The requirement to respect autonomy - The Royal New Zealand ...

ORIGINAL SCIENTIFIC PAPErSquantitative researchA recent Cochrane review concluded a lack ofclarity around the active ingredient of successfulself-management, and that the evidence for theeffectiveness of self-management programmeson long-term health outcomes is inconclusive. 5Uptake of self-management programmes withinprimary care is also inconsistent. Organisationalbarriers to implementing self-management programmeshave been identified as limited teamwork in general practice, resistance to change andan approach where ‘doctors know best’. 6One study has identified the enablers for selfmanagementprogrammes in Australian generalpractice as including education of staff, skillstraining, inclusion of negotiated self-managementsupport in client care plans, assessment of clients’self-management capacity and developing the roleof practice nurses to provide self-managementsupport. 3 Increasingly the role of practice nursesin self-management programmes is recognised. 3A United Kingdom (UK) study suggests thatclients find nurses easier to approach for informationthan doctors. 7 The capacity of nurses, thelargest group of health professionals, to engagein this role however may require attention, withlittle being done to equip them with knowledgeand skills for self-management education. 8 Manypractice nurses lack the time and competencies toundertake self-management programmes. 3 A UKstudy of practice nurse involvement in self-managementprogrammes found that little attentionhad been given to the ways practice nurses workand support self-management for chronically illclients. 9 Nurses were more confident with clientsin the early stages of their illness. When clientsdid not make suggested lifestyle changes, nursesresorted to didactic information-giving. Thisstudy highlighted the complexities of deliveringself-management programmes where health professionalsmust create partnerships with clients.The Flinders Program TM of Chronic ConditionSelf-Management is a self-management programmedeveloped from the 1990 Australian CoordinatedCare Trials, 10 based on cognitive behaviour therapy,problem solving and motivational interviewingtechniques. This model utilises a set of tools (Partnersin Health Scale, Cue and Response Interview,Problems and Goals Assessment and a Client CarePlan) and processes. Clinicians work one-on-oneWHAT GAP THIS FILLSWhat we already know: The Flinders Program TM of self-managementhas been adopted in NZ as a useful and appropriate approach for improvinglong-term condition management. Over 500 health professionals have beentrained in the use of the programme. The evidence for the effectiveness ofself-management is, however, inconclusive, and support for the introductionof new and complex interventions in primary care inconsistent.What this study adds: This paper demonstrates that, despite the considerableresource being directed to training primary care nurses in particular inthe Flinders Program TM , there is limited use of the Flinders tools and processesin clinical practice. Training for new and complex interventions in primary caremay not be aligned with structured support and general practice priorities.with clients to assess collaboratively self-managementbehaviours, barriers, psychosocial issues andclient preferences, followed by client-identifiedproblems and goal setting, leading to individualisedcare plans. 11 A key point of difference from traditionalcare planning includes the shift in powertowards a client-centred partnership with clientsactively sharing decision-making on their physical,emotional and social well-being. The care plan isbased on shared, agreed issues, goals and interventionsthat align with the client’s values, prioritiesand beliefs. Approximately 45 to 60 minutes isrequired for a Flinders assessment once a clinicianhas become confident and reached competency.The Flinders Program TM has been given focusin NZ as a useful and appropriate approach forincreasing knowledge and understanding aroundself-management support and improving longtermcondition management. Since 2005 approximately500 NZ health professionals haveparticipated in Flinders training, attending atwo-day workshop. For health professionals touse the Flinders Program TM they first attend atraining workshop conducted by a trainer accreditedby the Flinders Human Behaviour andHealth Research Unit (FHBHRU). Followingthis, completion of three client assessments andcare plans to an acceptable standard, as assessedby the accredited trainer, enables the health professionalto receive a Certificate of Competencein Chronic Condition Self-Management fromFlinders University. Flinders University charge alicence fee for each workshop attendee. This feeentitles the workshop participant to access ongoingprogramme updates. The Partners in HealthVOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 289