Self–management is increasingly promoted in healthcare policies and research (Wilkinson and Whitehead, 2009; Jones et al, 2011). Indeed, the World Health Organization (WHO) (2015) identified the importance of self-management for older adults given the ageing demographic profile globally, coupled with the increasing numbers of those living with chronic illness and multi-morbidity. Nurses aim to implement holistic person-centred care and work across the continuum of health care (Nursing and Midwifery Council (NMC), 2018) and are therefore ideally suited to the role of promoting self-management with older adults. The aim of this article is to provide conceptual clarity in relation to self-management by older adults living with chronic illness and multi-morbidity and to explore the implications of self-management support by nurses.
Ireland's Health Service Executive (HSE) (2017) has defined self-management as:
‘The tasks that individuals must undertake to live with one or more chronic conditions. These tasks include having the confidence to deal with medical management, role management and emotional management of their condition.’
Van de Velde et al (2019) emphasised the importance of the relationship with healthcare providers in their definition of self-management. They defined it as:
‘The intrinsically controlled ability of an active, responsible, informed and autonomous individual to live with the medical, role and emotional consequences of his chronic condition(s) in partnership with his social network and the healthcare provider(s).’
The key components of self-management and their relationship to each other are illustrated in Figure 1. As the definitions of self-management and Figure 1 illustrate, self-management takes place in the context of emotional and role management and involves medical management, self-monitoring and self-awareness. The emotional sequelae of chronic illness can include anger, fear, depression and anxiety about the future, and so management of the effects of the chronic illness on emotions and relationships is required (Lorig and Holman, 2003; HSE, 2017). Role management implies that older adults may need to modify household, workload or other tasks and therefore cognisance of this should be incorporated in the provision of healthcare advice or interventions to support self-management by older adults.
It is important to identify characteristics of proficiency in self-management among older adults prior to planning and evaluating self-management interventions in clinical practice. These proficiencies include (HSE, 2017):
- Active participation by older adults in decision making about health
- Concordance with a mutually agreed treatment plan with health professionals
- Management of the impact of chronic illness(es) on psychosocial and emotional wellbeing
- Adoption of health-promoting lifestyle choices
- Access to support services with the confidence to use them.
To support such proficiency, older adults will require knowledge of the chronic illness(es) they experience and associated morbidities, appropriate responses to any deterioration in a condition and the ability to monitor and manage the associated signs and symptoms (HSE, 2017).
Self-management therefore requires the promotion of autonomy and the facilitation of older adults to become empowered to direct their own care. Such an orientation moves away from the medical paternalistic positioning traditionally prevalent in health care, wherein a person's preference might be overridden to benefit them or to mitigate or prevent harm (Beauchamp and Childress, 2019). Furthermore, ageism must be challenged as this could result in a nurse believing that a person may not have the knowledge or skills to self-manage or not expecting them to self-manage (Daly et al, 2019; WHO, 2019). In contrast, self-management, and the professional support thereof, respects the autonomy, will and preferences of the older adult. Before discussing the nurses' role in promoting self-management, its relevance and the factors that affect self-management among older adults will be explored.
Relevance of self-management for older adults
The prevalence of chronic illness is increasing, and is particularly pronounced in later life, concomitant with demographic increases in those living into older age (Banerjee, 2015; WHO, 2015). In addition, multi-morbidity in later life is complex due to the potential overlap of physical and mental health conditions, frailty and polypharmacy (Yarnall et al, 2017). In a systematic review, Marengoni et al (2011) found that estimates of older adults living with multi-morbidity ranged between 55% and 98%. A more recent meta-analysis identified that multi-morbidity was found in 72% of older adults with frailty (Vetrano et al, 2019). Older adults are therefore more likely to live with multiple chronic conditions associated with reduced health, functional decline, disability, reduced quality of life, increased use of healthcare services, and higher mortality (Marengoni et al, 2011; Eckerblad et al, 2015; National Institute for Health and Care Excellence, 2016; Ploeg et al, 2017; Garnett et al, 2018; Hernández et al, 2019; Foo et al, 2020).
Health systems tend to focus on a single disease-oriented model that does not necessarily meet the needs of those living with multi-morbidity and can lead to fragmentation of care (Hernández et al, 2019). This is a particular concern in relation to older adults with complex needs (Ploeg et al, 2017). Kastner et al (2019) identified the underlying mechanisms that influence why chronic illness management interventions work or do not work, concluding that older adults focus on lessening undesired symptoms and supporting their quality of life, while health professionals focus on the condition that poses a threat to service users' mortality and morbidity. The reviewers concluded that care optimisation necessitates clinical and service user self-care management to be approached from service user, provider and system perspectives. Other researchers also support this multi-perspective approach centralising the older adult (Ploeg et al, 2017), which signals a move to balance the healthcare provider–service user relationship (Garnett et al, 2018). Such a person-centred orientation supports enhanced knowledge, skills, active involvement and is advocated to improve care for older adults (American Geriatrics Society Expert Panel on Person-Centered Care, 2016). The accompanying benefits are suggested to include those outlined in Box 1.
Box 1.Overview of the benefits of self-management for older adults
- Reduction in chronic illness-related burden
- An informed and empowered person
- Reduced family/informal carer burden
- Reduced reliance on the health system
- Better health, wellbeing and quality of life
- Reduced cost to the health system
Source: Gallagher et al, 2008; Garnett et al, 2018
Factors that can affect self-management for older adults
Many factors can affect an older adult's ability to self-manage their health and wellbeing needs, as shown in Table 1.
Table 1. Factors that can affect self-management of older adults
| Older adult | Nurse | Health system |
|---|---|---|
| AgeComorbidityFunctional abilityMental health difficultiesHealth literacySelf-efficacySocio-economic factorsSocial supportHealth locus of controlProblem-solving skillsHealth beliefsCognitive functionFrailtyRelationships with healthcare providers | Understanding of the concept of self-managementFocus on complianceDisease-focused careInterpersonal skillsApproaches to self-management | Models of care that are task orientedDisease–focused careMultiple professional caregiversSupport for nurses to promote self-managementFragmented careLack of integration of care and associated supportive technologyAccess to health careAgeism |
Source: Schulman-Green et al, 2016; HSE; 2017; Federman et al; 2019; Gobeil-Lavoie et al, 2019; Kastner et al, 2019
Older adult-related factors
An older adult's ability to engage in self-management activities is influenced by physical, psychosocial and cognitive factors (Federman et al, 2019). Gobeil-Lavoie et al (2019) found that adults with complex healthcare needs can find it hard to manage their conditions and can prioritise one dominant condition over another. There are also reports that self-management is time consuming and that medication management is complex, especially where multiple medications are involved (Jowsey et al, 2009; Maidment et al, 2020). Where the service user also experiences mental health difficulties, conditions such as clinical depression reduced service user motivation to engage in self-management and reduced the ability to prioritise health-related activities (Jowsey et al, 2009; Gobeil-Lavoie et al, 2019). In addition, self-management in the presence of cognitive impairment posed significant challenges (Kastner et al, 2019). Older adults' perceptions of their role as ‘service users’ could also influence their desire and ability to participate in care. For example, Protheroe et al (2013) found service users from lower socio-economic groups were less likely to ask questions and more likely to see self-management as following doctor's orders. Older adults from higher socio-economic groups were more likely to understand their illness and how to manage it and were more likely to self-manage (Protheroe et al, 2013). Informal caregivers also play a central role, especially in the presence of multiple complex conditions (Ploeg et al, 2017). In addition, a lack of social support can impact negatively on an older person's ability to engage in self-management activities (Gobeil-Lavoie et al, 2019).
Nursing-related factors
Nurses' understanding of self-management is described by Morgan et al (2017) as being either narrow or broad. A narrower focus concentrates on biomedical outcomes such as control of symptoms and limiting condition progression and medication adherence (Morgan et al, 2017). Narrow approaches to self-management can overlook the impact of multi-morbidity and personal and social contexts and concepts such as empowerment may be likened to compliance rather than self-management (Morgan et al, 2017; Dineen-Griffin et al, 2019). In contrast, more general support may underestimate the complexity of individual circumstances and can cognitively overload older people (Federman et al, 2019). Finally, poor relationships with healthcare providers, including nurses, and support not underpinned by positive interpersonal skills may also be less effective (Schulman-Green et al, 2016). In contrast, broader nursing conceptualisations of self-management, focusing on illness meaning, quality of life and autonomy, have been found to be more successful strategies, requiring nurse engagement in meaningful conversations with older adults and attuning to lived experiences (Morgan et al, 2017).
Health systems-related factors
Support of self-management is indivisible from high-quality healthcare involving a service culture that actively supports self-management needs for those living with chronic illness (Taylor et al, 2014). Access to health care, continuity of care and ability to navigate complex health systems may make self-management challenging (Schulman-Green et al, 2016). Multiple care providers may further result in the provision of conflicting information or information overload (Federman et al, 2019; Gobeil-Lavoie et al, 2019). There is a consequent need for organisational support, including the availability of a self-management infrastructure underpinned by policy, finances and resources (HSE, 2017). One such approach is the Chronic Care Model, an organisational model of care relevant across the continuum of care (Wagner et al, 2001). This model has the core elements of person-centred care, self-management support and clinical information systems to facilitate the integration of care. Finally, organisational support is also required to facilitate the education of nurses on the requisite skills of self-management support to underpin its implementation across the continuum of care (Taylor et al, 2014).
The role of the nurse in self-management support
Mills et al defined self-management support as a:
‘Grouping of structures, systems, policies, services and programs that extend across healthcare, social sectors and communities to support and improve the way people manage their own chronic conditions and optimize their health and live well. Self-management support can increase people's capacity to live well with chronic conditions by addressing some of the broad social and individual factors that influence their behaviour and is a shared responsibility between individuals and society.’
Self-management support needs to be reflective of the service users' circumstances and real-life priorities (Kennedy et al, 2014). Thus, nurses need to ascertain service user capacity for self-management and person-centred assets in this regard (Kastner et al, 2019). To this end, recognition that an individual living with chronic illness is the expert in their own personal experiences of their illness, determinants of health, personal goals, preferences and values is required. Nurses therefore need to prioritise the needs of the individual rather than the organisation, and the importance of interpersonal skills and building relationships cannot be underestimated. To achieve this, nurses need to deliver person-centred care to include physical, emotional and social wellbeing supports when promoting self-management with older adults (Gallagher et al, 2008).
The provision of person-centred care and integration of cross-organisation/cross-setting care are key competencies of registered nurses (NMC, 2018), both of which are relevant to self-management support. Furthermore, the Royal College of Nursing (2020) identified the key aspects of the nurse's role in promoting self-management support. These include: supporting healthy choices, information signposting, provision of advice and information by Making Every Contact Count and education to enable self-management and symptom management. Thus, nurse promotion of service user empowerment is a priority so that the older adult can implement the self–management interventions outlined in Figure 1. To support this, Figure 2 outlines the role of the nurse in promoting self-management and how the principles of person-centred care and Making Every Contact Count (HSE, 2016; Public Health England et al, 2016) underpin this role.
For those identified as vulnerable, person-centred self-management support requires a needs assessment focusing on health literacy and psychosocial functioning to minimise barriers to accessing self-management support programmes (WHO, 2013; Mills et al, 2017). The four key components of health literacy are accessing, understanding and appraising the information and, finally, using the information to make an informed decision about health care (Stormacq et al, 2020). One suggested strategy for nurses to foster the acquisition of knowledge to support self-management is the ‘Teach-back’ method, also known as ‘show me’, which requires ascertaining an older person's comprehension following education on a specific topic (Ha Dinh et al, 2016; Oh et al, 2021). The key components of this method are outlined in Box 2 (Teach-back Training, 2021).
Box 2.Key components of the ‘Teach-back’ method
- Use plain language when talking to older adults
- Use reader-friendly print materials to support learning
- Employ the principles of effective and person-centred communication skills such as a caring tone, good eye contact and attendance to body language
- Use open questions, avoid embarrassing questions and avoid closed questions
- Ask the service user to explain back what you have explained to them, using their own words
- If the service user is not able to Teach-back accurately, explain again and re-check
- The nurse should understand that the health service provider is responsible for explaining clearly to the older adult
Source: Teach-back Training, 2021
Other strategies that nurses may use to promote self-management support include identifying and referring to social support interventions that include peer mentoring, peer support and socialising or befriending others with the same chronic illnesses. The linked types of social support nurses may provide may include emotional, informational and tangible support in the form of advice on where to seek financial assistance, services, devices, peer support and, finally, appraisal support to assist an individual to become more self-aware and evaluate their progress (Taylor et al, 2014).
Nurses can also refer patients to relevant self-management programmes for a formalised support programme. For example, the Stanford Chronic Disease Self-management Programme, originally developed in the USA, is a 4 to 6-week peer-led programme that supports participants to enhance their knowledge, confidence and skills to manage their symptoms and thus their chronic illness (Hevey et al, 2020). This programme is for any individual with a chronic illness, whereas the Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND) programme is specifically for individuals with diabetes (Davies et al, 2008). Box 3 includes examples of website resources on these and other programmes.
Box 3.Examples of self-management support programmesProgrammes for health professionalsQISMET (Quality Institute for Self-Management Education and Training). Accredits self-management programmes in the UK: https://www.qismet.org.uk/Programmes for individuals with a chronic conditionStanford Self-Management Chronic Illness Programme (USA): https://selfmanagementresource.com/Living Well Programme (Ireland): https://www.hse.ie/eng/health/hl/selfmanagement/living-well-programme/living-well-programme.htmlProgrammes for individuals with diabetesX-Pert Health: https://www.xperthealth.org.uk/programmes/DESMOND (Diabetes Education and Self Management for Ongoing and Newly Diagnosed): https://www.desmond.nhs.uk/
There is a risk that support of self-management could lead to nurses assuming that older adults are willing to be involved and take responsibility for their health. However, nurses have reported some resultant tensions that can occur in practice. Van het Bolscher-Niehuis et al (2020) identified two such potential tensions:
- Striving for optimal health and wellbeing versus respecting older adults' choices
- Stimulating self-reliance and self-direction versus accepting a ‘dependent attitude’.
The nature of such tensions suggests the role of the nurse as an advocate is critical in self-management support. Advocacy can play an integral nursing role in the promotion of patient wellbeing, and involve respect of patient autonomy, acting on behalf of patients and advocating for social justice in health care (Vaartio and Leino-Kilpi, 2005; Bu and Jezewski, 2007). Abbasinia et al (2020) identified the attributes of nurse advocacy outlined in Table 2, which are relevant to supporting older adults to self-manage. This implies that nurses should personalise self-management support to the individual and demonstrate dexterous movement between related competencies and go beyond a traditional focus on the patient's medical condition(s) (Coates, 2017).
Table 2. Attributes of nursing advocacy
| Key attributes | Examples |
|---|---|
| Apprising | Information provision, education |
| Valuing | Enabling free decision-making, respect of values, beliefs, culture and choices |
| Mediating | Liaising and communicating patient preferences, supporting need articulation |
| Championing social justice in health care | Facilitating resource and service access, confronting policy |
| Safeguarding | Patient protection |
Source: Abbasinia et al, 2020
Conclusion
Older adults with chronic illness, including those living with multiple comorbidities, require nurses to have the necessary competencies to support self-management. While self-management support is viewed as a compendium of tools to support people to choose healthy actions, it is also to be understood as a person-professional relationship characterised by collaborative partnership and enablement (Dineen-Griffin et al, 2019). Nurses are ideally placed to practically support the implementation of innovative self-management practices across the continuum of care, with a key co-ordinating role. This is important, given the known fragmentation in care both within and across care settings. To this end, nurses require competency in supporting self-management using an empowering person-centred approach that is responsive to the individual needs and preferences of each older adult.
KEY POINTS
- The self-management of chronic illness includes medication management, self-testing, self-awareness and emotional and role management
- Older adults are more likely to have multiple comorbidities and thus the self-management of these is more complex
- Nurses are in a pivotal position to support self-management with older adults using a person-centred empowering framework
- Nurses can promote self-management support by delivering person-centred care and using social support strategies and teaching strategies such as the ‘Teach-back’ method
CPD reflective questions
- With reference to your role, what opportunities for self-management support with older people can you identify?
- Reflect on your current knowledge and competency in relation to self-management support. If you have related learning needs, how could you expand your current knowledge and skills to address these?
- Compare the self-management support strategies you currently draw on with those identified in this article. Are there opportunities within your scope of practice to expand and/or enhance those strategies you currently employ?