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ORIGINAL SCIENTIFIC PAPERSquantitative researchThe feasibility of assessing the FlindersProgram TM of patient self-management inNew Zealand primary care settingsMargaret P Horsburgh RN, EdD, MA (Hons), Dip Ed, FCNA(NZ); 1 Janine J Bycroft MBChB, Dip Obs, DipPaeds, MPH (Hons), FRNZGP; 2 Faith M Mahony RN, MPH; 3 Dianne E Roy RN, PhD, FCNA(NZ); 1 Denise JMiller RN, P G Cert HSc (Adv Ng); 4 Felicity A Goodyear-Smith MBChB, MGP, FRNZCGP; 2 Erin C J Donnell 51School of Nursing, TheUniversity of Auckland,Auckland, New Zealand2Department of GeneralPractice & Primary HealthCare, School of PopulationHealth, The University ofAuckland3Centre for Health ServicesResearch and Policy, Schoolof Population Health, TheUniversity of Auckland4Clinical Trials Research Unit,The University of Auckland5Visible Learning Laboratory,The University of AucklandABSTRACTIntroduction: The Flinders Program TM has been adopted in New Zealand as a useful and appropriateapproach for self-management with primary care clients who have chronic conditions. The FlindersProgram TM has not been evaluated in New Zealand settings.AIM: To assess the feasibility of undertaking a substantive long-term trial to gauge the effectiveness of primarycare nurses using the Flinders Program TM to improve health outcomes for New Zealand populations.Methods: A pilot study was undertaken considering four components of feasibility of conducting along-term trial: practice recruitment, participant recruitment, delivery of the intervention and outcomemeasures. This included comparing 27 intervention and 30 control patients with long-term health conditionswith respect to change in self-management capacity—Partners in Health (PIH) scale—qualityof care using the Patient Assessment of Chronic Illness Care (PACIC) scale and self-efficacy across sixmonths. Intervention participants received care planning with practice nurses using the Flinders ProgramTM in general practices, while control participants received usual care in comparable practices.Results: General practice and participant recruitment was challenging, together with a lack of organisationalcapacity and resources in general practice for the Flinders Program TM . The measures of selfmanagementcapacity (PIH), quality of care (PACIC) and self-efficacy were useful and valuable primaryoutcome measures.Discussion: The overall findings do not support a substantive trial of the Flinders Program TM in primarycare. Difficulties associated with participant recruitment and ability of practice nurses to undertakethe Flinders Program TM within general practice need to be resolved.KEYWORDS: Self-management; long-term conditions; chronic conditions; chronic illness; primary care;nursesJ PRIM HEALTH CARE2010;2(4):294–302.Correspondence to:Margaret HorsburghAssociate Professor,PO Box 25876,St Heliers, Auckland1740, New Zealandm.horsburgh@auckland.ac.nzIntroductionIncreasingly, self-management programmeswithin primary care are being considered a keystrategy for improving chronic care in a numberof countries throughout the world. 1 In NewZealand (NZ), long-term or chronic conditionsare responsible for approximately 70% of allgeneral practice encounters and 78% of all healthcare spending. 2 The 2006/7 NZ Health Survey 3found that two out of three New Zealanders havea long-term health condition, with Maori andPacific tending to experience more severe chronicdisease than non-Maori, non-Pacific. 4The Flinders Program TM of Chronic ConditionSelf-Management, developed by the FlindersHuman Behaviour and Health Research Unit (FH-BHRU), Australia, is an evidence-based self-managementprogramme developed from the learningsof the Coordinated Care Trials in Australia. 5294 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE
ORIGINAL SCIENTIFIC PAPErSquantitative researchThe programme is based on cognitive behaviourtherapy, problem solving and motivational interviewingtechniques to support positive behaviourchange. This model utilises a number of tools andprocesses that enable clinicians and clients to collaborativelyassess self-management behaviours,barriers, psychosocial issues and client preferencesfollowed by client-identified problems and goalsetting leading to individualised client care plans. 6The Flinders Program TM has been adopted in NZas a useful and appropriate approach for selfmanagementwith primary care clients who havechronic conditions. Since 2005 approximately500 NZ health professionals have participated in‘Flinders’ training. The largest group of healthprofessionals participating in training have beenprimary care nurses with 298 nurses completingthe training in 2007–9 within a postgraduatecertificate course which focuses on long-termconditions. The Flinders Program TM has not beenevaluated in NZ settings.While the evidence for self-management supportis considerable, 7 several authors 8,9 consider theevidence base for self-management to be underdevelopedand to have not provided convincingevidence. Australian studies of the FlindersProgram TM have not focussed on practice nursesin primary care settings. Other authors 9 considerthat men and ethnic groups are under-representedin studies.The aim of the 2008/2009 study was to assess thefeasibility of undertaking a substantive long-termtrial, including the usefulness of primary outcomemeasures, in order to assess the effectiveness ofprimary care nurses using the Flinders Program TMto improve health outcomes for ‘high needs’ NZpopulations (particularly Maori and Pacific).The overall challenges of undertaking researchwhich attempts to assess the evidence base for acomplex intervention in NZ primary care settingsare reported separately. 10MethodsWHAT 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 shows that, despite considerableresources being directed to training primary care nurses in particular in theFlinders Program TM , undertaking a substantive trial to evaluate the effectivenessof the Program TM is not feasible. Difficulties with introducing a new andcomplex intervention in primary care with structured support need to beresolved before a trial is undertaken.There were four components that required assessmentin terms of the feasibility of a substantivetrial: practice recruitment, participant recruitment,delivery of the intervention, and outcomemeasures. A pilot study was conducted to enableassessment.Recruitment of general practicesFor the pilot study, 100 patients were recruitedfrom 20 general practices with the intentionthat 50 patients would receive assessment andcare planning from nurses using the FlindersProgram TM (intervention group) in 10 generalpractices compared with a group of 50 patientswho received ‘usual care’ (control group) in 10comparable general practices. The interventionpractices employed nurses trained in the FlindersProgram TM whereas the control practices did nothave nurses similarly trained. The practices wereselected to allow for geographic spread and distributionacross socioeconomic areas.Recruitment of participantsEligible participants were enrolled generalpractice patients, aged over 18 years, with oneor more long-term conditions such as, but notlimited to, asthma, arthritis, gout, diabetes, heartdisease, metabolic syndrome, COPD, depression,as well as those with high CVD risk with modifiablerisk factors (15% or greater). Participantswere required to give informed consent, havesufficient English, Maori, Samoan or Tongan languageskills to complete written questionnairesand to be agreeable to follow-up over at least sixmonths. Questionnaires were not translated forVOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 295
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