Journal of Gerontological Nursing

Complex Health Problems: Clinically Assessing Self-Management Abilities

Mariah Snyder, PhD, RN, FAAN; Patricia Brugge-Wiger, PhD, RN; Sharon Ahern, BSN, RNC; Shirley Connelly, MSN, RN; Charlotte DePew, MPH, RN; Patricia Kappas-Larson, MPH, RN; Elizabeth Semmerling, MEd, RN; Susan Wyble, MS, RN

Abstract

Elderly persons account for 38% of acute hospital stay days.1 Many of these hospital stays result from exacerbations or complications associated with chronic health problems. This is not surprising because 45.6% of persons over the age of 65 have one or more chronic conditions that limit their activities.2 Many of these chronic conditions result in physical or cognitive deficits that may have a profound impact on a person's functional abilities. New knowledge and skills or other forms of assistance may be required if the person is going to be able to manage care at home. To enable nurses to assist hospitalized elderly in making adjustments, an assessment of the person's self-management abilities is required. Following the assessment, the hospital staff can begin to assist the patient and family to acquire the needed skills and to access resources so that self-management abilities are maximized.

The introduction of diagnosis related groups has reduced the length of hospital stays, resulting in less available time for hospital staff to assess which areas persons will need assistance with and to provide the necessary teaching. Lack of adequate preparation prior to discharge has been indicated as a significant contributing factor in hospital readmissions in elderly with chronic health conditions who have been hospitalized.1·3

Adequate assessments of abilities and deficits are a key in determining the interventions needed in assisting persons to achieve their optimum level of functioning in as independent of a manner as is possible. The adequacy of these assessments was a concern of practitioners/researchers at the Minneapolis Veterans Administration Medical Center. The group reviewed existing self-care instruments4·8 and functional assessment instruments9'14 to ascertain if any of these existing instruments would provide the data nurses needed for planning self-management for patients following discharge. After careful review of these instruments, a need was identified for developing an assessment instrument that staff nurses could readily use in determining a patient's self-management abilities.

Many of the self-care instruments focus on healthy persons and do not provide the necessary data related to the management of complex health problems. Data obtained on many of these instruments are via self-report; a means for verifying the accuracy of these data is necessary, particularly in those with cognitive impairments. A number of the functional assessment instruments are too long to use on busy hospital units. Many of the instruments do not assess instrumental activities of daily living, and few provide guidance in the type of assessments to be made. Thus, the group embarked on developing an instrument for assessing self-management abilities in persons hospitalized with complex health problems who would be dismissed to their own homes.

Older persons in the United States have the right to live in settings that allow them to be as independent as possible for the longest period.17 Continuity of care allows for me elderly person's movement between settings based on the person's self-care capabilities and requirements. The Self-Management Assessment Inventory provides the data necessary to identify the elderly person's current ability to manage. This information can be compared with the level of care provided by the patient's current living arrangement. If a discrepancy exists between ability and services, the decision to transfer the person is made. This movement can be to either a more assistive or less assistive setting. For example, the resident of a nursing home could be transferred to a hospital if more complex care is required or to a skilled living arrangement in a senior complex if improvement in selfmanagement is noted. Thus, adequate assessment is an important element in a system designed to provide continuity of care through the maximization of the level of…

Elderly persons account for 38% of acute hospital stay days.1 Many of these hospital stays result from exacerbations or complications associated with chronic health problems. This is not surprising because 45.6% of persons over the age of 65 have one or more chronic conditions that limit their activities.2 Many of these chronic conditions result in physical or cognitive deficits that may have a profound impact on a person's functional abilities. New knowledge and skills or other forms of assistance may be required if the person is going to be able to manage care at home. To enable nurses to assist hospitalized elderly in making adjustments, an assessment of the person's self-management abilities is required. Following the assessment, the hospital staff can begin to assist the patient and family to acquire the needed skills and to access resources so that self-management abilities are maximized.

The introduction of diagnosis related groups has reduced the length of hospital stays, resulting in less available time for hospital staff to assess which areas persons will need assistance with and to provide the necessary teaching. Lack of adequate preparation prior to discharge has been indicated as a significant contributing factor in hospital readmissions in elderly with chronic health conditions who have been hospitalized.1·3

Adequate assessments of abilities and deficits are a key in determining the interventions needed in assisting persons to achieve their optimum level of functioning in as independent of a manner as is possible. The adequacy of these assessments was a concern of practitioners/researchers at the Minneapolis Veterans Administration Medical Center. The group reviewed existing self-care instruments4·8 and functional assessment instruments9'14 to ascertain if any of these existing instruments would provide the data nurses needed for planning self-management for patients following discharge. After careful review of these instruments, a need was identified for developing an assessment instrument that staff nurses could readily use in determining a patient's self-management abilities.

Many of the self-care instruments focus on healthy persons and do not provide the necessary data related to the management of complex health problems. Data obtained on many of these instruments are via self-report; a means for verifying the accuracy of these data is necessary, particularly in those with cognitive impairments. A number of the functional assessment instruments are too long to use on busy hospital units. Many of the instruments do not assess instrumental activities of daily living, and few provide guidance in the type of assessments to be made. Thus, the group embarked on developing an instrument for assessing self-management abilities in persons hospitalized with complex health problems who would be dismissed to their own homes.

FIGURESELF-MANAGEMENT CONTINUUM

FIGURE

SELF-MANAGEMENT CONTINUUM

FRAMEWORK

Orem's self-care conceptual model was chosen for the organizing framework for the Self-Management Inventory. Orem organized self-care deficits into universal, therapeutic, and developmental demands.15 Universal demands include the need for air, food, and water. Developmental demands address areas related to a person's stage of development, such as adulthood or elderly, and included lifestyle adjustment. Therapeutic demands include needs related to specific problems, such as medication, diet, or treatments.

The group elected to use the term self-management rather than self-care to emphasize the control that people wield on their own behalf Individuals, particularly those with complex health problems, need to have a sense that they can function at their optimum level. The Figure depicts the selfmanagement continuum that served as the basis for instrument development. An interactive problem solving process among the person, family, and healthcare providers occurs in assisting individuals to obtain their optimum level of self-management. An adequate assessment is needed to ascertain the factors involved in this process.

INSTRUMENT DEVELOPMENT

The varied expertise of the eight members of the research team was used in the generation and critique of items, selection of format, and overall development of the inventory. Although group members were concerned about the need for a comprehensive selfmanagement inventory, a pragmatic concern was to have an inventory that was comprehensive yet usable by staff nurses on busy units. A criterion used in determining items to include was, "Is the data that would be gathered by a particular item necessary for the planning of self-management post-hospitalization?" Thus, a number of items were deleted when subjected to this criterion.

Items contained on self-care and functional assessment instruments were reviewed for inclusion on the inventory. Nurse practitioners on the research team, who work in clinics and home-based health care, provided valuable experiential information regarding items that are critical in planning posthospitalization care.

Unique to the instrument is the indicator column. These items highlight the specific aspects of the assessments that need to be made. Such assistance is invaluable for inexperienced nurses and contributes to consistency in assessing self-management abilities. Indicators for the assessment item, "Patient's ability to take medications is adequate," are that the person can describe a method for remembering to take medications at home, state how to obtain refills, and name health-care providers to call if side effects occur. These must all be present for the nurse to check "yes" for the self-management ability. Table 1 provides a sample of indicators for selected assessment items. Determining the indicators for psychosocial items was more of a challenge than identifying ones to include for physiological related items.

An initial self-management instrument consisting of 32 items was reviewed by three nurse experts in selfcare, who were asked to critique the items and indicators for clarity and the inclusiveness of the items for determining abilities. The degree to which each indicator was critical for ascertaining the presence or absence of the selfmanagement ability was also evaluated. Based on the feedback obtained, revisions in items and indicators were made and five new items were added.

The Self-Management Inventory discussed here consists of 37 items: 24 relate to developmental demands, 9 to universal demands, and 4 focus on therapeutic demands. Table 2 lists the items included on the Inventory. Motor, sensory, cognitive, and psychosocial areas are assessed in the developmental demands section. Communication, motivation, substance abuse, coping effectiveness, support system, home environment, financial resources, and access to transportation are included in the psychosocial section of developmental demands. Pulmonary, nutritional, elimination, and safety areas are contained in the universal demands section. Items in the therapeutic demands section assess the person's ability to take medications appropriately, perform special treatments/ therapies, and follow a special diet.

PILOT STUDY

The Self-Management Inventory was used in a pilot study that explored if deficits in specific self-management abilities in persons with complex healthcare problems would predict the use of health-care services after hospitalization. Data on the length of time required to make the assessment, inter-rater reliability, and item clarity were gathered.

Nine staff nurses from three medicalsurgical units at the Minneapolis Veterans Administration Medical Center were oriented to the use of the Inventory in a 1 -hour training session. The nurses subsequently assessed patients on their units who had been identified as meeting the study criteria. These criteria were having two or more chronic health problems, having been hospitalized for 5 or more days, and being slated for dismissal to their homes. Assessments were made several days before planned discharge. Forty-eight subjects were assessed by staff nurses. The majority of the subjects (75%) were between the ages of 55 and 74 years, were men (91%), married (70%), and retired (70%). Musculoskeletal (34%) and cardiovascular (28%) conditions were the most frequently occurring chronic conditions found in the sample.

A nurse practitioner, who was a member of the research team, assessed one subject who had been assessed by each of the staff nurses. This was done to ascertain the adequacy of the orientation in preparing staff nurses to assess self-care abilities. High inter-rater reliability was found (r=.75). Complete agreement was found on the majority of the physiological related items, with lower reliabilities (r=.66) found on a number of the cognitive and psychosocial related items. Subsequently, the indicators for these items have been revised or expanded and are being tested to determine if they provide more specific direction for making assessments.

Table

TABLE 1EXAMPLES OF ITEMS ON INVENTORY OF SELF-MANAGEMENT ABILITIES

TABLE 1

EXAMPLES OF ITEMS ON INVENTORY OF SELF-MANAGEMENT ABILITIES

An evaluation form was completed by the staff nurses following the data collection phase of the study. Questions requested responses on item and indicator clarity, inclusiveness of the items, repetition of items, duplication with other available data, and if the inventory would be useful in preparing patients for discharge. Five of the 37 inventory items presented difficulties in relation to the clarity of the item or its indicators; these items/indicators were for psychological assessment areas and have been revised. The majority of the nurses noted that the information obtained would be useful in planning for discharge. Staff nurses reported that the Inventory was easy to use. The average time required for completing the assessment was 28 minutes; this includes obtaining subjects' consents. Nurses used prior knowledge about the patient in answering some of the items on the Inventory.

IMPLICATIONS FOR USE

Discharge planning is a responsibility of the nurse, but it competes with a multitude of tasks ranging from attending to acute care needs to dealing with missing equipment. In an interview with 22 registered nurses employed in a university hospital, Knight16 found that most nurses spent 11% to 20% of their discharge planning time on teaching self-care to home-bound patients and only 0% to 2% of their time was devoted to assessment of discharge planning needs/abilities. Burnside17 states that assessment of the elderly requires outstanding observational ability, honed listening skills, patience, and time. A brief instrument, designed to allow the staff nurse to holistically, yet quickly, assess a person's selfmanagement abilities, would help in their attempt to adequately and efficiently assess the discharge planning needs of the elderly patient. This instrument could also be used for quality assurance monitoring of the discharge planning of individuals or groups.

Table

TABLE 2ITEMS ON SELF-DEVELOPMENT INVENTORY

TABLE 2

ITEMS ON SELF-DEVELOPMENT INVENTORY

Older persons in the United States have the right to live in settings that allow them to be as independent as possible for the longest period.17 Continuity of care allows for me elderly person's movement between settings based on the person's self-care capabilities and requirements. The Self-Management Assessment Inventory provides the data necessary to identify the elderly person's current ability to manage. This information can be compared with the level of care provided by the patient's current living arrangement. If a discrepancy exists between ability and services, the decision to transfer the person is made. This movement can be to either a more assistive or less assistive setting. For example, the resident of a nursing home could be transferred to a hospital if more complex care is required or to a skilled living arrangement in a senior complex if improvement in selfmanagement is noted. Thus, adequate assessment is an important element in a system designed to provide continuity of care through the maximization of the level of wellness and self-management ability in elderly individuals.

Although the Self-Management Inventory was developed for use with adults of all age groups who are hospitalized with complex health-care problems, the Inventory would be particularly useful for the elderly who frequently have one or more chronic conditions. The Inventory gives guidance to nurses for making holistic assessments of a person's self-management abilities. A person may be hospitalized because of a fractured hip; however, that person also may have diabetes and asthma. All of these conditions have ramifications for individuals being able to manage their care. Frequently, however, attention is given only to the presenting problem.

The high inter-rater reliability obtained suggests that the Inventory could be used for evaluating a patient's progress, either improvement or decline. Are the same problems present 1 month following discharge as were present in the hospital, or have new problems emerged? The indicators for the areas to be assessed provide specific guidance in the assessments to be made. Thus, nurses in hospitals, home health settings, or long-term care facilities would be directed in making the same type of assessment. Likewise, the Inventory could be used in long-term care facilities for determining the type of assistance that is needed in formulating plans for discharge from the facility.

Work on the Inventory is continuing. The research team is currently testing the revised Inventory with a small sample of patients hospitalized with complex health problems. A number of instruments are being administered during hospitalization and follow-up home visits to determine construct validity of the Self-Management Inventory. Plans are being made to use the Inventory in evaluating the effectiveness of interventions in optimizing self-management abilities. The team believes that the Inventory holds much promise for assisting nurses in assessing and helping elderly persons who have chronic complex health problems.

REFERENCES

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TABLE 1

EXAMPLES OF ITEMS ON INVENTORY OF SELF-MANAGEMENT ABILITIES

TABLE 2

ITEMS ON SELF-DEVELOPMENT INVENTORY

10.3928/0098-9134-19910401-06

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