Alternative Research Design

 Alternative Research Design


Implementing an interprofessional model of self-management support across a community workforce: A mixed-methods evaluation study Stefan Tino Kulnik a,b, Heide Pöstgesa,b, Lucinda Brimicombea,b, John Hammonda, and Fiona Jonesa,b

aFaculty of Health, Social Care and Education, Kingston University and St. George’s, University of London, London, UK; bBridges Self-Management Limited, London, UK

ABSTRACT The importance of implementing self-management support (SMS) is now widely accepted, but questions remain as to how. In 2015, we facilitated the implementation of an interprofessional model of SMS (Bridges Self-Management) for people with complex multiple long-term conditions through community rehabilitation and social care services in one Southeast England locality. Over 90 professionals and support workers from this workforce received interprofessional training to integrate SMS into their care and rehabilitation interactions. This gave an opportunity to explore how SMS can be implemented in practice. We conducted a mixed-methods study with unequal weighting (qualitative emphasis), con- current timing, and embedded design. Staff provided written feedback and case reflections, participated in group discussions, and completed a survey of self-management beliefs and attitudes. We recruited a convenience sample of 10 service users and conducted qualitative interviews and standardised ques- tionnaires. Findings showed that staff appreciated and benefited from the interprofessional learning environment. Staff reported changes in their interactions with service users and colleagues and had gained knowledge and confidence to support individuals to self-manage. Data also highlighted the need to facilitate SMS practice at the level of service organisation. Service user data illustrated the impact of interactions with staff, and how SMS had increased service users’ confidence and encouraged different skills to manage life with their conditions. This project has shown how multi-agency commu- nity teams can benefit from interprofessional training to enhance SMS for people living with long-term conditions, build a shared understanding of SMS, and integrate effective SMS strategies into everyday practices.

ARTICLE HISTORY Received 23 January 2016 Revised 19 August 2016 Accepted 5 October 2016

KEYWORDS Community rehabilitation; interprofessional education; long-term conditions; mixed-methods; self- management support; social care


Self-management support (SMS) is now considered a neces- sary component of health and social care provision, in order to adapt systems to increasing numbers of people who are living with one or more long-term conditions (Eaton, Roberts, & Turner, 2015). The concept of SMS is based on the under- standing that a person living with a long-term condition is at the centre of managing life with the condition, not healthcare services (Boger et al., 2015; Demain et al., 2015; Lorig & Holman, 2003). The principles of SMS focus on the ways in which individuals can work in partnership with health and social care professionals, predicting potential challenges and managing their health. This runs contrary to a traditional focus on episodic service provision in response to acute illness or crisis. Interventions to promote SMS can deliver promising clinical outcomes and more appropriate health and social care use (Coulter et al., 2015; de Silva, 2011; Hibbard & Greene, 2013). While the case for SMS has been made, questions remain as to the best ways of implementing effective SMS on a large scale.

In 2015, we facilitated the implementation of an interprofes- sional model of SMS (Bridges Self-Management) for people with different long-term conditions who are clients of community

rehabilitation and social care services in one locality in the South East of England. The organisation of these services broadly reflects current service provision in the United Kingdom (Allen & Glasby, 2009). Briefly, this workforce includes teams that provide rehabi- litation and social support to individuals with predominantly physical health concerns, in order to enable integration and parti- cipation in the local community. The workforce typically com- prises health professionals (nurses, occupational therapists, speech and language therapists, physiotherapists, and social workers) and support workers. The nature of the work consists of individual one-to-one support in the community and background case work. This workforce shares a client base of people with varying long- term conditions who may present with different individual impairments and activity limitations. For example, individuals may be referred for temporary community support after discharge from hospital; or for re-evaluation of community support systems and a period of community rehabilitation following deterioration in their long-term conditions.

For this project, we drew on two main perspectives. Firstly, we took an interprofessional approach to workforce education and practice, which has constituted a strong influence in the development and implementation of Bridges Self-Management since inception. Interprofessional education (IPE) is defined as

CONTACT Stefan Tino Kulnik Faculty of Health, Social Care and Education, Kingston University and St. George’s, University of London, Cranmer Terrace, London, SW17 0RE, UK.


© 2017 Taylor & Francis



an intervention whereby two or more professions learn from and about each other to improve collaboration and the quality of care (Oandasan & Reeves, 2005a). This approach suited the diverse workforce and the complexities of delivering SMS in this project. IPE has been found to improve professional competence, colla- boration, and patient-centred outcomes in pre- and post-licen- sure training of healthcare teams in various areas of practice (Hallin, Henriksson, Dalen, & Kiessling, 2011; Reeves et al., 2016; Reeves, Perrier, Goldman, Freeth, & Zwarenstein, 2013). However, there is currently little evidence relating to IPE in the field of self-management. While the objective of the present project was to impart knowledge and skills of SMS, this was framed and operationalised in training according to principles of IPE. In concrete terms, there was a focus on learning about and understanding others’ roles, and on communication across roles and team boundaries (Suter et al., 2009). We aimed to create a non-threatening learning environment which encouraged infor- mation exchange and discussion of individuals’ own role, per- ceptions of others’ role, and personal and professional biases and interests, to create shared meaning and a common purpose (Oandasan & Reeves, 2005a, 2005b). In addition, we placed emphasis on the need for critical reflection to be integrated into training. In IPE, reflection is used as a strategy to advance knowledge in the often confusing and ‘messy’ reality of real-life practice (Clark, 2009; Eaton, 2016). SMS training incorporated reflection by providing course attendees with a space and time for ‘reflection-on-action’ (Kinsella, 2010; Schön, 1992), includ- ing a written case reflection and group discussions.

We also drew on normalisation process theory (NPT) (Murray et al., 2010) to underpin the implementation and change manage- ment aspects of the project. Within the NPT framework, imple- mentation is defined as a cyclical, complex and emergent social process, in which participants collectively produce and embed new practices into their everyday work (May & Finch, 2009). NPT operationalises implementation in four mechanisms or compo- nents: coherence (meaning and sense making of the intervention by participants); cognitive participation (commitment and engage- ment by participants); collective action (the work participants do to

make the intervention function); and reflexive monitoring (parti- cipants reflect on or appraise the intervention; May & Finch, 2009). Figure 1 outlines where opportunities for NPT components were focussed along our project timeline.

Current health and social care policy in England directs that different organisations and professions are expected to align their approach to supporting self-management, but these groups often have very different starting points in their understandings and operationalisation of SMS, and experience different challenges to implementation (Mudge, Kayes, & McPherson, 2016; Norris & Kilbride, 2014; van Hooft, Dwarswaard, Jedeloo, Bal, & van Staa, 2015; Young et al., 2015). While these studies highlight the differ- ent professional perspectives, it is more challenging to evaluate how teams overcome these issues and work more effectively to support person-centred outcomes (Reeves et al., 2013). Therefore, an evaluation of SMS implementation can be useful and provides the rationale for incorporating an evaluation study in our project. Here, we report the findings from our evaluation study to describe howa workforcecancometogether,createasharedunderstanding and common purpose for SMS, and defineand deal with particular challenges in the local context. We use these data to illustrate the implementation process, discover participants’ views and reflec- tions, and interpret the observed trends and themes. The aim was to evaluate the project and provide insights into how SMS can be implemented in this community setting. The research question was: what are the processes, successes, and challenges of imple- menting SMS in this particular context?


Research design

We chose a mixed methods design, which is frequently used in the evaluation of health services research (O’Cathain, Murphy, & Nicholl, 2007). We considered that the research question would best be addressed through an emphasis on qualitative data from course attendees’ reflections according to an ‘epistemology of practice’ (Kinsella, 2010; Schön, 1992).


Month 1

Month 2

Month 3

Month 4

Month 5

Month 6

Month 7

Month 8

Month 9

Month 10

Month 11

Month 12










SMS training delivery



Contextualisation to local

services and client groups



Project steering

group meeting 1

Introduction of

project in team


Project steering

group meeting 2

Project steering

group meeting 3

Observation of


Service user focus group

Qualitative interviews with

service users

Production of bespoke self –

management booklet

Part 1

Part 2

Part 3

Data collection for evaluation study

Practitioner data Service user data



(SMS beliefs and


Written feedback

and case reflections

Group discussions

Written feedback



(SMS beliefs and


2 research visits

per participant,

8 weeks apart:





Figure 1. Overview of project timeline and structure. NPT, normalisation process theory; SMS, self-management support.




This allowed a focus on in-depth understanding of organisa- tional context (Robert & Fulop, 2014), the normalisation process (Murray et al., 2010) and reflection on practice (Clark, 2009). We used quantitative data to supplement the description of the study setting and participants through standardised instruments.

Accordingly, our study used an embedded mixed-methods design, i.e. one type of data provided a supportive, secondary role to the other data type (Creswell, 2014). The weighting was unequal with an emphasis on qualitative data. The timing was concurrent, i.e. qualitative and quantitative data were collected, analysed and interpreted at the same time. Mixing of qualitative and quantitative data was embedded at the design level (Fetters, Curry, & Creswell, 2013).


The setting was a community rehabilitation and social care workforce in one South East England locality. The group comprised four distinct services, which operated within dif- ferent organisational parameters but with overlapping and aligned service aims. Service details are given in Table 1.


Ninety-two members of staff attended training in SMS. This was a diverse group of social workers, enablement officers, physiotherapists, occupational therapists, speech and language therapists, therapy assistants, care workers, support workers, and voluntary sector workers. For the purpose of this article, we refer to this workforce as ‘practitioners’. A project steering group including service leads was set up, which provided managerial support and facilitated spread and adoption of the project. Depending on the service, training was either arranged as a scheduled activity for the entire team, or practi- tioners were invited to attend on the basis of interest.

After workforce training, we recruited a convenience sam- ple of 10 service users living with long-term conditions. Service users were eligible if they were newly referred, and if

the practitioner/s working with the person intended to imple- ment SMS strategies. Service users were excluded if they lacked decisional capacity to give informed consent to the study, or if they were unable to participate due to commu- nication difficulty. Recruitment took place during summer 2015. Eligible service users were invited to the study through the participating teams. Out of 13 service users who expressed interest, ten consented to take part.


The intervention was Bridges Self-Management, originally developed in stroke rehabilitation (Jones et al., 2016, 2012). Based on self-efficacy and behaviour change principles, this intervention supports practitioners to integrate SMS through their interactions with service users, team and organisation processes, and through utilisation of unique self-management tools for people with long-term conditions. It is a complex intervention, in which practitioners promote self-manage- ment principles, placing particular emphasis on the language used in conversation with clients. Practically, the implementa- tion of Bridges is supported by utilising co-production meth- ods (de Silva, 2011; Newbronner, Chamberlain, Borthwick, Baxter, & Sanderson, 2013).

Training sessions were held in interprofessional groups of up to 20 practitioners and incorporated interactive activities and group discussions, which challenged practitioners to reflect on knowledge held about self-management and how support was delivered both at an individual level and within and across teams. Practitioners were also encouraged to utilise experiences from their own caseload, successes and chal- lenges, to construct ways of integrating SMS. To mitigate potential issues of power, trainers adopted the role of facil- itators rather than ‘expert teachers’. Strategies were utilised to facilitate sharing individual and interprofessional perspectives, and to challenge assumptions and common practices in rela- tion to SMS. Training was structured in three parts, each delivered in a three-hour session. Parts one and two delivered theory and practical aspects of SMS, and part three provided

Table 1. Characteristics of participating services.

Type Aim Staffing structure Service provision Funding Service user groups

Community rehabilitation service

Rehabilitation therapy for people living in the community and unable to access outpatient services

Physiotherapists, occupational therapists, speech and language therapists, therapy assistants

Flexible, dependent on clinical need, with no restrictions on time period or number of visits; on average one initial visit and four follow-up visits

NHS Adults who require rehabilitation or therapy management

Enablement service Care support and rehabilitation therapy to people living in the community to achieve independence

Enablement officers, rehabilitation support workers, physiotherapists, occupational therapists

Time-limited, up to six weeks, with up to four daily visits

NHS and local authority

Adults who require support to achieve or re-gain independence, for example after a period of hospitalisation or illness

Adult social care service

Assessment of needs, support planning, safeguarding, advice and information, signposting

Social workers, occupational therapists, support planners

Variable service provision, mostly one single face-to-face meeting, followed by background casework

Local authority

Adults who qualify for social services input

Community development service

Prevention and early intervention to support vulnerable and isolated people living in the community

Development workers, support facilitators, volunteers

Flexible, individual meetings from short-term input up to three months of one-to-one support, including signposting, advocacy, case-work, practical support

Local authority and voluntary sector organisation

Vulnerable and isolated adults

NHS, National Health Service.




an opportunity for practitioners to give feedback, reflect, and share ideas after trialling SMS strategies in practice.

Data collection

The following methods were used to collect qualitative data from practitioners: feedback forms, which practitioners com- pleted during training sessions two and three; written case reflections, which practitioners prepared after trialling SMS in practice; and six group discussions held in training sessions three. Group discussions were moderated by two facilitators (HP and LB). Hand-written notes by one researcher were taken at discussion groups. Course attendees were first guided to discuss experiences of applying SMS in pairs, and then share with the whole group, while key learning points were noted on a flip chart by one of the facilitators. Service users participated in audio-recorded semi-structured in-depth interviews. These were conducted by FJ and SK in the second of two research visits and aimed at eliciting participants’ experiences and reflections on the SMS received through the participating service. The topic guide for group discussions and the service user interview schedule are given in Table 2. Qualitative data collection aimed at exploring how practi- tioners worked with each other and with service users to implement SMS into their practice, capturing successes but also documenting challenges and barriers and how practi- tioners dealt with these.

Quantitative data collection comprised a survey of SMS beliefs and attitudes (Jones & Bailey, 2013), which practitioners completed before and after training. Service users completed the following standardised interviewer-administered question- naires in the first of two research visits: EQ-5D-5L (van Reenen & Janssen, 2015), Nottingham Extended Activities of Daily

Living (NEADL) questionnaire (Nouri & Lincoln, 1987), General Self-Efficacy scale (GSE; Schwarzer & Jerusalem, 1995), and Client Socio-demographic and Service-Receipt Inventory (CSSRI; Chisholm et al., 2000). These instruments capture constructs that are relevant to the self-management intervention and describe participants in a standardised way, allowing comparison with groups of participants in other contexts.

Data analysis

All qualitative and quantitative data were anonymised. Practitioner data were analysed for the group as a whole (as opposed to analysis according to service or professional background). Qualitative data were transcribed using Microsoft Word 2013 software and analysed manually. Thematic analysis was selected as an appropriate approach in preliminary health service research (Green & Thorogood, 2013). Quantitative data were used to describe the participants (practitioners and service users) and processed using Microsoft Excel 2013 software.

Qualitative data analysis was conducted by SK in the first instance. SK read and re-read data sources and summarised prevalent themes, following a structured process of coding and constant comparison, and taking note of extreme or negative accounts. Coded passages that aligned with dominant themes were copied and pasted into another text document according to emerging themes. Key themes were then reviewed against the raw data by FJ, HP, and LB and finalised following discussion. Findings were presented to the members of the project steering group, whose feedback provided an additional layer of peer review. Rigour was further enhanced by maintaining an audit trail of data sources, data analysis steps and key analysis deci- sions; and through a reflexive approach of the study team

Table 2. Topic guide for practitioner group discussions and interview schedule for service user interviews.

Topic guide for practitioner group discussions

Topic Questions Feedback about your experiences of supporting self-management using Bridges principles

What do you remember from training parts 1 and 2? What—if anything—have you done differently since then? Did you get a chance to use the self-management tool [client-held booklet] with someone? What’s one example of a self-management challenge you came across? What did you do? What’s one example of a self-management success you had, however small? What happened?

Strength, weaknesses, opportunities, threats (SWOT) analysis of your practice or service

How are you currently supporting self-management? How could it be more effective? Strengths—What elements of your current practice/service are supporting self-management? Weaknesses—What elements of your current practice/service could be better at supporting self-management? Opportunities—What elements about your practice/service could you change? Threats—What elements about your practice/service could cause barriers to these changes?

Personal action plan What is the one thing you will do differently in your practice going forward?

Interview schedule for service user interviews

Opening question Prompts I would like to ask you about the [relevant service/team]. I understand that you were referred to them about eight weeks ago. Can you tell me a little about how that went?

Do you remember who you met from the [service] and what you did with them How did the sessions start—can you give me an example of what you would do first Generally who would decide what you did in your sessions and what you worked on Were you asked your views about what your priorities were What goals did you have What did you learn from working with the service How much do you feel the sessions followed a format set by the practitioner or by you How did you feel when the services stopped

Is there anything you remember particularly well about the [relevant service/team]?

Was there anything you thought was particularly good Was there anything that you wished had happened differently

Some people feel quite confident to continue to manage under their own steam once sessions stop—how did you feel?

Is there anything you continued to do after session stopped Did you achieve the things you were aiming for, or are you continuing to work towards them If you ran into a problem/difficult situation in the future, how would you deal with that




members (FJ, HP, LB, SK), who made transparent their parallel roles of training providers and project evaluators and reflected on potential influences in open discussions.

Ethical considerations

Ethical approval was obtained from the UK National Research Ethics Service (Committee South East Coast—Surrey, refer- ence 15/LO/0621). Organisational and managerial research approvals were obtained for each participating team. All ser- vice users gave written informed consent.


Participant overview

Fifty-five practitioners completed all three training sessions, and 28 completed two out of three sessions. Eighty-two prac- titioners attended part one, 84 practitioners attended part two, and 65 practitioners attended part three. There was a wide range of work experience and level of seniority amongst practitioners. There was some fluctuation in this group over the duration of the project, due to individuals moving in and out of teams (rotational posts, temporary employment) and absences due to annual leave and sickness. At the beginning of the project, just under two thirds of practitioners were certain that they would still be working in their current team at the end of the training and implementation cycle. This accounts for the differing cohorts and completion rates for the survey of SMS beliefs and attitudes, with only 34 practitioners com- pleting the survey both before and after training.

In total, 10 service users participated and completed the stan- dardised interviewer-administered questionnaires in the first of two research visits. Qualitative in-depth interviews with service users were conducted in the second research visit, approximately eight weeks later. Two service user participants were unavailable for interview. One withdrew because they found the first visit too tiring, and one participant could not be reached.

Service user participants were an overall diverse group (seven women, three men, age range 20–79) living with differ- ent and multiple long-term conditions (multiple sclerosis, myalgic encephalopathy, stroke, cancer, arthritis, diabetes, hypertension, asthma, chronic obstructive pulmonary disease, sickle cell anaemia, epilepsy, chronic pain). The quantitative questionnaire results illustrate the complex needs of this group. In EQ-5D-5L descriptors (mobility, self-care, usual activities, pain/discomfort and anxiety/depression) service users reported moderate, severe or extreme problems for 43 (86%) out of overall 50 domain descriptors. The median (range) EQ-5D- VAS rating was 30 (5, 55), compared to a UK population mean of 82.8 across all age groups (Janssen & Szende, 2014). The median (range) NEADL score was 20 (0, 36), compared to a maximum score of 66 indicating full independence in activ- ities of daily living. Participants’ GSE scores were spread across the possible range (10–40), with a median (range) of 22 (10, 38). Over six weeks, each participant had an average of four consultations with general practitioners, six contacts with com- munity health professionals (not including any of the teams participating in this study), five outpatient clinic appointments,

three hospital admission days, and there was one Emergency Department attendance. In the same time period, each partici- pant received an average of ten weekly hours of publicly funded care support, two weekly hours of care support through volun- tary agencies, and an estimated 30 weekly hours of care support from friends or family.

How self-management support was implemented

Qualitative data sources from practitioners comprised 121 writ- ten feedback forms, 29 written case reflections, and six group discussions. We analysed these data with a focus on practi- tioners’ views and reflections. Quantitative results from the survey of SMS beliefs and attitudes add to these qualitative data, as per our concurrent embedded study design.

Four themes were prevalent across practitioner data, which we describe under the following headings: individual practitioner learning, reflections on collaborative working, perceived barriers to SMS, and need to facilitate SMS at organisational level. We supplement practitioner data with service user accounts from eight qualitative interviews. Service user accounts are presented under the heading ‘service users’ experience of SMS’.

Individual practitioner learning Practitioners’ feedback illustrated their reflective learning pro- cesses at an individual level. Talking about their experiences after trialling SMS, practitioners commented on the deliberate appli- cation of different practical SMS strategies discussed in the training sessions, for example the use of problem solving, small steps to achieve targets, encouraging service users to reflect, use of open-ended questions and active listening to discover clients’ hopes and plans for the future. Some practitioners acknowledged their own limited confidence and the need to work at applying these strategies, as one practitioner noted, “I need to practice this more” (case reflection 27, physiotherapist). Others felt the train- ing programme validated their current practice:

Actually I use a client-centred, client-expert perspective in my work. I think the process has empowered me to use/recognise this approach. (case reflection 24, speech and language therapist)

Several reflections illustrated how training and application of SMS highlighted and reinforced fundamentals of SMS for practitioners, such as the overall purpose of SMS, the practi- tioner’s role in SMS, and the use of language:

I have learned that when you start working in the self-manage- ment model, you are thinking or looking at how the person can take control of what is going on with them, even if it’s a small step or achieving a small goal. (case reflection 12, enablement officer)

[The training] made me reflect on language I had been using that was counter-productive to providing patients with a sense of control. (feedback form 57, occupational therapist)

Individual learning was further illustrated by practitioners’ personal action plans to strengthen individual SMS practice going forward, for example to use the strengths of clients as starting point rather than focusing on what ‘we’ (i.e. the practitioner/service) can do and to take a step back and let people figure out what works well for them. The survey of SMS beliefs and attitudes before and after training also shows




how over the duration of the project practitioners as a group shifted towards a mind-set that is more aligned with SMS principles (Table 3).


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