The Journal of Continuing Education in Nursing

Original Article 

Best Practices for Patient Self-Management: Implications for Nurse Educators, Patient Educators, and Program Developers

Barbara Pinchera, RN, DNP, ANP-BC; Donna DelloIacono, RN, PhD, MSN, BSN; Carolyn A. Lawless, RN, DEd, MS, BA

Abstract

Background:

A major concern for nurses and program developers is to deliver the best practices for teaching self-management to people with chronic disease. This study aimed to identify the best practice strategies and interventions across heart failure (HF), chronic obstructive pulmonary disease (COPD), and diabetes mellitus type 2 (DM2) chronic illnesses.

Method:

The research design was an integrative review of research using 36 research studies. The analysis and synthesis of these studies provided information from 786 individual studies.

Results:

The results indicated the best strategies were programs that were individualized and prolonged in duration to improve self-management. The best interventions for teaching–learning methods were the use of a combination of direct contact options with technological devices. The common barriers to self-management were identified.

Conclusion:

Nurses educators and program developers of self-management programs will need to use technology creatively and develop programs that are individualized to fit the patients' chronic illness.

J Contin Educ Nurs. 2018;49(9):432–440.

Abstract

Background:

A major concern for nurses and program developers is to deliver the best practices for teaching self-management to people with chronic disease. This study aimed to identify the best practice strategies and interventions across heart failure (HF), chronic obstructive pulmonary disease (COPD), and diabetes mellitus type 2 (DM2) chronic illnesses.

Method:

The research design was an integrative review of research using 36 research studies. The analysis and synthesis of these studies provided information from 786 individual studies.

Results:

The results indicated the best strategies were programs that were individualized and prolonged in duration to improve self-management. The best interventions for teaching–learning methods were the use of a combination of direct contact options with technological devices. The common barriers to self-management were identified.

Conclusion:

Nurses educators and program developers of self-management programs will need to use technology creatively and develop programs that are individualized to fit the patients' chronic illness.

J Contin Educ Nurs. 2018;49(9):432–440.

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.

Purpose

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.

Research Questions

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?

Method

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).

Literature Search

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.

Figure.

Data extraction: heart failure (HF), chronic obstructive pulmonary disease (COPD), and diabetes mellitus 2 (DM2) studies.

Results

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 Strategies and Interventions for Heart Failure (HF), Chronic Obstructive Pulmonary Disease (COPD), and Diabetes Mellitus Type 2 (DM2)Self-Management Strategies and Interventions for Heart Failure (HF), Chronic Obstructive Pulmonary Disease (COPD), and Diabetes Mellitus Type 2 (DM2)Self-Management Strategies and Interventions for Heart Failure (HF), Chronic Obstructive Pulmonary Disease (COPD), and Diabetes Mellitus Type 2 (DM2)Self-Management Strategies and Interventions for Heart Failure (HF), Chronic Obstructive Pulmonary Disease (COPD), and Diabetes Mellitus Type 2 (DM2)

Table A:

Self-Management Strategies and Interventions for Heart Failure (HF), Chronic Obstructive Pulmonary Disease (COPD), and Diabetes Mellitus Type 2 (DM2)

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

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.

Limitations

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.

Discussion

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.

Implications

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.

Future Research

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)?

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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 StudiesProgram and ProcessTeach – Learn Method
Barnason et al., 2011Interventions: 1:1, group; multimethod Duration: once to >6 monthsTelephone, videos, CD-ROM, telehealth knowledge, skills, attitude (KSA)
Boren et al., 2009Interventions: multidiscipline Duration: average 8 monthsKSA, verbal teaching, handouts, telephone
Currie et al., 2015Relationship of mild cognition to SM Duration: no reportKSA measured
Falk et al., 2013Intervention: SM, QoL, older adults Duration: once; 1.5 months, 1.5 years; 3 no reportMotivation interview self-efficacy, KSA
Feltner et al., 2014Transitional Care/Intervention and 1-hour education versus usual care Duration: 3–6 monthsHome visits, STS, telemonitoring, KSA training
Graven & Grant, 2014Identify relationship: social support and SM Duration: once to 90 days; 4 no report1:1 interviews KSA measured
Hopp et al., 2010Identify/describe: SM and symptom management Duration: no report1:1 interviews; survey KSA
Inglis et al., 2011Interventions: SM QoL, admits/readmits Duration varied: 2–12 months and 5, >1 yearSTS; telemonitoring. combination; KSA
Spaling et al., 2015Meta-synthesis KSA Duration: no reportStructured interviews; surveys, KSA
Tierney et al., 2011Identify barriers to SM Duration: no reportFocus groups; 1:1 interviews; KSA
Vedel/Khanassov, 2015Transitional Care/interventional Duration varied: 3–12 months, >12 monthsHome visits w/telecare, telephone and/or clinic follow-up
Wingham et al., 2014Synthesis to develop model on KSA Duration: no reportall interviews on KSA & self-care
Zavertnik et al., 2014Intervention: elders and SM Duration: no reportKSA monitoring; telephone & education
COPD StudiesProgram and ProcessTeach-Learn Method
Bentsen et al., 2012Interventions: group, multimethod Duration: 4 weeks to 2 yearsWritten materials, action plans, discussion therapy
Brunton et al., 2015Identify/describe: experiences Duration: 2 times to 6 monthsSemistructured interviews, focus groups situation interviews, participant observation
Bryant et al., 2013Interventions:1:1, multimethod Duration: 2 weeks to 12 monthsCognitive behavior therapy, action plans, Skill training, motivation interviews
Harrison et al., 2015Interventions:1:1, multimethod Duration: 3 weeks to 12 monthsWritten materials, action plans, skill training
Jung-Yu et al., 2012Interventions:1:1, group, multimethod Duration: 3 months to 12 monthsWritten materials, action plans
McCarthy et al., 2015Interventions:1:1, multimethod Duration: 4 weeks to 2 yearsEducation combined with exercise program or exercise program only
Puhan et al., 2011Interventions:1:1, multimethod Duration: 10 days to 6 monthsPulmonary rehabilitation with exercise program, individual action plans
Quiñones et al., 2014Interventions:1:1, multimethod Duration: 4 to 8 weeksDidactic education, exercise programs
Walters et al., 2010Interventions:1:1, multimethod Duration: 6 to 12 monthsAction plans with limited education (< 1 hour)
Zwerink, 2014Interventions:1:1, multimethod Duration: < 1 day to 5 yearsIndividual action plans, exercise programs, education A/V or written
DM 2 StudiesProgram and ProcessTeach-Learn Method
Baptista et al., 2016Interventions: multimethod A1C levels as outcome, KSA, physical activity, blood sugar testing Duration: 4 months to 3 yearsVarious elements of Chronic Care Model delivered in group, individually, and via telemedicine
Bonner et al., 2016Intervention: mixed, self-efficacy, prevention of ulcer, foot care knowledge scores self-care, SM health outcomes Duration: 3–12 monthsInterviews, education sessions, learning, behavioral videos, pamphlet, MD-reminders, and exercise sessions
Connolly et al., 2013Intervention: self-management, physical activity fitness, active educational engagement, KSA supports system Duration: 6 weeks to 10 monthsTechnology-based e-mail, coaching, and web-based modules
Huang et al., 2015Intervention: self-management, glycemic control, and A1C levels Duration: 3 months to 5 yearsTelecare interventions compared to routine follow-up
Hunt, 2015Interventions: blood glucose exercise, problem solving, medication adherence, KSA Duration: 4 weeks to 6 monthsTechnology-based monitor, internet, mobile telephones, texting
Klein et al., 2014Intervention Diabetes S-M Education mixed-method: A1C levels, group, individual, or with support persons Duration: 5 weeks to 5 yearsSelf-management, glycemic control and technology on KSA, cognitive, social outcomes
Liddy et al., 2014Self-management, access to care, physical symptom prioritizing, health beliefs, satisfaction with communication with providers, perceived barriers, and facilitators Duration: not reportedFocus groups, reframing and emotional, cognitive strategies
Niemczewski, 2013Intervention: Telephone-based, Diabetes Self-Management Education Duration: 1–4 monthsEducational content: self-efficacy, vaccinations, A1C, depression, health care cost, foot and eye care; adherence to American Diabetes Association guidelines, and satisfaction
Pal et al., 2013Intervention: computer-based. KSA, self-management, nutrition. Duration: 1–12 monthsIn office or at home: feedback, advice, reinforcement, goal setting, and decision support
Sherifali et al., 2015Interventions: Health coaching Duration: 1–11 monthsSelf-management/self-care by telephone, telephone and face-to-face, or telephone and face-to-face
Steinsbekk et al., 2012Interventions: group-based DM self-management knowledge. Duration: 6 months to 2 yearsClinical knowledge group, lifestyle behaviors, KSA, and psychosocial measures
Stellefson et al., 2013Evaluation of the Chronic Care Model education delivery; varied individual, group, and frequency Duration: 12 monthsAssessed SM, supports, and QoL
Vernooij et al., 2016Interventions KSA psychological strategies and lifestyle management Duration: not consistently reportedMotivation, active participant, KSA, disease information, and lifestyle advice
Authors

Dr. Pinchera is Professor and Traditional Program Coordinator, Dr. DelloIacono is Senior Lecturer, and Dr. Lawless is Senior Lecturer, School of Nursing, Curry College, Milton, Massachusetts.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Carolyn A. Lawless, RN, DEd, MS, BA, 19 Hartshorn Place, Walpole, MA 02081; e-mail: clawless19@verizon.net.

Received: March 14, 2018
Accepted: May 22, 2018

10.3928/00220124-20180813-09

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