Implementing, embedding and integrating self-management support tools for people with long-term conditions in primary care nursing: A qualitative study

Implementing,

embedding

and

integrating

self-management

support

tools

for

people

with

long-term

conditions

in

primary

care

nursing:

A

qualitative

study

Anne

Kennedy

*

,

Anne

Rogers

,

Robert

Bowen

,

Victoria

Lee

,

Tom

Blakeman

,

Caroline

Gardner

,

Rebecca

Morris

,

Joanne

Protheroe

_,

_Carolyn

_Chew-Graham

a

UniversityofSouthampton,UnitedKingdom

b

UniversityofManchester,UnitedKingdom

c

KeeleUniversity,UnitedKingdom

ARTICLE INFO

Articlehistory: Received16April2013

Receivedinrevisedform18November2013 Accepted19November2013

Keywords:

Long-termconditions NormalisationProcessTheory Nursing

Primarycare

Self-managementsupport

ABSTRACT

Background:Animplementationgapexistsbetweenpolicyaspirationsforprovisionand thedeliveryofself-managementsupportinprimarycare.Anevidencebasedtrainingand supportpackageusingawholesystemsapproachimplementedaspartofarandomised controlledtrialwasdeliveredtogeneralpracticestaff.Thetrialfoundnoeffectofthe interventiononpatientoutcomes.Thispaperexploreswhyself-managementsupport failedtobecomepartofnormalpractice.Wefocussedonimplementationoftoolswhich capture two key aspects of self-management support – education (guidebooks for patients)andformingcollaborativepartnerships(ashareddecision-makingtool). Objectives:Toevaluatetheimplementationandembeddingofself-managementsupport inaUnitedKingdomprimarycaresetting.

Design:Qualitativesemi-structuredinterviewswithprimarycareprofessionals. Settings:12GeneralPracticesintheNorthwestofEnglandlocatedwithinadeprivedinner cityarea.

Participants: Practiceswereapproached3–6monthsafterundergoingtrainingina self-managementsupportapproach.Apragmaticsampleof37membersofstaff–General Practitioners,nurses,andpracticesupportstafffrom12practicesagreedtotakepart.The analysisisbasedoninterviewswith11practicenursesandoneassistantpractitioner;all werefemalewithbetween2and21years’experienceofworkingingeneralpractice. Methods:Aqualitativedesigninvolvingface-to-face,semi-structuredinterviews audio-recordedandtranscribed.NormalisationProcessTheoryframeworkallowedasystematic evaluationofthefactorsinfluencingtheworkrequiredtoimplementthetools. Findings:Theguidebooks were embedded in daily practice but the shared decision-makingtoolswerenot.Guidebookswereconsideredtoenhancepatient-centrednessand wereminimallydisruptive. Practicenurses werereluctantto engage with behaviour changediscussions.Self-managementsupportwasnotformulatedasapracticepriority andtherewasminimalsupportforthisactivitywithinthepractice:itwasnotauditable;

* Correspondingauthor.Tel.:+4402380598956. E-mailaddress:[email protected](A.Kennedy).

ContentslistsavailableatScienceDirect

International

Journal

of

Nursing

Studies

journalhomepage:www.elsevier.com/ijns

0020-7489ß2013TheAuthors.PublishedbyElsevierLtd.

http://dx.doi.org/10.1016/j.ijnurstu.2013.11.008

Whatisalreadyknownaboutthistopic?

Practice nurses are increasingly responsible for most long-termconditionmanagementinprimarycare. Thedevelopmentofmorecollaborative

patient–practi-tioner relationships is key tothe ethos of supporting patientself-managementoflong-termconditions. Whilst ostensibly widely and rhetorically valued, the

necessary increasedpatient involvement in self-man-agementsupportviatheconsultationprocessis challen-gingforpractitionerstoimplementinpractice.

Whatthispaperadds

ThecurrentorganisationalprioritiesofGeneralPractice meansthattheworkneededtoimplement self-manage-mentsupportremainsunder-initiatedandvaluedbythe currentsystemsoisnotgiventhepriorityrequiredforit tobeembeddedintheday-to-dayworkofprimarycare. Displacingexistingpracticesinordertoincorporatenew onesisdiscouragedbythetask-drivennatureofnurses’ routines that hinderincorporatingalternativewaysof working.

Underlying scepticismofthewill ofmany patients to takeadequateresponsibilityfortheirhealthundermines the motivation of some nurses to engage with self-managementsupportactivities.

1. Introduction

A randomised controlled trial of an approach to improvethehealthoutcomesofpatientswithlong-term conditionsthroughimprovingtheself-management sup-portthey received fromprimary careshowedno effect (Kennedyetal.,2013).Thetrialwasoneofthelargestever tobeconductedofself-managementsupport, recruiting 5599 patients. This paper uses qualitative methods to exploretheworkofself-managementsupportandexplain whytheimplementationofasystemisedevidence-based approach failed to engage the nurses tasked with supportingpatientstoself-manage.

The organisation of care for people with long-term conditionsisintransitionandself-managementsupport policies have been designed to enhance peoples’ self-managementcapabilities aimingtoimprovehealth out-comesandreducethefiscalburdenonhealthcaresystems (DepartmentofHealth,2005).Self-managementhasbeen definedas: ‘thecaretaken byindividualstowardstheir ownhealthandwell-being:itcomprisestheactionsthey take to lead a healthy lifestyle; to meet their social, emotionalandpsychologicalneeds;tocarefortheir long-termcondition;andtopreventfurtherillnessoraccidents’

(Department of Health, 2005). In relation to long-term conditionmanagementandbasedonasystematicreview, theinterventionsmostlikelytobeeffectiveinthecontext of primary care wereengagement for self-management support through education and training for general practitioners and practice nurses (Dennis et al., 2008). Primary care potentially provides ready access and continuityofcareforpatientsandthereforeanappropriate location for guideline-based disease management pro-grammesforpatients,andmorerecentlyasakeyprovider of self-management support (Truglio et al., 2012). In UnitedKingdomprimarycare,long-termcondition man-agement operates through an increasingly biomedical, specialisedandreductionistframework,partlyasaresult of theQualityand OutcomesFramework (DoH,2004), a system of payment to practices for activities done and outcomes achieved. Togain through the payfor perfor-mance system, practices have to demonstrate through clinicalinformationsystemsusingcomputertemplates,the undertakingofspecificprocessesandtasks(suchassetting up a register of patientswith hypertensionand regular recordingofbloodpressurewithanaimofensuringblood pressure is controlled according to a target). These financially incentivised tasks have been shown to have both intendedandunintended consequencesand are,in the case of long-term condition management, usually delegatedtopracticenurses(McDonaldandRoland,2009). Self-managementsupportholdsouttheofferofamore patient-centred,socialandpsychologicalapproach.There havebeennumerousstudiesoftheeffectivenessof self-skillstrainingdeliveredtopatientsandthefactorsrelating toacceptabilityanduptakebypatientsofone-offtraining courses.Weknowmuchlessabouttheimplementationof a whole systemsapproach to self-management support andanimplementationgaphasbeenidentifiedbetween thenationalaspirationsfor self-managementpolicyand local meansof delivery (Lee etal., 2006;Rogers, 2009). Thus, there is a need to understand how a systemic approachtoself-managementsupportreconfigures exist-ingrelationships,communicationandpracticesandhow the principles of a whole systems patient-centred approach toself-managementcantranslateandbecome embeddedandintegratedintoroutinepractice(Grayetal., 2011; Macdonaldet al.,2008). Thelatter isparticularly salient in a context where the labour of primary care professionals has ostensibly become biomedical and bureaucratic due to the pressures and demands of governancearrangementslinkedtopay-for-performance (Doranetal.,2011)andinthediverseandwidelyspread contextofprimarycare(Greenhalghetal.,2004).

We have based ourtheoretical understanding ofthe implementation ofself-management supportinprimary

wasinsufficientlydifferentiatedfromexistingcontentandprocessesofworkto valueinitsownright,andconsideredtoodisruptiveandtime-consuming. Conclusion:Supportingself-managementthroughtheencouragementoflifestyle changewasproblematictorealisewithlimitedevidenceofthedevelopmentofthe neededcollaborativepartnershipsbetweenpatientsandpractitionersrequiredby theethosofself-managementsupport.

careonNormalisationProcessTheorywhichisconcerned with the extent to which complex interventions (in particular new technologies) are implemented and embedded in health care and provides an orientating conceptual framework to identify the social processes influencing the embedding of self-management support withinexisting practice(Bamfordetal., 2012;May and Finch,2009).NormalisationProcessTheoryfocusesonthe workthatparticipantsengageinandhowthiscontributes to processes becoming normalised in everyday practice andisusefulinconceptualisingbarrierstoimplementation (Bamford et al., 2012). Normalisation Process Theory sensitises analytical thinking to four implementation processes. ‘Coherence’ refers to the extent to which technology or health care practice makes sense to stakeholdersforsuccessfuladoption.‘Cognitive participa-tion’concernsthecommitmentandcollectiveengagement of stakeholders. ‘Collective action’refers tothe relation-shipsandtheworkrequiredforanewinterventiontobe takenupinpracticeandtoidentifythefactorsthatserveas barriers to implementation and embedding. ‘Reflexive monitoring’holdsthatsuccessfulembeddingofresources and technologies in everyday practice relies upon a continuousprocessofevaluationthatcanfeedbackinto refiningtheobjectofimplementationtoensureitisfitfor purpose. The four constructs are outlined in Table 1. Normalisation Process Theory has been the guiding theory throughout the process of implementing the WISE approach (Whole System Informing Self-manage-ment Engagement); in developing the intervention

(Kennedy et al., 2010) and setting up the randomised controlled trial(Murray et al., 2010) and as such, it is appropriatethatit formstheframeworkfortheprocess evaluationofthetrial(Grantetal.,2013).

1.1. Theimplementationofaprogrammeofself-management support

TheWISEapproach(Kennedyetal.,2007)ispredicated on a WholeSystems perspective that engagespatients, practitionersandtheserviceorganisationandisinformed by an understanding of the ways in which healthcare professionals and patients respond tolong-term condi-tions.Oneaspectofpromotingpartnershipworkingwas theinclusionandforegroundingofthepatient’s perspec-tiveandwaysofself-managingduringself-management support consultations. A large-scale randomised con-trolled trial was designed to test its effectiveness and cost-effectiveness (Bower et al., 2012; Kennedy et al., 2010). Theexemplar conditions were:diabetes, chronic obstructivepulmonary disease and irritable bowel syn-drome.Fig.1outlinesthetwotrainingsessionsdelivered tothepracticesinthetrial.Thetrainingwaswellattended. 90%ofeligiblestaffattendedsession1(n=179)and82% (n=85)attendedsession2.Trainingwasratedpositively (meanscoreover2.5ona5pointscale)by76%ofsession1 participantsandby89%ofsession2participants.

Withinthetrial,allprimarycarehealth professionals wereconsideredrelevant toimplementing self-manage-ment support, however, practice nurses were a focus

Table1

KeyfindingsandtheirrelationtoNormalisationProcessTheoryconstructs.

Constructdefinitions Findingsfromnurses Propositionssupported

Coherenceandcognitiveparticipation: Understandingandbuy-in

WISEprinciplesnotseenasdifferenttothoseunderpinning theirpractice,perceptionsthatthisiswhattheydoalready

4 Collectiveaction–contextualintegration:

Howwellself-managementsupportsupportedby infrastructureandcultureinprimarycare

Self-managementsupportisnotrenumeratedbyQuality andOutcomesFrameworkthusithaslittlevalueorpriority forthepractice

Seenasgenericallya‘goodthing’butnotdiscussedwithin practiceteams

1,2

Collectiveaction–skillssetworkability: Allocationoftheworkandfitwithroutines

Nursesdotheworkofself-managementsupport–butitis hiddenandseenasadditionaltothemorevaluedwork relatedtoQualityandOutcomesFramework

Guidebookfitseducationroleandpatient-centred approachbutPRISMSdisruptsroutinesandnoteasily‘to hand’

1,2,3,7

Collectiveaction–relationalintegration: Confidenceinworthandsafetyofproviding

self-managementsupport

Guidebookhandy,trusted,easytodistributebutin competitionwithexistinglong-establishedsources PRISMSseenasimpedingtasksandpriorities,generates newneedstorespondto

7

Collectiveaction–interactionalworkability: Waysinwhichself-managementsupporthelpsor

hinderscareforpatientswithlong-termconditions

Potentialtospoilestablishedrelationshipswithpatients Difficulttoengagemostpatientswithbehaviourchange andself-managementsupportapproachseenas time-consuming

4,5,6

Reflexivemonitoring: Appraisingandsustaining

Ofminimumvalue–notmeasuredoraudited,notworth theeffort.AfewwhotriedPRISMSnotedapositiveimpact onpatientengagement

1,3

1:Thedelegation,prioritisationandauditabilityofworkassociatedwithself-managementsupportisnotapriorityforpractices. 2:Theresponsibilityforself-managementispassed‘down’fromGeneralPractitionertonursetopatient.

3:Autonomousworkingpracticesprovidespaceforoptimalself-managementsupportdiscussionsbetweennursesandpatients. 4:Self-managementsupportisnotperceivedasdifferentenoughtowarrantthefurtherinvestmentoftimeandeffort. 5:Thelackoffeasibilityandsuccessofchangingbehaviourisademotivatorofpraxis.

6:It’seasytodismissorunder-acknowledgetheneedsofpatients.

because of their increased role in long-term condition managementwithinthepractice.Generally,incentivised payment for long-term condition management has resulted in General Practitioners delegating work to practice nurses (Charles-Jones et al., 2003; McDonald andRoland,2009;DepartmentofHealth,2004).Fornurses, twoaspectsofself-managementsupportimplementation have been identified: using education, techniques and tools to help patients improve their self-management abilitiesandamoredemandingrequirementtotransform the patient–caregiver relationship into a collaborative partnership(Bodenheimaretal.,2005).

1.2. Thetools

AnumberoftoolsweredevelopedaspartoftheWISE interventionandpracticestaffweretrainedintheir use (Kennedyetal.,2010).Toolsincludedanonlinedirectory of local self-management support resources, a patient reporttool,writteninformation(guidebooks)forpatients and explanatory models to explain the need for beha-vioural change. For this paper, we focus on the imple-mentationoftwoofthesetoolswhichexemplifythetwo aspectsofself-managementsupport–forming collabora-tivepartnershipsandeducation–becauseimplementation processesareilluminatedmostclearlywhentechnologies areinvolved(Elwynetal.,2008;Mayetal.,2011). ThePRISMS(PatientReportInformingSelf-Management

Support)tool (Protheroeetal.,2010)aimstopromote patient engagement in the consultation by asking

patients to identifywhat wasimportant tothem and usingthisasthebasisforanopendiscussionabout self-managementsupport.Theself-reportformencouraged patients to reflect on their support needs through considering how they were managing and which symptomsandillness-relatedmattersrequiredattention intheireverydaylives.Thiswasdesignedtohighlightthe patients’ priorities as a basisfor negotiated decision-making and access to appropriate information or resources.

The guidebooks were developed with patients and provided information based on the experience of patientsandmedicalevidenceabouttreatmentoptions (Kennedyetal.,2003;KennedyandRogers,2002).The guidebooks were intended to encourage patients to consider changes they could make to manage their condition.

1.3. Aims

TheWISErandomisedcontrolledtrialfoundnoeffectof the intervention. This paper aims to explain this by evaluationoftheextenttowhichWISEwasimplemented andembeddedinprimarycarethroughanexaminationof the attempts tonormalise theWISE tools and services withineverydaypractice.

2. Design

Thestudyadoptedaqualitativedesigninvolving face-to-face,semi-structured interviews.Framework analysis

Session 1: 3 hours WHOLE PRACTICE – General Praconers, nurses and administrave staff Brief introducon to WISE

Care pathways exercise - Mapping the Process of Care From Recepon to Self-management Interacve session - making the WISE tools work in your pracce: PRISMS form, guidebooks and opons for support:

Informaon sources

Web based informaon Guidebooks

Group training and support

Expert Paents Programme courses Group educaon

Exercise classes

Voluntary sector and local support Paent support groups Health trainers

Session 2: 3 hours CLINICIANS – General Praconers and nurses Refresh on WISE approach

Show DVD giving examples of WISE approach consultaons plus discussion Skills training – role play to pracce three core skills:

How to assess what each paent can do and needs to do How to share decisions with paents

How to make sure paents get the right support

Discussion on how to ensure sustainability of WISE

informedbyNormalisationProcessTheoryconstructswas usedtosystematicallyidentifytheworkof self-manage-mentsupportandhowtheWISEtoolswereembeddedin existingroutines.

2.1. Participants

Practiceslocatedwithinadeprivedinnercityareaina NorthwestEnglishPrimaryCareTrustwereapproached3– 6monthsafterundergoingtrainingintheWISEapproach. A pragmatic sample of 37 members of staff – General Practitioners,nurses, and practicesupportstaff from12 practicesagreedtotakepartinqualitative interviews.A decisionwasmadetobasetheanalysisoninterviewswith 11practicenursesandoneassistantpractitionerbecause allintervieweeswereinagreementthattheworkof self-managementsupportwasdonebynurses.Allnurseswere female with between 2 and 21 years’ experience of workingin general practice.Interviews withotherstaff providedcontextconcerningthewaythepracticeswere organised.

2.2. Datacollection

TheinterviewswereconductedbyVLandRBin2011/ 2012.Aninterviewschedulewasdevelopedwithreference topilotinterviewscarriedoutbyARwithtwopractices priortomaintrialcommencing(Kennedyetal.,2010).The schedulewasusedtoasknursesabouttheirinvolvement in supporting patients’ self-management of diabetes, chronicobstructivepulmonarydiseaseandirritablebowel syndrome, their impressions of PRISMS and the guide-books, and attempts to integratethe tools within their dailyroutines.Interviewslastedupto1h.Theinterviews wererecordedusingdigitalaudioequipment.Field-notes summarisingtheinterviewsand highlightingkey issues werewrittenupsoonaftereachinterview.

2.3. Ethicalconsiderations

ThestudywasapprovedbytheSalford&TraffordLocal ResearchEthicsCommittee.RECreferencenumberwas09/ H1004/6.

Toensuretheanonymity oftheparticipantsandthe practices where they work, all identifiers have been removed.

2.4. Dataanalysis

Verbatim transcriptions of the audio-recorded inter-views werediscussed overthecourseofdatacollection during meetings attended by all authors enabling an iterativeapproachtodatacollection,coding,discussionof emergingthemes andfurtherexplorationneeded. Ques-tions relating to each component within the four core NormalisationProcessTheoryconstructsweregenerated (Murrayetal.,2010)(seeTable1)andacodingframework wasdrawnupbasedonthesequestionswhichalloweda systematicevaluationofthefactorsinfluencingthework requiredtoimplementandembedthetools(Ritchieand

Spencer, 1994). The content of the interviews was

considered on a case-by-case basis and comparisons drawnacrosscasestoidentifysimilaritiesanddifferences intheunderstandingandvaluesattachedtothetoolsand individuals’ attempts to integrate them in everyday practice.Theanalysisfocussedonthewaysnursesspoke about the work of managing patients with long-term conditions and how using WISE tools impacted on or changed their everyday and self-management support practices. All authors contributed to the coding of individualtranscripts,RBreadandcodedallthetranscripts providing inter-rater reliability. The main analysis was donebyAK,RBandAR.

3. Results

Someelements of WISEwerereported toworkwell, suchasdistributionoftheguidebooksandtheiracceptance bypatients,butotherelements,suchasusingthePRISMS tooltohelpaddresspatient’s needsand priorities,were rarelyengagedwith,acknowledgedortakenup.

As advocated by other researchers, Normalisation ProcessTheory hasbeenused as a methodtosensitise theanalysistoconceptsandprocessesofimplementation (MacFarlane and O’Reilly-de Brun, 2012). A number of themesemergedasaresultofcodingandthinkingabout thedatausingaNormalisationProcessTheoryframework whichwehaveposedasasetoftheoreticalpropositions (Bradleyetal.,2007).Table1providesasummaryofhow thesystematicidentificationofworkundertakenbynurses mapped onto the Normalisation Process Theory frame-work. Illustrative data is presented and labelled with respondentidentifier.

3.1. Whopaysthepipercallsthetune

Proposition1. Thedelegation,prioritisationandauditability of workassociatedwith self-managementsupportisnota priorityforpractices.

Althoughallthepracticesinvolvedhadsigneduptothe trial and participated in the training, the WISE self-management support approach did not emerge as a priorityandfailedtodisruptthestatusquooftheexisting orientationandworkofthenurses.

Practicenursesgenerallyworktoasetoftasksinaway whichisdictatedbypracticepriorities.Onepriorityisto ensure Quality and Outcomes Framework financially incentivisedtargets are reached –this involvessetting upandcarryingoutreviewappointmentswithpatientson the practice disease register. In these appointments, nurses monitor and record vital signs such as blood pressure,bloodsugarsandlungcapacityasrequiredby Quality and Outcomes Framework. Such prioritisation marginalises othernon-incentivised worksuchas self-managementsupportwithmorecomplexandchallenging workof providingself-management support remaining hidden.Withinpractices,nurseswereviewedashaving thespecific skills,time andopportunity todolifestyle change workwith patients anddelegated thiswithout interestfromotherpracticestaffinhowthiswasactually achieved.

Thismeantthatfornurses,theworkofproviding self-managementsupporthadtobefittedbetweenothertasks which were generally formulaic and box-ticking on computertemplates. Thisledto cognitiveand practical tensions for nurses who were at pains toconvey their ability to provide holistic care for their patients, yet servicingtheQualityandOutcomesFrameworkagendafor whichtheyhadbeentaskedtookprecedence.

‘Wellnow.ThethingisI’vealwaysbeentaughttofocus on the patient and you’ve got to tick ... you know you’vegottofulfilyourQualityandOutcomes Frame-workcriteriaand stuff so... It’s chronicobstructive pulmonarydisease,lookingifthereareanychangesin theirconditionoveraperiodof12months.Ifthereis anything they can’t do, if it’s impacting on their lifestyle, are they more breathless, are they getting moreexacerbations.Youarelookingatdepressionand how it’s impacting on that kind of thing generally.’ (NurseE,P12)

Nurses identify patient education as key to self-managementsupport, buttheneedtofulfilQualityand Outcomes Framework criteria wins out, producing a didactic approach to dealing withpatients in consulta-tions. Handing out written information whilst telling patients what to do is theeasiest and quickest way to undertakethetask.

‘Ihaveloadsofliterature,yeah.That’sit.Wehavearaft ofinformationfordiabetes.SoIdogiveoutinformation. AndIthinkchronicobstructivepulmonarydisease... diabetes, I’m the same. With the diabetic ones we managethemandwesortoftellthem.Itsoundsawful tellthem.Wedon’ttellanybodybutwedosortoftell them,‘‘Youneedtodothis.Youneedtodothat.You needtodotheother.’’.’(NurseNP28)

HandingouttheWISE guidebooks fittedreadily into this way of workingand the guidebooks were seen as fillinginthemissingpatient-centrednessoftheirpractice. Inthisrespectguidebookswereminimallydisruptiveso wereeasilynormalised(Mayetal.,2009).

‘WegivethemtheWISEbook.Andwejustaskthemto readthatandiftheyhaveanyconcerns,thatthere’sa littleproblemthingatthebacktheycanalwaystalkto usaboutitwhentheynextcome...Ithinkit’smade people more aware of how to manage their own condition.Theinformationisinthebook.Theyknow theycanlookatthat anytime. Ifthereis something theretheydon’tunderstand orwhatever,Ithink the informationisallinthere,youknow,andwegothrough it withthem whentheycome, and we tellthem,‘If you’reeverstuckorworried,pleaselookatthebook. Pleasereadandseewhereyoucanmakethesechanges ifyouneedit.’(NurseFP3)

Proposition 2. The responsibility for self-management is passed‘down’fromGeneralPractitionertonursetopatient. Thedemarcationofroleswithinthepracticeimpacted onhow nursesviewedand dealtwithself-management

support.GeneralPractitionersdelegatedself-management support to nurses and in their turn, nurses delegate responsibility to patients. In both cases, this was not necessarilyanempoweringprocessbasedinapartnership andshareddecision-makingapproach–littlewasshared withpatientsandworkoutsidethetestingofbiomedical markersofdiseasewasnotconsideredacentralelementof consultations. Nurses viewed General Practitioners as ignorantoftheworktheydid.

‘Theytendtoleaveustoourowndevices, Iknowit sounds awful,but,toourowndevices,because,they don’treallyknowwhatwedo,intheclinics.’(NurseM P19)

Thegenerallackofinterestinnurses’workwithinthe practice was given as justification for why the WISE approachwasnottakenuporengagedwithbynurses.

‘It’salrightbeingapilotandstuff,butyou’vegottowant todoitandifthey’renot...Whyshouldonepersondo itontheirown.’(NurseEP12)

Thefewnurseswhodidmakeuseofthetoolstochange theirpracticefoundWISEprovidedastructuredapproach toself-helpandbroughtamorepatient-centredfocusto consultationspreviously‘drivenbytargetsandguidelines’. Patientswerefelttoneedtimetounderstandwhatthey hadtodoandtheworkofself-managementsupportcould bedoneinagradualandsharedway.

‘Itsortofhaschangedmypracticequitealot,butwhatI mean,Ithink,isIdidn’tnecessarilysaytothepatient, whatdoyouwanttotalkabouttoday?Whereasmaybe Idonow,becausethey’vegoneawaywiththebooklet and they’ve come back with ... they’ve highlighted whatitisthat’sreallyworthtalkingabout.’(NurseBP22)

Proposition3. Autonomousworkingpracticesprovidespace for optimal self-management support discussions between nursesandpatients.

Somenursesrecognisedthatalthoughtheyhadcertain coretaskstoperform,theydidhaveautonomyinplanning their work. A fewnursesbuilt inelements of theWISE approachandwereenabledtodothisbybeingseentobe efficientmanagersofQualityandOutcomes Framework-relatedwork.Therecognitionandrespecttheygarneredas a result meantthey wereleftwith autonomytocreate spaceforworkinginotherspheres:

‘I’vedonethisjobfor21yearsnow,I’vebeenherealong time,sowedohaveaverygoodunderstandingofeach other’srolesandIcertainlyknowwheremylimitsare and I don’t overstep that. But within my sphere of expertise I do all the respiratory care, I do all the diabetescare,thechronichealthdiseasestuff,...I’m reallylefttoitbecausemy,it’sobviouswhatI’mdoing, it’sinthere,it’sallauditable,it’seasytosee.So you knowand theQualityandOutcomesFramework has beengoodforthat’(NurseBP22)

Thisnursewentontotalkabouthowshehadbeenable tousethePRISMStoolinherconsultationsandhowithad

helped to open up the conversation and focus on the priorities of patients rather than the priorities of the practice.

‘Basicallywhatitdoes,itenablesmetotalkaboutthe things that are worrying them, and things like, for example, sexualhealth. Unlessyou ask thequestion they are never, ever, ever going to bring it up in a consultation in amillion years.So havingsomething likethatdoeshelpfocusonthewholeshebang,really. ButIthinkitjustenablesthepatienttofeelthatthey’re bringingsomething,it’snotjustaboutmeyappy,yacky, yappingonatthem,it’saboutthemsharingmoreand having,[whispering](becauseIdotalkalotattimes)... youknowit’sallowingthemtohavealittlebitoftime to...formetoshutup.’(NurseBP22)

Forothers,havingautonomyallowednursestoidentify withactinginapatient-centredmannerthrough establish-ingrelationshipswithpatients.Relationality,ideologically, is seenasa centralpartof theirwork(Blakemanetal., 2006;Macdonaldetal.,2008).However,inpracticemost nurseswerenotabletousetheirexistingstyleofrelating toengagepatientsinin-depthconversationsandagendas about support or lifestyle behaviour change. This was becausetheygavemoresuperficialandbriefrelationality workpriority overthemore negativeandhard workof challenging‘problem’behaviours.

‘Yeah.Itjustdepends,because,alotofthetime,youcan getthemchattingwhenyou’redoingotherthings,as well.’(NurseMP19)

3.2. Oldhabitsdiehard

Proposition4. Self-managementsupportisnotperceivedas differentenoughtowarrantthefurtherinvestmentoftime andeffort.

Intermsofmakingsenseofthenewinnovationthere appearedtobelittledifferentiationmadebetween self-managementsupportandtheWISEapproachfromnormal practice.Self-managementsupportworkwasviewedin termsofbeingpatient-centred;addressinglifestyleand behavioursandeffectingchange;andhavingtimetolisten –allofwhichwereconsideredtobe‘normalpractice’.This senseoftherebeingnothingnewtranslatedintotheview thattherewasnoneedforchange.Indeedtothefollowing respondent, the time constraints of practice meant that thought of adopting new ways of managing was ridiculous:

‘Iknowitsoundsawful,itwas,like,itwasteachingusto suckeggs!... Because,we’ve allbeencliniciansfor a longtime,Iknowitgivesyouanotherwayoflookingat things,but,it’s,like,wealreadyknowwhatthepatients are going through, we’ve all been experienced clin-icians,it’snot,like,we’renewtothepostandthefact that,it’s,like,wehavea limitedamountoftime,ina consultation,we’venotgotanhour,perpatient,Iwish wedid,...wehavetenminutesand youtryandget everything done in them ten minutes and, then, somebodyiscomingalongandtellingyou,oh,thisis

whatyoushouldbedoingandthisisthisandthisand this and it’s,like, and where arewe supposed tofit everythingin,intenminutes.’(NurseMP19)

Proposition5. Thelackoffeasibilityandsuccessofchanging behaviourisademotivatorofpraxis.

Changing people’s behaviour is seen as difficult or impossible.Inthisrespectthisviewpointissupportedby theliteratureonbehaviouralchange.Therewaslittleorno talkabouthowhealthprofessionalscouldchangepeople’s behaviourineverydaypractice.Givingpatients informa-tionand instructionswasseen aseasy androutine,but examplesofhowtomotivateandengagepeoplewithnew practicesandbehavioursweremissingfromthenarratives of respondents. PRISMS was supposed to assist this process,butthefewnurseswhoreportedusing PRISMS did not get much further than using it to open the consultation to patient needs and had well-formulated views bornout ofprevious experience of workingwith patients shown in themetaphors usedto describe non behaviourchange:

‘Wecanpoint...takeahorsetowaterbutIcan’tmake himdrink.Icangivethemallthesethings,butIcan’t makethemaccessthem.ButIcandomybestand... that’sall.’(NurseEP12)

Nursessuggestedthattheirpatientswerenotsuitable candidates for a self-management approach, their lives weretoochaotic ortheyhad toomanyotherproblems. Theyfoundithardtoengagepatientswithlifestylechange andapatient-centredapproachwasthoughttobeatodds with providing self-management support where the shiftingof responsibility is a longer-term aim. Thishas theeffectthat self-managementsupportworkis puton holdforanothertimeorindefinitely.

‘Ithinkchronicobstructivepulmonarydisease,Imean, the main lifestyle is you have to address there is obviouslysmokingandIwillgostraightinandsaydo yousmoke,haveyouthoughtaboutstopping...Ifthey don’twanttoaddressit,ifthey’renotinterestedthenI just leave it because it’s pointless trying to force somebodytodosomethingthatthey’renotpreparedto do.AndI’lljustleaveitopen.’(NurseDP12)

3.3. Thetroublewithpaper

Proposition6. It’seasytodismissorunder-acknowledgethe needsofpatients.

The PRISMS tool was easy to dismiss for several reasons: lack of time; it could open up too many complexities in structured time-limited consultations; practicesystems werenot geareduptosupportit;and costtothepractice:

‘Thehappy,smileyface-ything.Wedidn’tuseit.We primarily,I’llbehonestandsayIdidn’tuseitbecauseI didn’thavethetimebecausethere’sonlymeandIonly workpart-time.AndIthink itwasanothertool,you knowwhatImean?AndI’dlovetobeabletosithere and have half an hour consultation about patient’s

prioritiesandI’mgoingtosaythatIdobutinamore roundaboutway,andyouknow.ButIdidn’thavethe timereallytobefair.’(NurseNP28)

‘Iamdoingit,butnotquiteinthesameformasthey thought.I’mnotdoingthePRISMSbecausenobodyhas giventheformsout.Youseewedon’tsendlettersout forappointmentsbecauseit’stooexpensive.Ifwecould sendletterswecouldsendthePRISMformsandthey couldbringitinwhentheycomeforanappointment.’ (NurseEP12)

Some nurses were more reflexive and thefollowing quote illustrates how PRISMS could be dismissed as somethingthatwasnotpossibletofitintotheconstraints ofdailypracticeandhowshewentontorationaliseitsuse. ‘They’rethinking,they’reweighingeverythingin,‘I’ve got Quality and Outcomes Framework, I’ve got this comingout,I’vegotameetinghere,I’vegotda-da-da, I’vegotall...’Andyoucandothis,it’shumannature,it’s natural,youthink,‘ohno,notanotherthingcomingat us!’...Yeah,it’sareactionalthing.Butifyou...really, you know it is beneficial, it’s a couple of minutes difference.Soit’showyouseeit...’(NurseSP5) Proposition7. Self-managementsupportresourcesneedto bereadilyaccessibleandtrustworthy.

Nurseswork withina structuredprimary care team, however,theirday-to-dayworkcanbedistantfromother practicestaff.Thusintermsoftoolsandtechnologies,they willusewhatisreadilytohand,anddrawonresourcesthat theytrust.

The guidebooks were seen as a positive benefit to patients,anice‘gift’fornursestohandoutandsuperiorto computerprintouts.Solongasthesupplieswereonthe officeshelf,theywereeasytoworkwith.

‘SayIhaveanewdiabeticthat’sthe...usuallythetime thatIwouldintroducethebookletbecauseIfindthe informationisveryeasytounderstand.Soandtheycan takeawaythatisaformit’snotjustanA4pieceofpaper becausewetendtouseanawfullotofthepatient.co.uk stuffwhichisexcellent,butit’sonlyascrapofpaper, isn’tit.WhereasthebookletIthink[whispering]you know,andtheygoawaywithanicelittlebookletand it’snice,but it’s alsovery pertinent information, it’s easytoread,ithaspicturesthatarecolouredin,andI thinkthathelpstheeye,andallofthat.’(NurseBP22) Forsome,theiruseofresourceswasdeterminedbythe trust they had in the organisation which produced the information,ratherthananyengagementwiththecontent. ‘ImeantheBritishLungFoundationisawell-recognised organisation, so they’re theones that I tend to use. Therearealsosomeotherbookletswhich,tobehonest withyou, I don’t remember where they’refrom but they’re...theywillbefromarecognisedorganisation.’ (NurseDP12)

FormssuchasPRISMSweremoretroublesometodeal withbecause more thought was neededinto how and whentheyareutilisedintheconsultationsandintegrated

intopracticesystems.Thelogisticsofdistributingformsto patientswasviewedasproblematic.Anumberofoptions wereconsideredincludingsendingthemoutwithpatient reminders to attend review appointments, however, practices either lacked theimpetus toconsider change, orimmediatelydismissedthepossibilityofengaginginthe work necessary to coordinate the adjustments to staff routines.

‘I’vegottobe100percentandtellyouthetruth,Idon’t knowouttherebecauseI’minhere[intheconsulting room]fromeighto’clockinthemorning‘tilhalffour.I don’treallygoouttobehonest.SoI’vegotmehandon heartandsayIdon’treallyknow.’(NurseGP2) One practice did embrace WISE and were able to integrate the forms into their systems; however, most practices didnotattempttofindwaystomake PRISMS easilyaccessibleforstaff.

‘Yes, we have them out in Reception for them to complete.WelltheReceptionstaffknowwho’sdiabetic or who’s chronic obstructive pulmonary disease or whatever,the long-standingcondition,and theywill givethemtheformatReceptionwhentheycomein,if they can please fill this form in before you see the nurse.’(NurseFP3)

4. Discussion

Theaimofthisstudywastoevaluatethe implementa-tion and embedding of a self-management support approach in primary care. The WISE approach failedto benormalisedinroutinecare,apartfromhandingoutthe guidebooks. WISE was intended to encourage reassess-mentofworkpracticeswhilstintroducingnewelements thatfittedwithexistingworkandimprovedpatientcare. Thelong-termconditionmanagementworkdelegatedto nurses was the routinised biomedical processes of monitoring and recording necessary for Quality and OutcomesFramework.Practicenursesviewedthemselves as being patient-centred and holistic, yet respondents reported use of didactic and non-tailored information-giving and generally, they did not incorporate psycho-social and behaviourchangesupport;all indicatorsthat patient-centred practicewasnot happening.Nurses had concerns about the burden of providing enhanced self-management supportboth interms oftheir own work-loads,and inwhattheyfelttheirpatients could accom-modate;provisionoftheguidebookswastheoneelement that could be considered minimally disruptive work, fulfilling their needto providegood information whilst enhancingtheirabilitytobepatient-centred(Mayetal., 2009).

Thechallengesofchangingprofessionalbehaviourand attitudesinordertoimplementself-managementsupport arewidelyreported(Blakemanetal.,2006;Harrisetal., 2008;Hibbardetal.,2010;Macdonaldetal.,2008;Walters etal.,2012).TheWISEapproachaimedtopragmatically address existing evidence and recommendations and providedtoolsandtraininginskillstoassist self-manage-mentsupportinthecontextofanorganisationgearedup

toprovideappropriateresources(Kennedyet al.,2007). Using Normalisation Process Theory was of value as it madeusfocusontheeverydayworkofnursestofindan explanationastowhyWISEdidnotembed: self-manage-mentsupportwasnotapracticepriorityasitwasnotpart ofQualityandOutcomesFramework;itwasnotseenas differentenoughtoexistingworktovalueyetconsidered toodisruptiveandtime-consuming;andtherewaslackof communicationorsupportwithinthepractice.

The collective action Normalisation Process Theory construct helpedprovide mostinsight into theworkof nursesandhowit fittedwithinpracticeproceduresand priorities for patient care. The three themes which emerged(‘‘Whopaysthepipercallsthetune’’,‘‘Oldhabits diehard’’ and ‘‘Thetrouble withpaper’’)and theseven resulting propositions reflect the nature of this work. Nurses’workisconstrainedbythefinancialrequirements ofthepractice;moneygainedfromreachingQualityand Outcomes Framework pay-for-performance targets dic-tateshownursesarerequiredtoworkanditisonlywhen nursesfeeltheyhavegainedenoughtrustandexperience tohaveautonomyintheirpracticethattheyareableto build in self-management support. On top of this, past experienceandthebelief(cognitiveparticipation)thatitis futile and time-consuming to take on theworkof self-management support with patients, meant the PRISMS toolinparticularwasnotused.PRISMSwasapaperbased toolandthecollectiveactionrequiredofstafftogetitto patientswasnotworthwhile,especiallyasanydatafrom the form was not being collected or appraised in any formal way (reflexive monitoring); the sustainability of handing out forms is feasible only if there is continual reflection andreappraisalofthebenefitofPRISMSatall levelsofthepractice.Theguidebook,however,didfitwith hownursesconsideredself-managementsupportshould bedelivered(coherenceandcognitiveparticipation).

Other researchers have used Normalisation Process Theoryas a frameworktostudytheembedding ofnew innovations. Elwyn et al. (2008) conducted a ‘thought experiment’usingNormalisationProcessTheoryto iden-tify factorspromotingand inhibitingimplementation of shared decision-making support technologies in health-care, the insights they gained were that negotiations surroundingthe introductionof newtechnologies were influencedandcharacterisedbyasymmetriesofpowerand knowledge.Ourfindingsaddempiricallytothiswiththe addedinsightthatthepartnershipworkingaspectof self-managementsupportisfarremovedandtoodisruptiveto nurse/patientrelationshipstoinitiate.Ehrlichetal.(2013) usedNormalisationProcessTheorytoassistunderstanding oftheimplementationofnurse-providedchroniccare co-ordination in primarycare in Australia. Theyfoundthe majorchallengewastheorganisationalcontextandshared understandings and claimed that nurses needed to be autonomouspractitionersaswellasteamplayerstoallow thenewroletobecomeembedded.Autonomouspractice wastheoneenablerofself-managementsupportwefound butisdifficulttomaintaingiventhecompetingpriorities within primary care; it is easierto accedeto the task-relatedQualityandOutcomesFrameworkactivities–togo with the status quo and not to challenge pre-existing

notionsofwhatpatientsarecapableofwhenitcomesto engagementwithself-managementsupport.Aswiththe findings of Murray et al. (2011) Normalisation Process Theory is useful in explaining observed variations in implementationprocessesratherthansimplyfocusingon notionsofbarriersandfacilitators.

Inshowingreluctancetoengageinbehaviouralchange discussionswithpatients,nursesdemonstratedan aware-ness that for patients, self-care involves a complex, embodied, practical knowledge that clashes with the abstract,rationalisedmodelsassumedbothinbiomedical approaches tolong-term condition management and in programmesliketheExpertPatientsProgramme( Depart-mentofHealth,2001).Weknowthatpatientsdemonstrate the enacting of self-care as not something acquired externally but something you useexisting resourcesto do, and in a biographical domestic as well as clinical context.Whilstnursesdidnotarticulateanunderstanding ofthepracticeofembodiedself-care(PickardandRogers, 2012),wesuggestgroundingself-managementinto every-day life may have been key to providing effective professionalsupportand discussionswhich would have challengedthepre-existingfocusonQualityandOutcomes Frameworkworkandthemorebiomedicalregimesofthe practicestowhichthetoolsofself-managementsupport werebeingadded.Dressingupmorecomplexprocessesas toolsinthehopethattheywillbeadoptedandnormalised in everyday practice proved erroneous. The claim by nursestointegratepatients’livedexperienceandpriorities intoclinicalencountersisnotnew,butforthemostpart thisistreatedasanadditionorassomethingtofitintothe tasksofmonitoringandtestinginawaywhichrepresents only marginal movement towards patient needs and knowledgeconcerningself-managementsupport. Inthis respectnurseswerenotabletodeploythebasesofWISE which included recognition of knowledge as practical activity and interventions that fitted with patients’ agendas,needsorexperienceofmanagingaconditionin theirdailylives.Rather,theycouldnotadoptandembeda new system at odds with their protocol-based system whichisbiomedicalandreductionist,butwhichensures thefinancialincomeofthepracticeswhichemploythem. Limitations of the study included our inability to observenursepatientconsultationspost-trainingbecause practices refused access (though we were able to gain somevalidationofthenatureofroutineworkandfitwith accountsofpracticefromaudiotapesofconsultationswith patientsundertakenaspartofthepilotworkpriortothe trial).Thereluctancetoallowaccessinitselfmayindicate thelackofengagementwithprovisionofself-management support in practices. Observations might have clarified where and how opportunities to providesupport were takenupormissed.NormalisationProcessTheory high-lightedthenearuniversallackofinterestinthinkingabout andbuildingself-managementsupportintopractice,but considerationofthepatientperspectiveon implementa-tionismissing–asinmostotherimplementationtheories. Therareoccasionswhereaspectsofself-management supportwerereportedtobeincorporatedwerebynurses experiencedandconfidentenoughtodisruptthe prevail-ingsystem,andpreparedtoovercometheunauditedand

thereforehiddennatureofself-managementsupport,and thelackofrecognitionoftheworkentailedinprovidingit. In other words those individuals were willing to try different approaches, were professionally confident enough for independence/autonomy and thus able to reflectonthebenefitstheysawfortheirpatients.Evenso, theywerenotabletoreportmovingbeyondopeningup theconsultation to addresspatient priorities – lifestyle changeisnotreadilydoableinprimarycareandfallsmore withintheday-to-dayworldofthepatient(Rogersetal., 2011). In terms of policy, a culture of collaborative partnershipsbetweenpatientsandpractitionersisstilla longwayaway.

Acknowledgements

MembersofthewiderWISEteamnotincludedabove: PeterBower, Martin Eden, Catherine Fullwood, Hannah Gaffney,DavidReeves,GerryRichardson,CarolineSanders, AngelaSwallowandtheSalfordNIHRGIprogrammeGrant ResearchGroup:KarenArmstrong,DavidBackhouse,Paula Beech, Peter Bower, Carolyn Chew-Graham, Andrew Clough/Karen Proctor (Chair), Anne Kennedy, Karina Lovell, Jim Nuttall, Sarah O’Brien, David Reeves, Gerry Richardson, Anne Rogers, David Thompson, and Peter Whorwell.

We would like to thank and acknowledge the con-tributionofparticipatingpracticesandstaff.

Conflictofinterest:Nonedeclared.

Funding:Thestudyhasbeenfunded by theNational Institutefor Health Research and The National Primary Care Research and Development Centre (funded by the DepartmentofHealth).Thispaperpresentsindependent research commissioned by the National Institute for HealthResearch(NIHR)underitsProgrammeGrantsfor Applied Research funding scheme (RP-PG-0407-10136). Membersoftheresearchteam werealsofunded bythe NationalInstituteforHealth Research(NIHR) Collabora-tionforLeadership inAppliedHealthResearchandCare (CLAHRC)forGreaterManchester.Theviewsexpressedin this paperare those of theauthorsand not necessarily thoseoftheNHS,NIHRortheDepartmentofHealth.

Ethicalapproval:ThestudywasapprovedbytheSalford &TraffordLocalResearchEthicsCommittee.RECreference number09/H1004/6.

References

Bamford,C.,Heaven,B.,May, C.,Moynihan, P., 2012. Implementing nutritionguidelinesforolderpeopleinresidentialcarehomes:a qualitativestudyusingNormalizationProcessTheory. Implementa-tionScience7.

Blakeman,T.,Macdonald,W.,Bower,P.,Gately,C.,Chew-Graham,C., 2006.AqualitativestudyofGPs’attitudestoself-managementof chronicdisease.BritishJournalofGeneralPractice56(257)407–414.

Bodenheimar, T., MacGregor, K., Shafiri, C.,2005. Helping Patients ManageTheirChronicConditions.CaliforniaHealthcare Founda-tion,California.

Bower,P.,Kennedy,A.,Reeves,D.,Rogers,A.,Blakeman,T.,Chew-Graham, C.,Bowen,R.,Eden,M.,Hann,M.,Lee,V.,Morris,R.,Protheroe,J., Richardson,G.,Sanders,C.,Swallow,A.,Thompson,D.,2012.Acluster randomisedcontrolledtrialoftheclinicalandcost-effectivenessofa ‘wholesystems’modelofself-managementsupportforthe manage-mentoflong-termconditionsinprimarycare:trialprotocol. Imple-mentationScience7,7.

Bradley,E.H.,Curry,L.A.,Devers,K.J.,2007.Qualitativedataanalysisfor healthservicesresearch:developingtaxonomy,themes,andtheory. HealthServicesResearch42(4) 1758–1772.

Charles-Jones,H.,Latimer,J.,May,C.,2003.Transforminggeneral prac-tice:theredistributionofmedicalworkinprimarycare.Sociologyof Health&Illness25(1) 71–92.

Dennis,S.M.,Zwar,N.,Griffiths,R.,Roland,M.,Hasan,I.,Davies,G.P., Harris,M.,2008.Chronicdiseasemanagementinprimarycare:from evidencetopolicy.MedicalJournalofAustralia188(8) S53–S56.

DepartmentofHealth,2001.TheExpertPatient:ANewApproachto ChronicDiseaseManagementinthe21stCentury.TheStationery Office.

DepartmentofHealth,2004.TheNHSImprovementPlan–PuttingPeople attheHeartofPublicServices.TheStationeryOffice,London.

DepartmentofHealth,2005.SelfCare:ARealChoice–SelfCareSupport: APracticalOption.GatewayReference4401..

Doran, T., Kontopantelis, E.,Valderas, J.M., Campbell,S.,Roland, M., Salisbury,C.,Reeves,D.,2011.Effectoffinancialincentiveson incen-tivisedandnon-incentivisedclinicalactivities:longitudinalanalysis of data from the UKQualityand Outcomes Framework. British MedicalJournal342.

Ehrlich,C.,Kendall,E.,St.John,W.,2013.Howdoescarecoordination providedbyregisterednurses‘‘fit’’withintheorganisational pro-cessesandprofessionalrelationshipsinthegeneralpracticecontext? Collegian20(3) 127–135.

Elwyn,G.,Legare,F.,vanderWeijden,T.,Edwards,A.,May,C.,2008. Arduousimplementation: does the NormalisationProcess Model explainwhyit’ssodifficulttoembeddecisionsupporttechnologies forpatientsinroutineclinicalpractice.ImplementationScience3(57)

,http://dx.doi.org/10.1186/1748-5908-3-57.

Grant,A.,Treweek,S.,Dreischulte,T.,Foy,R.,Guthrie,B.,2013.Process evaluationsforcluster-randomisedtrialsofcomplexinterventions:a proposedframeworkfordesignandreporting.Trials14.

Gray,C.,Hunt,K.,Lorimer,K.,Anderson,A.,Benzeval,M.,Wyke,S.,2011.

Wordsmatter:aqualitativeinvestigationofwhichweightstatus termsareacceptableandmotivateweightlosswhenusedbyhealth professionals.BMCPublicHealth11(1) 513.

Greenhalgh,T.,Robert,G.,Macfarlane,F.,Bate,P.,Kyriakidou,O.,2004.

Diffusionofinnovationsinserviceorganizations:systematicreview andrecommendations.MilbankQuarterly82(4) 581–629.

Harris,M.F.,Williams,A.M.,Dennis,S.M.,Zwar,N.A.,Davies,G.P.,2008.

Chronicdiseaseself-management:implementationwithandwithin Australiangeneralpractice.MedicalJournalofAustralia189(10) S17–S20.

Hibbard,J.H.,Collins,P.A.,Mahoney,E.,Baker,L.H.,2010.The develop-ment and testing ofa measure assessingclinicianbeliefs about patientself-management.HealthExpectations13(1) 65–72.

Kennedy,A.,Bower,P.,Reeves,D.,Blakeman,T.,Bowen,R.,Chew-Graham, C.,Eden,M.,Fullwood,C.,Gaffney,H.,Gardner,C.,Lee,V.,Morris,R., Protheroe,J.,Richardson,G.,Sanders,C.,Swallow,A.,Thompson,D., Rogers,A.,2013.Implementationofselfmanagementsupportfor longtermconditionsinroutineprimarycaresettings:cluster rando-misedcontrolledtrial.BritishMedicalJournal346.

Kennedy,A.,Robinson,A.,Rogers,A.,2003.Incorporatingpatients’views andexperiencesoflifewithIBSinthedevelopmentofanevidence basedself-helpguidebook.PatientEducationandCounseling50(3) 303–310.

Kennedy,A.P.,Rogers,A.,2002.Improvingpatientinvolvementinchronic diseasemanagement:theviewsofpatients,GPsandspecialistsona guidebookforulcerativecolitis.PatientEducationandCounseling47 (3) 257–263.

Kennedy, A.,Chew-Graham,C.,Blakeman,T., Bowen,A., Gardner,C., Protheroe,J.,Rogers,A.,Gask,L.,2010.DeliveringtheWISE(Whole SystemsInformingSelf-managementEngagement)trainingpackage inprimarycare:learningfromformativeevaluation.Implementation Science5(1) 7.

Kennedy,A.,Rogers,A.,Bower,P.,2007.Supportforselfcareforpatients withchronicdisease.BritishMedicalJournal335(7627) 968–970.

Lee,V.,Kennedy,A.,Rogers,A.,2006.Implementingandmanagingself management skills trainingwithin primarycareorganisations: a nationalsurveyoftheexpertpatientsprogrammewithinitspilot phase.ImplementationScience1,1–6.

Macdonald,W.,Rogers,A.,Blakeman,T.,Bower,P.,2008.Practicenurses andthefacilitationofself-managementinprimarycare.Journalof AdvancedNursing62(2) 191–199.

MacFarlane,A.,O’Reilly-deBrun,M.,2012.Usingatheory-driven con-ceptualframeworkinqualitativehealthresearch.QualitativeHealth Research22(5) 607–618.

May,C.,Finch,T.,2009.Implementation,embedding,andintegration:an outlineofNormalizationProcessTheory.Sociology43(3) 535–554.

May,C.,Montori,V.M.,Mair,F.S.,2009.Weneedminimallydisruptive medicine.BritishMedicalJournal339.

May,C.R.,Finch,T.,Ballini,L.,MacFarlane,A.,Mair,F.,Murray,E.,Treweek, S.,Rapley,T.,2011. Evaluatingcomplex interventionsandhealth technologiesusingnormalizationprocesstheory:developmentofa simplifiedapproachandweb-enabledtoolkit.BMCHealthServices Research11.

McDonald,R.,Roland,M.,2009.Payforperformanceinprimarycarein Englandand California:comparisonofunintendedconsequences. AnnalsofFamilyMedicine7(2) 121–127.

Murray,E.,Burns,J.,May,C.,Finch,T.,O’Donnell,C.,Wallace,P.,Mair,F., 2011.Whyisitdifficulttoimplemente-healthinitiatives?A quali-tativestudy. ImplementationScience6(1) 6.

Murray,E.,Treweek,S.,Pope,C.,MacFarlane,A.,Ballini,L.,Dowrick,C., Finch,T.,Kennedy,A.,Mair,F.,O’Donnell,C.,Ong,B.N.,Rapley,T., Rogers,A.,May,C.,2010.Normalisationprocesstheory:aframework fordeveloping,evaluatingandimplementingcomplexinterventions. BMCMedicine8(1) 63.

Pickard,S.,Rogers,A.,2012.Knowingaspractice:self-careinthecase of chronic multi-morbidities. SocialTheory and Health 10 (2) 101–120.

Protheroe,J.,Blakeman,T.,Bower,P.,Chew-Graham,C.,Kennedy,A.,2010.

Aninterventiontopromotepatientparticipationandself-management

inlongtermconditions:developmentandfeasibilitytesting.BMC HealthServicesResearch10(1) 206.

Ritchie,J.,Spencer,L.,1994.Qualitativedataanalysisforappliedpolicy research.In:Bryman,A.,Burgess,R.G.(Eds.),AnalyzingQualitative Data.1sted.RoutledgePress,London, pp.173–194.

Rogers,A., 2009.Advancing theexpertpatient. PrimaryHealthCare ResearchandDevelopment10(3) 167–176.

Rogers,A.,Vassilev,I.,Sanders,C.,Kirk,S.,Chew-Graham,C.,Kennedy,A., Protheroe,J.,Bower,P.,Blickem,C.,Reeves,D.,Kapadia,D.,Brooks,H., Fullwood,C.,Richardson,G.,2011.Socialnetworks,workand net-work-basedresourcesforthemanagementoflong-termconditions:a frameworkand study protocol for developing self-care support. ImplementationScience6.

Truglio,J.,Graziano,M.,Vedanthan,R.,Hahn,S.,Rios,C.,Hendel-Paterson, B.,Ripp,J.,2012.Globalhealthandprimarycare:increasingburdenof chronicdiseasesandneedforintegratedtraining.MountSinaiJournal ofMedicine79(4) 464–474.

Walters,J.A.E.,Courtney-Pratt,H.,Cameron-Tucker,H.,Nelson,M., Robin-son, A.,Scott, J.,Turner,P., Walters, E.H.,Wood-Baker,R.,2012.

Engaginggeneralpracticenursesinchronicdiseaseself-management supportin Australia:insights from a controlled trial inchronic obstructivepulmonarydisease.AustralianJournalofPrimaryHealth 18(1) 74–79.