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ORIGINAL ARTICLE
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.
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 s.t.kulnik@sgul.kingston.ac.uk Faculty of Health, Social Care and Education, Kingston University and St. George’s, University of
London, Cranmer Terrace, London, SW17 0RE, UK.
JOURNAL OF INTERPROFESSIONAL CARE
2017, VOL. 31, NO. 1, 75–84
http://dx.doi.org/10.1080/13561820.2016.1246432
© 2017 Taylor & Francis
http://orcid.org/0000-0001-5419-6713
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).
Timeline
Month 1
Month 2
Month 3
Month 4
Month 5
Month 6
Month 7
Month 8
Month 9
Month 10
Month 11
Month 12
NPT
mechanisms
Coherence
Cognitive
participation
Collective
action
Reflexive
monitoring
SMS training delivery
Project
management
Contextualisation to local
services and client groups
Training
sessions
Project steering
group meeting 1
Introduction of
project in team
meetings
Project steering
group meeting 2
Project steering
group meeting 3
Observation of
practitioners
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
Pre-training
questionnaires
(SMS beliefs and
attitudes)
Written feedback
and case reflections
Group discussions
Written feedback
Post-training
questionnaires
(SMS beliefs and
attitudes)
2 research visits
per participant,
8 weeks apart:
standardised
questionnaires,
qualitative
interview
Figure 1. Overview of project timeline and structure. NPT, normalisation process theory; SMS, self-management support.
76 S. T. KULNIK ET AL.
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).
Setting
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.
Participants
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.
Intervention
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.
JOURNAL OF INTERPROFESSIONAL CARE 77
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
78 S. T. KULNIK ET AL.
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.
Findings
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
JOURNAL OF INTERPROFESSIONAL CARE 79
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).
Several practitioners commented that the interaction with
others during training had been enjoyable; and that meeting
and learning with and from others across the boundaries of
professional roles led to enrichment as well as critical reflection
on own roles and practices: “[I] found enjoyment and assistance
in the interactive elements of the training” (feedback form 94);
“[The training was] extremely informative and thought provok-
ing sharing professional experiences” (feedback form 13).
Reflections on collaborative working
These referred to interactions with service users as well as
other practitioners. Talking about their relationships with
clients, several practitioners reflected on how SMS training
had fostered a more collaborative working style, and a more
liberated approach to goal setting and treatment planning.
They described tangible changes in language and the nature
of their interactions, which illustrated collaboration in action.
For example, several practitioners reported reducing verbal
prompts and guidance, letting the client find out for them-
selves what works and being flexible to follow the client’s lead.
One practitioner reported purposely doing less for the person
but encouraging them to do things for themselves, and
another practitioner reflected, “I could be more positive, [ask-
ing clients] ‘what can you do now’” (group discussion 3).
Collaboration in action was also evident in the stance
practitioners took towards their clients’ goals, plans and
hopes for the future. For example, several practitioners
reflected on changing from ‘what I think they need’ to asking
and listening to what clients say they need, giving the service
user a chance to say what is important to them. A number of
practitioners shared insights into accepting the choices people
make, for example acknowledging a client’s own goal and
plan, despite it being perceived as unwise by the practitioner;
the insight that a client might give up on a goal, ‘but this is ok
if it is their decision’; and an example of a successful transfer
of control by giving the client a say in the decision about
occupational therapy.
In this context, practitioners talked about the importance of
interprofessional collaboration and good communication across
professional and team boundaries to facilitate SMS. For example,
an occupational therapist talked about the intention to work
more closely with enablement officers when setting goals, to
draw on insights from their interactions with clients and achieve
a more coherent SMS approach. Another practitioner thought
that time constraints may present a barrier, but noted, “hopefully
by meeting with team and making issue of [SMS] part of our
processes we can overcome this” (feedback form 57).
Perceived barriers to self-management support
Prior to trialling SMS in practice, the following anticipated
barriers were listed most frequently by practitioners: time
constraints and inconsistency in staff (i.e. barriers relating to
the service provider); and clients’ lack of engagement with the
approach (i.e. barrier relating to service users). After imple-
menting SMS, time constraints were less prominent in practi-
tioners’ feedback, and the majority agreed that there was
generally time within their role to introduce clients and
their family/carers to self-management strategies. Several
practitioners did, however, report that inconsistency in staff-
ing made it difficult to build the rapport and trust with clients
they felt was needed for successful SMS.
Lack of clients’ engagement was to some extent confirmed
as a potential barrier. Where lack of engagement had been
encountered, in some cases this was attributed to clients’
cognitive and communication difficulty (e.g. due to advanced
dementia, long-term alcohol dependency):
The approach is perhaps not for everyone. It varies very much,
depending on the client’s level of cognition and the stage they are
at in their journey. (case reflection 25, speech and language therapist)
In other cases it was attributed to high levels of depen-
dency and complex health and social care needs; or to indi-
viduals’ attitudes of entitlement and expectation that ‘the
system‘ was there to ‘deliver goods and services’, which was
seen as counter-productive to the SMS approach:
Breaking the barrier of patient expectation with some difficult
patients, who I may recognise to have the ability to self-manage
but are reluctant to stop having professional input. (feedback form
52, physiotherapist)
Table 3. Survey of self-management support (SMS) beliefs and attitudes, before
and after training completion.* Shown are survey items (sentiments) that elicit
respondents’ beliefs and attitudes towards core constructs of SMS. Response
options are strongly agree, agree, disagree, and strongly disagree. Analysis
shows the percentage of respondents who answered in concordance with SMS
principles.
Questionnaire item (in brackets the response
in concordance with SMS)
Percentage of respondents in
concordance with SMS
Before
training
(n = 60)
After
training*
(n = 54)
When ideas/goals suggested by clients are
unrealistic, it holds back progress (disagree)
43% 67%
It is important to educate the client about
setting achievable goals (disagree)
5% 44%
The practitioner should usually lead the
rehabilitation/enablement process
(disagree)
50% 54%
A self-management programme mostly
includes education for the client and their
family (disagree)
16% 38%
Where possible, goals or targets of
rehabilitation/enablement should always be
written in the client’s own words (agree)
79% 88%
A client’s confidence has more influence on
the outcome of rehabilitation/enablement
than the skills of the practitioner (agree)
84% 88%
Rehabilitation/enablement plans should be
guided by the practitioner (disagree)
29% 51%
Self-management should always be
introduced just before discharge from
services (disagree)
33% 62%
Self-management is all about getting people
to do more for themselves (disagree)
14% 19%
If clients have cognitive problems they would
be unable to learn to self-manage
(disagree)
74% 78%
*Due to fluctuation in the practitioner sample, only 34 respondents completed
the survey both before and after training.
80 S. T. KULNIK ET AL.
As a consequence, some practitioners reflected on feeling
the need to get to know clients in order to ‘possibly cherry-
pick the right person’ for a dedicated SMS approach. In
contrast, other practitioners reported successes when trialling
the approach without such pre-selection and also, for exam-
ple, with clients who exhibited challenging behaviour patterns
or complex psychological states. Sharing and discussing these
reflections on successful experiences in the interprofessional
learning environment supported the credibility of the inter-
vention from within the group, and facilitated meaning and
sense-making for other practitioners, who commented: “[I got
to know] useful new options/ways of empowering clients”
(feedback form 72); “I will take this on board both profes-
sionally and personally” (feedback form 74).
Need to facilitate self-management support at the
organisational level
Practitioner reflections highlighted that, in addition to the
integration of SMS principles as individuals, the approach
needs to be facilitated and fostered at organisational level.
One practitioner, for example, commented that although the
SMS intervention was thought to be:
Very positive as to how to promote the service user to make
changes themselves, due to service needs it is going to be difficult
for this to be effective in the team I am based in. (case reflection
23, social worker)
The most commonly mentioned difficulty was frequent
change-over in practitioners working with one client. This
was most prominent for the enablement service, which oper-
ates a high-intensity seven-day service with up to four daily
calls, necessitating multiple visits to one client by different
members of staff. Other organisational aspects were men-
tioned, for example making services more flexible, re-thinking
rigid goal setting practices and optimising interprofessional
communication to facilitate a shared SMS approach. These
points were also acknowledged by senior and managerial team
members, who reported intentions to review service processes
to facilitate SMS.
Overall, the need to facilitate SMS at organisational level
was consistently represented throughout data sources and
across project stages. Despite acknowledging tangible changes
in individual practice this highlights uncertainty and frustra-
tion perceived by some practitioners that their team structures
and processes would be challenged to support this new way of
working. Reflective discussions emphasised that SMS was
more effective if the same self-management messages were
being used across teams, but how to manage this consistent
approach operationally would be a challenge. There were
however, examples of successful continuation of SMS by
practitioners who covered for colleagues, and acknowledge-
ment of the importance of good communication within and
across teams to achieve consistency in SMS.
Service users’ experiences of self-management support
Service user interviews revealed the complex and precar-
ious nature of living with a long-term condition, and the
wide-ranging needs of those accessing community ser-
vices. Most service user accounts told an illustrative
story of the impact of interactions with practitioners in
this study. In many cases the support they had received
had increased confidence and encouraged different skills
to manage their condition. Overall most participants felt
positive about the SMS intervention. There were two par-
ticipants who highlighted some of the negative aspects of
services they had received, comments mostly related to
time and budgetary constraints and not directly to the
question about SMS. But, they raise an important distinc-
tion between how services and the efforts of practitioners
are interpreted by service users. Whilst some service users
may appreciate being given freedom and flexibility to
define solutions to issues of living with their condition,
others may take a critical view of ‘self-management’. One
service user, for example, interpreted the self-management
rhetoric as a strategy to justify cuts in health and social
care support:
In the last three or 4 years, I feel that they are just looking for
reasons to find you ineligible for services, you know . . . So, it feels
a bit more like . . . you prove that you’re as disabled as you say you
are, sort of thing, rather than someone saying, I can see you’ve got
all these problems, it must be pretty difficult, how can we help.
(Participant M2)
There were a number of examples given by service users
which illustrated how support to self-manage had been
received and the positive impact it had made. Some service
users talked about how working with practitioners had
increased their self-confidence:
[The practitioner] found ways of helping me to be confident in
myself, and letting me know, you can do that . . . Like a coach, it’s
like having a coach . . . So yeah, it was fantastic having someone
coming in the home and supporting to help me to get back to
being able to function better and that, rather than other people
doing things for me, you know. (Participant F3)
Other service users gave accounts that demonstrated
appreciation of and satisfaction with practitioners’ SMS
intervention:
[The practitioner] always kept in mind what I wanted to achieve
and asked me about that. It was more [the practitioner] provided
me the tools to do what I wanted to be able to do . . . But it made
sense to finish when we did in some ways, because I have a list of
exercises that I can carry on with. (Participant F6)
These illustrative quotes indicate some of the ways in
which SMS was constructed by service users. The language
they use also reflects some of the methods used by practi-
tioners, such as enhancing self-efficacy (self-confidence), pro-
blem-solving around person-centred goals, and putting the
person at the centre of their long-term management.
This study described how practitioners from different profes-
sional groups and agencies came together to learn ways of
implementing contextualised SMS for people with long-term
conditions living in one South East England locality.
Researchers in the field of self-management and rehabilitation
increasingly recognise the added value of operationalising
SMS through interprofessional training, such as in the work
JOURNAL OF INTERPROFESSIONAL CARE 81
by Gucciardi, Espin, Morganti, and Dorado (2016), Kawi,
Schuerman, Alpert, and Young (2015), Semrau et al. (2015),
and McColl et al. (2009). However, few of these studies
provide in-depth insights into processes of interprofessional
learning and implementation of SMS practices. In our evalua-
tion study we used a number of ways to measure and explore
the impact of the project and used NPT (Murray et al., 2010)
as a framework to help us understand how practitioners made
sense of this way of working, how it was distinct from their
previous practice and how collectively they reflected on SMS
in practice in this interprofessional context. Our data touch
on many of the key themes of interprofessional learning and
practice, showing positive findings for most of the commonly
defined educational outcomes of IPE, i.e. reaction to the IPE
approach, modification of attitudes/perceptions, acquisition of
knowledge/skills, behavioural change, change in organisa-
tional practice, and benefits to clients (Freeth, Hammick,
Koppel, Reeves, & Barr, 2002; Oandasan & Reeves, 2005b).
Skills, attitudes, and beliefs of the workforce are critical for
successful implementation of SMS (Ahmad, Ellins, Krelle, &
Lawrie, 2014; de Longh, Fagan, Fenner, & Kidd, 2015; de
Silva, 2011; Newbronner et al., 2013). A dedicated interpro-
fessional focus of the SMS intervention and the training
programme suited the structure and organisation of the work-
force in our project, and particularly helped staff understand
the shared purpose and their own role within this collabora-
tive context. Although our survey of SMS beliefs and attitudes
was limited due to the fluctuation in the group between the
first and second survey time points, these data nevertheless
reflect some group shift in attitudes and beliefs towards a
mind-set more aligned with SMS principles. Importantly, we
delivered training sessions in a non-threatening environment
of mutual respect and appreciation, using facilitators rather
than ‘expert teachers’. This helped the normalisation mechan-
ism of ‘reflexive monitoring’, by allowing for open and also
self-critical discussion amongst a mixed audience of practi-
tioners from varying professional and support roles and dif-
fering levels of seniority. Frequently described challenges to
effective interprofessional teamworking are differing patterns
of professional socialisation, lack of knowledge and apprecia-
tion of others’ roles, and issues of hierarchy and power
(Baxter & Brumfit, 2008; Brown et al., 2011; Gucciardi et al.,
2016; Hall, 2009). Our findings reflect some of these chal-
lenges and highlight overlap with findings from other self-
management research, for example variations in how self-
management is understood (Van Hooft et al., 2015; Young
et al., 2015) and tensions around control and partnership
working (Mudge et al., 2016; Norris & Kilbride, 2014). In
addition, our study provides evidence of how these challenges
can be addressed. Our findings show that practitioners chan-
ged their understanding and practical application of SMS, as
they reflected on more conscientious collaboration with and
deliberate hand-over of control to service users. Our findings
also demonstrate intentions of closer collaboration and com-
munication with colleagues within and across teams. This
resonates with work by Sims, Hewitt, and Harris (2015),
who describe how interprofessional teamworking affects out-
comes and patient experience through mechanisms of shared
purpose, critical reflection, innovation, and leadership.
Our data also provide some evidence of benefit to clients.
As opposed to many previous condition-specific and/or
group-based self-management programmes, the intervention
in this project delivered generic individualised SMS to people
with heterogeneous medical background, utilising the existing
workforce and infrastructure of community rehabilitation and
intermediate care services. These services work on the basis of
client home visits, which gives a convenient route to deliver-
ing provider-based integrated SMS to groups that are tradi-
tionally ‘hard-to-reach’, such as people with complex health
and social care needs or restricted mobility. The small con-
venience sample of service users in our study represented such
a group. Our data give many tangible examples of small
changes to individual practitioners’ practice having a positive
impact on the self-management of service users, and service
user accounts provided corroborating evidence of that. That
SMS strategies were successfully implemented with service
users who experienced considerable levels of disability coun-
ters the frequently held view that self-management
approaches are not suitable for groups with complex and
significant disability—a view that may perpetuate a prescrip-
tive ‘doing to’ the person approach in this type of rehabilita-
tion setting, which is counter-productive to self-management.
Successful SMS requires change across a whole system and the
success of this project was contingent on a number of key areas, all
of which align with the current evidence (Ahmad et al., 2014; de
Longh et al., 2015). We made considerable efforts to adopt an
interprofessional approach to facilitate shared meaning and col-
laboration. While these aspect were well received by the workforce
in this study, practitioners cited practical organisational barriers
that hindered SMS, for example frequent staff turnover and com-
munication across boundaries. These challenges echo findings
from other studies of interprofessional teamwork in multi-agency
settings. For example, Robinson and Cottrell (2005) highlighted
how participants perceived the responsibility to overcome some of
these issues should be initiated or enabled through changes in
service organisation. This is not uncommon in research that
attempts to evaluate the impact of IPE on practice (Reeves et al.,
2013), and strategies to empower practitioners to initiate changes
at organisational level through interprofessional discussions need
to be explored.
Nevertheless, our findings highlight the importance of enga-
ging senior managers through site visits and involvement in our
project steering group. This helped to ‘sell’ the idea of the work-
force working differently in an interprofessional manner, and how
this could lead to greater efficiencies as well as improve service user
experience. This was further supported by a political drive for
integration of health and social care and implementation of SMS
in the locality, which contributed to creating a ‘receptive context’
(Robert & Fulop, 2014). Moreover, our data show that there
remained scope for adapting organisational and team processes
in order to facilitate individual SMS practice. A clear message from
our data therefore is that this way of working requires ongoing
sustainability work and commitment at organisational level to
ensure long-lasting implementation and effect—a finding which
is supported by other research in self-management (Ahmad et al.,
2014; De Longh et al., 2015; Eaton et al., 2015; Newbronner et al.,
2013) and interprofessional teamworking (Brown et al., 2011;
Robinson & Cottrell, 2005). The conditions need to be created to
82 S. T. KULNIK ET AL.
foster the type of ongoinginterprofessional development that leads
to social learning in the workplace and contributes to continuous
service improvement (Wilcock, Janes, & Chambers, 2009).
There are some limitations to this study. We acknowledge that
this was a small, single-institutional project, and that our data are
perceptions-based and relate to short-term outcomes of IPE and
SMS only. Based on a number of recently updated systematic
reviews of the interprofessional literature (Reeves et al., 2016,
2013), there has been a call to develop the interprofessional field
further by conducting larger multi-centre studies, utilising empiri-
cal observational methods and demonstrating longer-term out-
comes and economic impact of IPE through longitudinal study
designs (Reeves, 2016). While we recognise that these approaches
will bring considerable advances to the scholarship and evidence
base of interprofessional learning and practice, it was not possible
to address these aspects in our study, which was a publicly
commissioned SMS implementation project with an integrated,
but opportunistic evaluation study and therefore constrained by
project resources. A further limitation to our study design was
fluctuation within the group of practitioners and the challenges
associated with organising training for large numbers of staff.
Lack of group stability, in particular in post-licensure training,
and logistical problems are known barriers to implementing IPE
(Oandasan & Reeves, 2005a, 2005b). This identifies considerations
for sustainability and the planning of future implementation
projects in this sector. We developed good lines of communica-
tion with team leads who helped to expedite and streamline
processes, but these challenges need to be considered when inter-
preting our findings.
This study provides an insight into the processes of implementing
SMS for people living with long-term conditions through a diverse
community workforce of rehabilitation and social care practi-
tioners. Our data illustrate how theory and application of inter-
professional learning and practice can add value to
operationalising a self-management approach in community reha-
bilitation and social care. We conclude that it is possible to embed
a self-management model like Bridges Self-Management in this
setting and to impact on interactions between service users and
staff, leading to increased service user confidence and encouraging
different skills to manage long-term conditions. An important
enabling factor is organisational commitment to addressing pro-
cesses and structures that facilitate interprofessional teamworking.
FJ is founding director and CEO of Bridges Self-Management Limited, a
social enterprise conducting research and training in self-management
support in health and social care. HP, LB, and SK are employees of
Bridges Self-Management Limited. JH reports no conflict of interest. The
authors alone are responsible for the content and writing of this article.
ORCID
Stefan Tino Kulnik http://orcid.org/0000-0001-5419-6713
Ahmad, N., Ellins, J., Krelle, H., & Lawrie, M. (2014). Person-centred care:
From ideas to action. Bringing together the evidence on shared decision
making and self-management support. London, UK: The Health
Foundation.
Allen, K., & Glasby, J. (2009). English report on prevention and rehabili-
tation. Birmingham, UK: University of Birmingham, Health Services
Management Centre.
Baxter, S. K., & Brumfit, S. M. (2008). Professional differences in inter-
professional working. Journal of Interprofessional Care, 22, 239–251.
doi:10.1080/13561820802054655
Boger, E., Ellis, J., Latter, S., Foster, C., Kennedy, A., Jones, F., . . .
Demain, S. (2015). Self-management and self-management support
outcomes: A systematic review and mixed research synthesis of sta-
keholder views. PLoS ONE, 10(7), e0130990. doi:10.1371/journal.
pone.0130990
Brown, J., Lewis, L., Ellis, K., Stewart, M., Freeman, T. R., & Kasperski, M. J.
(2011). Conflict on interprofessional primary health care teams – Can it
be resolved? Journal of Interprofessional Care, 25, 4–10. doi:10.3109/
13561820.2010.497750
Chisholm, D., Knapp, M. R. J., Knudsen, H. C., Amaddeo, F., Gaite, L., &
van Wijngaarden, B.; for the Epsilon Study Group. (2000). Client
Socio-demographic and Service-Receipt Inventory – European ver-
sion: Development of an instrument for international research.
Epsilon Study 5. The British Journal of Psychiatry, 177(39), s28–s33.
doi:10.1192/bjp.177.39.s28
Clark, P. G. (2009). Reflecting on reflection in interprofessional educa-
tion: Implications for theory and practice. Journal of Interprofessional
Care, 23, 213–223. doi:10.1080/13561820902877195
Coulter, A., Entwistle, V., Eccles, A., Ryan, S., Shepperd, S., & Perera, R.
(2015). Personalised care planning for adults with chronic or long-
term conditions. Cochrane Database of Systematic Reviews, 3. Art. No.:
CD010523. doi:10.1002/14651858.CD010523.pub2
Creswell, J. W. (2014). Research design. Qualitative, quantitative, and
mixed methods approaches (4th ed.). Los Angeles, CA: Sage.
de Longh, A., Fagan, P., Fenner, J., & Kidd, L. (2015). A practical guide to
self-management support. Key components for successful implementa-
tion. London, UK: The Health Foundation.
Demain, S., Goncalves, A.-C., Areia, C., Oliveira, R., Marcos, A. J., Marques,
A., . . . Hunt, K. (2015). Living with, managing and minimising treatment
burden in long term conditions: A systematic review of qualitative
research. PLoS ONE, 10, e0125457. doi:10.1371/journal.pone.0125457
de Silva, D. (2011). Evidence: Helping people help themselves. A review of
the evidence considering whether it is worthwhile to support self-man-
agement. London, UK: The Health Foundation.
Eaton, C. (2016). “I don’t get it”, – The challenge of teaching reflective
practice to health and care practitioners. Reflective Practice, 17(2),
159–166. doi:10.1080/14623943.2016.1145582
Eaton, S., Roberts, S., & Turner, B. (2015). Delivering person centred care
in long term conditions. The BMJ, 350, h181. doi:10.1136/bmj.h181
Fetters, M. D., Curry, L. A., & Creswell, J. W. (2013). Achieving integra-
tion in mixed methods designs – principles and practices. Health
Services Research, 48(6 Part 2), 2134–2156. doi:10.1111/1475-
6773.12117
Freeth, D., Hammick, M., Koppel, I., Reeves, S., & Barr, H. (2002). A critical
review of evaluations of interprofessional education. London, UK:
Learning and Support Network, Centre for Health Sciences and Practice.
Green, J., & Thorogood, N. (2013). Qualitative methods for health
research (3rd ed.). Los Angeles, CA: Sage.
Gucciardi, E., Espin, S., Morganti, A., & Dorado, L. (2016). Exploring
interprofessional collaboration during the integration of diabetes
teams into primary care. BMC Family Practice, 17, 12. doi:10.1186/
s12875-016-0407-1
Hall, P. (2009). Interprofessional teamwork: Professional cultures as
barriers. Journal of Interprofessional Care, 19(Suppl. 1), 188–196.
doi:10.1080/13561820500081745
Hallin, K., Henriksson, P., Dalen, N., & Kiessling, A. (2011). Effects of
interprofessional education on patient perceived quality of care.
Medical Teacher, 33(1), e22–e26. doi:10.3109/0142159X.2011.530314
JOURNAL OF INTERPROFESSIONAL CARE 83
http://dx.doi.org/10.1080/13561820802054655
http://dx.doi.org/10.1371/journal.pone.0130990
http://dx.doi.org/10.1371/journal.pone.0130990
http://dx.doi.org/10.3109/13561820.2010.497750
http://dx.doi.org/10.3109/13561820.2010.497750
http://dx.doi.org/10.1192/bjp.177.39.s28
http://dx.doi.org/10.1080/13561820902877195
http://dx.doi.org/10.1002/14651858.CD010523.pub2
http://dx.doi.org/10.1371/journal.pone.0125457
http://dx.doi.org/10.1080/14623943.2016.1145582
http://dx.doi.org/10.1136/bmj.h181
http://dx.doi.org/10.1111/1475-6773.12117
http://dx.doi.org/10.1111/1475-6773.12117
http://dx.doi.org/10.1186/s12875-016-0407-1
http://dx.doi.org/10.1186/s12875-016-0407-1
http://dx.doi.org/10.1080/13561820500081745
http://dx.doi.org/10.3109/0142159X.2011.530314
Hibbard, J. H., & Greene, J. (2013). What the evidence shows about
patient activation: Better health outcomes and care experiences; fewer
data on costs. Health Affairs, 32(2), 207–214. doi:10.1377/
hlthaff.2012.1061
Janssen, B., & Szende, A. (2014). Population norms for the EQ-5D. In A.
Szende, B. Janssen, & J. Cabasés (Eds.), Self-reported population health:
An international perspective based on EQ-5D (pp. 19–30). Heidelberg,
Germany: Springer Open.
Jones, F., & Bailey, N. (2013). How can we train stroke practitioners
about patient self-management? Description and evaluation of a path-
way wide training programme. European Journal for Person Centered
Healthcare, 1(1), 246–254. doi:10.5750/ejpch.v1i1
Jones, F., Gage, H., Drummond, A., Bhalla, A., Grant, R., Lennon, S., . . .
Liston, M. (2016). Feasibility study of an integrated stroke self-man-
agement programme: A cluster-randomised controlled trial. BMJ
Open, 6, e008900. doi:10.1136/bmjopen-2015-008900
Jones, F., Waters, C., Benson, L., Jones, C., Hammond, J., & Bailey, N.
(2012). Evaluation of a shared approach to interprofessional learning
about stroke self-management. Journal of Interprofessional Care, 26,
514–516. doi:10.3109/13561820.2012.702147
Kawi, J., Schuerman, S., Alpert, P. T., & Young, D. (2015). Activation to
self-management and exercise in overweight and obese older women
with knee osteoarthritis. Clinical Nursing Research, 24(6), 644–660.
doi:10.1177/1054773814544167
Kinsella, E. A. (2010). The art of reflective practice in health and social
care: Reflections on the legacy of Donald Schön. Reflective Practice, 11
(4), 565–575. doi:10.1080/14623943.2010.506260
Lorig, K. R., & Holmann, H. R. (2003). Self-management education:
History, definition, outcomes, and mechanisms. Annals of Behavioral
Medicine, 26(1), 1–7. doi:10.1207/S15324796ABM2601_01
May, C., & Finch, T. (2009). Implementing, embedding and integrating
practices: An outline of Normalization Process Theory. Sociology, 43
(3), 535–554. doi:10.1177/0038038509103208
McColl, M. A., Shortt, S., Godwin, M., Smith, K., Rowe, K., O’Brien, P.,
. . . Donnelly, C. (2009). Models for integrating rehabilitation and
primary care: A scoping study. Archives of Physical Medicine and
Rehabilitation, 90(9), 1523–1531. doi:10.1016/j.apmr.2009.03.017
Mudge, S., Kayes, N., & McPherson, K. (2016). Who is in control?
Clinicians’ view on their role in self-management approaches: A
qualitative metasynthesis. BMJ Open, 5, e007413. doi:10.1136/bmjo-
pen-2014-007413
Murray, E., Treweek, S., Pope, C., MacFarlane, A., Ballini, L., Dowrick,
C., . . . May, C. (2010). Normalisation Process Theory: A framework
for developing, evaluating and implementing complex interventions.
BMC Medicine, 8, 63. doi:10.1186/1741-7015-8-63
Newbronner, L., Chamberlain, R., Borthwick, R., Baxter, M., &
Sanderson, D. (2013). Sustaining and spreading self-management sup-
port: Lessons from Co-creating Health phase 2. London, UK: The
Health Foundation.
Norris, M., & Kilbride, C. (2014). From dictatorship to a reluctant democracy:
Stroke therapists talking about self-management. Disability and
Rehabilitation, 36(1), 32–38. doi:10.3109/09638288.2013.776645
Nouri, F. M., & Lincoln, N. B. (1987). An extended activities of daily
living scale for stroke patients. Clinical Rehabilitation, 1(4), 301–305.
doi:10.1177/026921558700100409
Oandasan, I., & Reeves, S. (2005a). Key elements for interprofessional
education. Part 1: The learner, the educator and the learning context.
Journal of Interprofessional Care, 19(Suppl. 1), 21–38. doi:10.1080/
13561820500083550
Oandasan, I., & Reeves, S. (2005b). Key elements of interprofessional educa-
tion.Part 2: Factors, processes and outcomes. Journal of Interprofessional
Care, 19(Suppl. 1), 39–48. doi:10.1080/13561820500081703
O’Cathain, A., Murphy, E., & Nicholl, J. (2007). Why, and how, mixed
methods research is undertaken in health services research in
England: A mixed methods study. BMC Health Services Research, 7,
85. doi:10.1186/1472-6963-7-85
Reeves, S. (2016). Ideas for the development of the interprofessional
education and practice field: An update. Journal of Interprofessional
Care, 30(4), 405–407. doi:10.1080/13561820.2016.1197735
Reeves, S., Fletcher, S., Barr, H., Birch, I., Boet, S., Davies, N., . . . Kitto, S.
(2016). A BEME systematic review of the effects of interprofessional
education: BEME Guide No. 39. Medical Teacher, 38(7), 656–668.
doi:10.3109/0142159X.2016.1173663
Reeves, S., Perrier, L., Goldman, J., Freeth, D., & Zwarenstein, M. (2013).
Interprofessional education: Effects on professional practice and
healthcare outcomes (update). Cochrane Database of Systematic
Reviews, 3. Art. No.: CD002213. doi:10.1002/14651858.CD002213.pub3
Robert, G., & Fulop, N. (2014). The role of context in successful
improvement. In The Health Foundation (Ed.), Perspectives on con-
text. A selection of essays considering the role of context in successful
quality improvement (pp. 31–58). London, UK: Editor.
Robinson, M., & Cottrell, D. (2005). Health professionals in multi-dis-
ciplinary and multi-agency teams: Changing professional practice.
Journal of Interprofessional Care, 19, 547–560. doi:10.1080/
13561820500396960
Schön, D. A. (1992). The crisis of professional knowledge and the pursuit
of an epistemology of practice. Journal of Interprofessional Care, 6, 49–
63. doi:10.3109/13561829209049595
Schwarzer, R., & Jerusalem, M. (1995). Generalized Self-Efficacy scale. In
J. Weinman, S. Wright, & M. Johnston (Eds.), Measures in health
psychology: A user’sportfolio. Causal and control beliefs (pp. 35–37).
Windsor, UK: NFER-NELSON.
Semrau, J., Hentschke, C., Buchmann, J., Meng, K., Vogel, H., Faller, H.,
. . . Pfeifer, K. (2015). Long-term effects of interprofessional biopsy-
chosocial rehabilitation for adults with chronic non-specific low back
pain: A multicentre, quasi-experimental study. PLoS ONE, 10(3),
e0118609. doi:10.1371/journal.pone.0118609
Sims, S., Hewitt, G., & Harris, R. (2015). Evidence of a shared purpose,
critical reflection, innovation and leadership in interprofessional
healthcare teams: A realist synthesis. Journal of Interprofessional
Care, 29, 209–215. doi:10.3109/13561820.2014.941459
Suter, E., Arndt, J., Arthur, N., Parboosingh, J., Taylor, E., &
Deutschlander, S. (2009). Role understanding and effective commu-
nication as core competencies for collaborative practice. Journal of
Interprofessional Care, 23, 41–51. doi:10.1080/13561820802338579
Van Hooft, S. M., Dwarswaard, J., Jedeloo, S., Bal, R., & Van Staa, A.
(2015). Four perspectives on self-management support by nurses for
people with chronic conditions: A Q-methodological study.
International Journal of Nursing Studies, 52(1), 157–166. doi:10.1016/
j.ijnurstu.2014.07.004
van Reenen, M., & Janssen, B. (2015). EQ-5D-5L user guide. Basic informa-
tion on how to use the EQ-5D-5L instrument. Version 2.1, April 2015.
Rotterdam, the Netherlands: EuroQol Research Foundation.
Wilcock, P. M., Janes, G., & Chambers, A. (2009). Health care improve-
ment and continuing interprofessional education: Continuing inter-
professional development to improve patient outcomes. Journal of
Continuing Education in the Health Professions, 29(2), 84–90.
doi:10.1002/chp.20016
Young, H. M. L., Apps, L. D., Harrison, S. L., Johnson-Warringon, V. L.,
Hudson, N., & Singh, S. J. (2015). Important, misunderstood, and
challenging: A qualitative study of nurses’ and allied health profes-
sionals’ perceptions of implementing self-management for patients
with COPD. International Journal of COPD, 10(1), 1043–1052.
doi:10.2147/COPD.S78670
84 S. T. KULNIK ET AL.
http://dx.doi.org/10.1377/hlthaff.2012.1061
http://dx.doi.org/10.1377/hlthaff.2012.1061
http://dx.doi.org/10.5750/ejpch.v1i1
http://dx.doi.org/10.1136/bmjopen-2015-008900
http://dx.doi.org/10.3109/13561820.2012.702147
http://dx.doi.org/10.1177/1054773814544167
http://dx.doi.org/10.1080/14623943.2010.506260
http://dx.doi.org/10.1207/S15324796ABM2601%5F01
http://dx.doi.org/10.1177/0038038509103208
http://dx.doi.org/10.1016/j.apmr.2009.03.017
http://dx.doi.org/10.1136/bmjopen-2014-007413
http://dx.doi.org/10.1136/bmjopen-2014-007413
http://dx.doi.org/10.1186/1741-7015-8-63
http://dx.doi.org/10.3109/09638288.2013.776645
http://dx.doi.org/10.1177/026921558700100409
http://dx.doi.org/10.1080/13561820500083550
http://dx.doi.org/10.1080/13561820500083550
http://dx.doi.org/10.1080/13561820500081703
http://dx.doi.org/10.1186/1472-6963-7-85
http://dx.doi.org/10.1080/13561820.2016.1197735
http://dx.doi.org/10.3109/0142159X.2016.1173663
http://dx.doi.org/10.1002/14651858.CD002213.pub3
http://dx.doi.org/10.1080/13561820500396960
http://dx.doi.org/10.1080/13561820500396960
http://dx.doi.org/10.3109/13561829209049595
http://dx.doi.org/10.1371/journal.pone.0118609
http://dx.doi.org/10.3109/13561820.2014.941459
http://dx.doi.org/10.1080/13561820802338579
http://dx.doi.org/10.1016/j.ijnurstu.2014.07.004
http://dx.doi.org/10.1016/j.ijnurstu.2014.07.004
http://dx.doi.org/10.1002/chp.20016
http://dx.doi.org/10.2147/COPD.S78670
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Introduction
Methods
Research design
Setting
Participants
Intervention
Data collection
Data analysis
Ethical considerations
Findings
Participant overview
How self-management support was implemented
Individual practitioner learning
Reflections on collaborative working
Perceived barriers to self-management support
Need to facilitate self-management support at the organisational level
Service users’ experiences of self-management support
Discussion
Concluding comments
Declaration of interest
References
