The new Dutch professional profiles acknowledge self-management support as a key-feature of nursing. What this entails is not self-evident, however. Nurse education programs need to be adapted in view of the increasing attention to self-management. Until now it is not clear how nurses are prepared for self-management support during their education. The studies in this thesis are part of the research program NURSE-CC (Nursing Research into Self-management and Empowerment in Chronic Care).
Chapter 2 describes a Q-methodological study with 39 nurses from various settings. The goal was to identify nurses’ perspectives on self-management. Four distinctive perspectives were revealed, which we described as the Coach perspective, the Clinician perspective, the Gatekeeper perspective, and the Educator perspective. The differences between the perspectives lie in the perceived goal of self-management, and in the patients’ and nurses’ roles in the self-management process.
The realist review in Chapter 3 aims to examine how nurse-led interventions that support self-management of outpatients with chronic conditions work and in what contexts they work successfully. We included 35 different interventions, described in 38 papers. Our review showed three different mechanisms in the interventions: increase patients’ knowledge, enhance patients’ skills, and increase patients’ motivation. These were the starting points for the interventions. Also, three outcomes of the interventions were identified: behavioural change, increase of coping, and increase of self-efficacy. Interventions that focused on patients’ intrinsic processes were most successful.
Chapter 4 describes the development and the psychometric evaluation of the self-efficacy and performance in self-management support (SEPSS) instrument. With this instrument we assessed both self-efficacy (the extent to how confident participants were that they were able to perform the asked competency), and performance (the extent to how often participants performed this competency). The psychometric evaluation showed that the final 36-item instrument has good content and construct validity, as well as good internal consistency reliability. Chapter 5 describes a study exploring nurses’ self-reported behaviour in self-management support and the factors that influence this behaviour. We used a total sample approach with a cross-sectional design. Results showed that nurses perceived a patient’s lack of knowledge, lack of ability to make choices, and lack of motivation as the most important factors potentially influencing their self-management behaviour. But these did not affect the self-management support behaviour of these nurses. The differences in scores between self-efficacy and behaviour were significant. This implies that nurses had a lower score on behaviour than expected from the scores on self-efficacy. Stepwise regression analysis showed that three factors were significant predictors for self-management support behaviour: perceived lack of own knowledge, the presumed absence of a patients’ need for self-management support, and nurses’ self-efficacy in self-management support. The study in Chapter 6 aims to describe how Dutch Bachelor of Nursing students are prepared for self-management support in practice. Four Bachelor of Nursing schools participated. The scan of learning objectives showed that self-management was often taught in relation to communicative skills, models for behaviour change, and lifestyle adaptations. The interviews revealed that students encounter contradicting values when they have to apply what they have learned about self-management into clinical practice.
Conclusion
This thesis contributed to the understanding of the role of nurses in self-management support. Supporting patients’ self-management, according to the broad view on self-management, is however not necessarily current practice, neither in clinical nursing practice nor in Dutch Bachelor of Nursing education. Equal partnership, which is an essential aspect of self-management support, seems to be difficult for nurses in everyday practice. Nurse education could facilitate students in empowering them and teaching them the value of patient’s expertise.