhan, M.A., Gimeno-Santos, E., Scharplatz, M., Troosters, T., Walters, E.H. & Steurer, J. (2011). Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD005305.pub3 [CrossRef]
- Qualis Health. (2013). Implementation guide: Patient-centered interactions, safety net medical home initiative. Seattle, WA: Qualis Health Organization. Retrieved November 1, 2017, from http://www.safetynetmedicalhome.org
- Quiñones, A.R., Richardson, J., Freeman, M., Fu, R., O'Neil, M.E., Motu'apuaka, M. & Kansagara, D. (2014). Educational group visits for the management of chronic health conditions: A systematic review. Patient Education & Counseling, 95, 3–29. doi:10.1016/j.pec.2013.12.021 [CrossRef]
- Ryan, P. & Sawin, K.J. (2009). The individual and family self-management theory: Background and perspectives on context, process, and outcome. Nursing Outlook, 57, 217–225. doi:10.1016/j.outlook.2008.10.004 [CrossRef]
- Schulman-Green, D., Jaser, S., Martin, F., Alonzo, A., Grey, M., McCorkle, R. & Whittemore, R. (2012). Processes of self-management in chronic illness. Journal of Nursing Scholarship, 44, 136–144. doi:10.1111/j.1547-5069.2012.01444.x [CrossRef]
- Sherifali, D., Bai, J.W., Kenny, M., Warren, R. & Ali, M.U. (2015). Diabetes self-management programmes in older adults: A systematic review and meta-analysis. Diabetic Medicine32, 1404–1414. doi:10.1111/dme.12780 [CrossRef]
- Sherwood, G. & Barnsteiner, J. (2012). Quality and safety in nursing: A competency approach to improving outcomes. Oxford, UK: Wiley-Blackwell.
- Spaling, M.A., Currie, K., Strachan, P.H., Harkness, K. & Clark, A.M. (2015). Improving support for heart failure patients: A systematic review to understand patients' perspective on self-care. Journal of Advanced Nursing, 71, 2478–2489. doi:10.1111/jan.12712 [CrossRef]
- Stanley, J.M. (2010). Introducing the clinical nurse leader: A catalyst for quality care. In Harris, J.L. & Roussel, L. (Eds.), Initiating and sustaining the clinical nurse leader role (pp. 3). Sudbury, MA: Jones & Bartlett.
- Steinsbekk, A., Rygg, L., Lisulo, M., Rise, M.B. & Fretheim, A. (2012). Group based diabetes self-management education compared to routine treatment for people with type 2 diabetes mellitus: A systematic review with meta-analysis. BMC Health Services Research, 12, 213. doi: http://doi.org/10.1186/1472-6963-12-213 doi:10.1186/1472-6963-12-213 [CrossRef]
- Stellefson, M., Chaney, B., Barry, A.E., Chavarria, E., Tennant, B., Walsh-Childers, K. & Zagora, J. (2013). Web 2.0 chronic disease self-management for older adults: A systematic review. Journal of Medical Internet Research, 15(2), e35 http://doi.org/10.2196/jmir.2439 doi:10.2196/jmir.2439 [CrossRef]
- Tan, J.Y., Chen, J.X., Liu, X.L., Zhang, Q., Zhang, M., Mei, L.J. & Lin, R. (2012). A meta-analysis on the impact of disease-specific education programs on health outcomes for patients with chronic obstructive pulmonary disease. Geriatric Nursing, 33, 280–296. doi:10.1016/j.gerinurse.2012.03.001 [CrossRef]
- Tierney, S., Mamas, M., Skelton, D., Woods, S., Rutter, M.K., Gibson, M. & Deaton, C. (2011). What can we learn from patients with heart failure about exercise adherence? A systematic review of qualitative papers. Health Psychology, 30, 404–410. doi:10.1037/a0022848 [CrossRef]
- Vedel, I. & Khanassov, V. (2015). Transitional care for patients with congestive heart failure: A systematic review and meta-analysis. Annals of Family Medicine, 13, 562–571. doi:10.1370/afm.1844 [CrossRef]
- Vernooij, R.W., Willson, M. & Gagliardi, A.R. (2016). Characterizing patient-oriented tools that could be packaged with guidelines to promote self-management and guideline adoption: A meta-review. Implementation Science, 11, 52. doi:10.1186/s13012-016-0419-1 [CrossRef]
- Waldrop-Valverde, D. (2015, September9). Cognitive and affective issues in chronic illness [Blog post]. Retrieved November 1, 2017, from http://oppnet.nih.gov/
- Walters, J.A., Turnock, A.C., Walters, E.H. & Wood-Baker, R. (2010). Action plans with limited patient education only for exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD005074.pub3 [CrossRef]
- Wingham, J., Harding, G., Britten, N. & Dalal, H. (2014). Heart failure patients' attitudes, beliefs, expectations and experiences of self-management strategies: A qualitative synthesis. Chronic Illness, 10, 135–154, doi:10.1177/1742395313502993 [CrossRef]
- Zavertnik, J.E. (2014). Self-care in older adults with heart failure: An integrative review. Clinical Nurse Specialist, 28, 19–32. doi:10.1097/NUR.0000000000000021 [CrossRef]
- Zwerink, M., Brusse-Keizer, M., van der Valk, P.D., Zielhuis, G.A., Monninkhof, E.M., van der Palen, J. & Effing, T. (2014). Self-management for patients with chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD002990.pub3 [CrossRef]
Best Self-Management Strategies and Interventions Common in Heart Failure, Chronic Obstructive Pulmonary Disease, and Diabetes Mellitus Type 2
|Strategy (Program Structure and Process)|
|Programs that are personalized with prolonged duration to sufficiently improve self-efficacy.|
|Educational program that are personalized for knowledge, skills training, and attitude with frequent health care professional contact for at least 6 months.|
|Intervention (Teaching–Learning Method)|
|Teaching and learning methods that use a combination of direct contact options with technological devices, such as structured telephone support, telemonitoring, e-monitoring, and Web-based applications.|
|Duration of the interventions individualized for age, gender, and ethnicity/race|
Self-Management Strategies and Interventions for Heart Failure (HF), Chronic Obstructive Pulmonary Disease (COPD), and Diabetes Mellitus Type 2 (DM2)
|HF Studies||Program and Process||Teach – Learn Method|
|Barnason et al., 2011||Interventions: 1:1, group; multimethod
Duration: once to >6 months||Telephone, videos, CD-ROM, telehealth knowledge, skills, attitude (KSA)|
|Boren et al., 2009||Interventions: multidiscipline
Duration: average 8 months||KSA, verbal teaching, handouts, telephone|
|Currie et al., 2015||Relationship of mild cognition to SM
Duration: no report||KSA measured|
|Falk et al., 2013||Intervention: SM, QoL, older adults
Duration: once; 1.5 months, 1.5 years; 3 no report||Motivation interview self-efficacy, KSA|
|Feltner et al., 2014||Transitional Care/Intervention and 1-hour education versus usual care
Duration: 3–6 months||Home visits, STS, telemonitoring, KSA training|
|Graven & Grant, 2014||Identify relationship: social support and SM
Duration: once to 90 days; 4 no report||1:1 interviews KSA measured|
|Hopp et al., 2010||Identify/describe: SM and symptom management
Duration: no report||1:1 interviews; survey KSA|
|Inglis et al., 2011||Interventions: SM QoL, admits/readmits
Duration varied: 2–12 months and 5, >1 year||STS; telemonitoring. combination; KSA|
|Spaling et al., 2015||Meta-synthesis KSA
Duration: no report||Structured interviews; surveys, KSA|
|Tierney et al., 2011||Identify barriers to SM
Duration: no report||Focus groups; 1:1 interviews; KSA|
|Vedel/Khanassov, 2015||Transitional Care/interventional
Duration varied: 3–12 months, >12 months||Home visits w/telecare, telephone and/or clinic follow-up|
|Wingham et al., 2014||Synthesis to develop model on KSA
Duration: no report||all interviews on KSA & self-care|
|Zavertnik et al., 2014||Intervention: elders and SM
Duration: no report||KSA monitoring; telephone & education|
|COPD Studies||Program and Process||Teach-Learn Method|
|Bentsen et al., 2012||Interventions: group, multimethod
Duration: 4 weeks to 2 years||Written materials, action plans, discussion therapy|
|Brunton et al., 2015||Identify/describe: experiences
Duration: 2 times to 6 months||Semistructured interviews, focus groups situation interviews, participant observation|
|Bryant et al., 2013||Interventions:1:1, multimethod
Duration: 2 weeks to 12 months||Cognitive behavior therapy, action plans, Skill training, motivation interviews|
|Harrison et al., 2015||Interventions:1:1, multimethod
Duration: 3 weeks to 12 months||Written materials, action plans, skill training|
|Jung-Yu et al., 2012||Interventions:1:1, group, multimethod
Duration: 3 months to 12 months||Written materials, action plans|
|McCarthy et al., 2015||Interventions:1:1, multimethod
Duration: 4 weeks to 2 years||Education combined with exercise program or exercise program only|
|Puhan et al., 2011||Interventions:1:1, multimethod
Duration: 10 days to 6 months||Pulmonary rehabilitation with exercise program, individual action plans|
|Quiñones et al., 2014||Interventions:1:1, multimethod
Duration: 4 to 8 weeks||Didactic education, exercise programs|
|Walters et al., 2010||Interventions:1:1, multimethod
Duration: 6 to 12 months||Action plans with limited education (< 1 hour)|
|Zwerink, 2014||Interventions:1:1, multimethod
Duration: < 1 day to 5 years||Individual action plans, exercise programs, education A/V or written|
|DM 2 Studies||Program and Process||Teach-Learn Method|
|Baptista et al., 2016||Interventions: multimethod
A1C levels as outcome, KSA, physical activity, blood sugar testing
Duration: 4 months to 3 years||Various elements of Chronic Care Model delivered in group, individually, and via telemedicine|
|Bonner et al., 2016||Intervention: mixed, self-efficacy, prevention of ulcer, foot care knowledge scores self-care, SM health outcomes
Duration: 3–12 months||Interviews, education sessions, learning, behavioral videos, pamphlet, MD-reminders, and exercise sessions|
|Connolly et al., 2013||Intervention: self-management, physical activity fitness, active educational engagement, KSA supports system
Duration: 6 weeks to 10 months||Technology-based e-mail, coaching, and web-based modules|
|Huang et al., 2015||Intervention: self-management, glycemic control, and A1C levels
Duration: 3 months to 5 years||Telecare interventions compared to routine follow-up|
|Hunt, 2015||Interventions: blood glucose exercise, problem solving, medication adherence, KSA
Duration: 4 weeks to 6 months||Technology-based monitor, internet, mobile telephones, texting|
|Klein et al., 2014||Intervention Diabetes S-M Education mixed-method: A1C levels, group, individual, or with support persons
Duration: 5 weeks to 5 years||Self-management, glycemic control and technology on KSA, cognitive, social outcomes|
|Liddy et al., 2014||Self-management, access to care, physical symptom prioritizing, health beliefs, satisfaction with communication with providers, perceived barriers, and facilitators
Duration: not reported||Focus groups, reframing and emotional, cognitive strategies|
|Niemczewski, 2013||Intervention: Telephone-based, Diabetes Self-Management
Duration: 1–4 months||Educational content: self-efficacy, vaccinations, A1C, depression, health care cost, foot and eye care; adherence to American Diabetes Association guidelines, and satisfaction|
|Pal et al., 2013||Intervention: computer-based.
KSA, self-management, nutrition.
Duration: 1–12 months||In office or at home: feedback, advice, reinforcement, goal setting, and decision support|
|Sherifali et al., 2015||Interventions: Health coaching
Duration: 1–11 months||Self-management/self-care by telephone, telephone and face-to-face, or telephone and face-to-face|
|Steinsbekk et al., 2012||Interventions: group-based DM self-management knowledge.
Duration: 6 months to 2 years||Clinical knowledge group, lifestyle behaviors, KSA, and psychosocial measures|
|Stellefson et al., 2013||Evaluation of the Chronic Care Model education delivery; varied individual, group, and frequency
Duration: 12 months||Assessed SM, supports, and QoL|
|Vernooij et al., 2016||Interventions KSA psychological strategies and lifestyle management
Duration: not consistently reported||Motivation, active participant, KSA, disease information, and lifestyle advice|