Evidence on self-care support within community nursing. This is an extended version of the article published in Nursing Times; 104: 14, 32-33.
Colin Macduff, PhD, MSc, DipN, RMN, RGN, is lecturer, The Robert Gordon University, Aberdeen; Judy Sinclair, RGN, RSCPHN, is family health nurse, NHS Orkney.
Macduff, C., Sinclair, J. (2008) Evidence on self-care support within community nursing. This is an extended version of the article published in Nursing Times; 104: 14, 32-33.
BACKGROUND: There is a lack of explicit research evidence on community nurses’ support for self-care with patients with long-term conditions.
AIM: To examine the nature and extent of support for patient self-care documented in district and family health nursing casenotes.
METHOD: Qualitative case-study and audit methods were used to review 47 casenotes from three Scottish sites on six long-term conditions.
RESULTS: Considerable variation in written evidence of support for self-care was evident within and across sites, and across the different long-term conditions.
DISCUSSION: Questions about support for self-care and related anticipatory care are highlighted when the rhetoric of current policy and the reality of current service provision meet.
CONCLUSION: There is scope for more systematic consideration of support for self-care within community nursing casenotes.
During the past five years UK health policy has strongly advocated the promotion of self-care as a means for improving health, particularly for patients with long-term conditions (Department of Health, 2005). A number of models to enable this development have been tested (Singh and Ham, 2006), but evidence of their effectiveness is mixed (Coulter and Ellins, 2006). Supporting self-care has been identified recently as one of the seven core elements of a redesigned community nursing model in Scotland (Scottish Executive Health Department, 2006). Nevertheless, little is known about support for self-care currently provided by community nurses for patients with long-term conditions. This article aims to address this gap.
Although other community nurses, such as practice nurses and health visitors, have valuable roles in supporting patients with long-term conditions, this article focuses on district nursing and family health nursing. District nursing takes place primarily in patients’ homes and has a long tradition of working with people who have long-term conditions (Goodman et al, 2003). By contrast, family health nursing is a much newer discipline, introduced in Scotland in 2001 as part of a World Health Organization pilot project (Macduff, 2007). The family health nurse (FHN) role is multifaceted and aspires to help individuals, families and communities to cope with illness and improve their health.
Self-care is a broad term comprising everything that people do to maintain health, prevent illness, seek and adhere to treatment, manage symptoms and side-effects, accomplish recovery and rehabilitation, and manage the impact of long-term illness and disability (Alliance for Self-care Research, 2008). Professional support for self-care may also range widely, from general facilitation (such as setting up the conditions under which self-care might take place), through to actively enabling self-management programmes (for example, focus on joint goal-setting and follow up). The document Delivering for Health (SEHD, 2005) uses the tiered triangle, developed in the US by Kaiser Permanente (Fig 1) to illustrate the relationship between professional care and self-care in managing long-term conditions.
As Fig 1 suggests, the main interface for community nurses and their teams is likely to be at the ‘shared care’ level, engaging with patients who have existing morbidity, and often co-morbidities. However, the district and family health nursing contribution to supporting self-care with these patients is largely unknown in Scotland.
This premise (outlined above) stems from our initial review of UK community nursing literature, which found little published material focusing specifically on nursing support for self-care. Instead, previous studies have examined related topics where the idea of support for self-care may often be implicit but is rarely made explicit. For example, Cantrell’s (1998) qualitative research found that district nurses perceived health education to be an important part of their role, but neither the nurse participants nor the researcher overtly discussed this in terms of support for self-care. The same can be said for other relevant studies of district nursing knowledge (McIntosh, 1996); community nurses’ decision-making (Bryans and McIntosh, 1996); district nursing skills (McIntosh et al, 1999); and district nursing assessment practice (Kennedy, 2004).
However, a more recent review of selected international literature by Kennedy et al (2006) suggested that interventions delivered over a prolonged period may have value in supporting self-care for patients and their families. As there are rapidly growing bodies of research on long-term conditions and self-care respectively, our team is currently working to identify, map and review areas of intersection with community nursing (Fig 2).
It seems clear from our ongoing searches that there is little empirical evidence about the actual nature and scope of Scottish community nursing practice in supporting self-care for patients with long-term conditions. Moreover, it is unclear which elements of practice are useful. Our team is therefore researching district nursing and family health nursing practice in two Scottish regions. We are focusing on three sites, each of which uses different nursing models:
- Orem’s (1971) self-care deficit nursing model;
- Roper et al’s (1983) activities of daily living model;
- A family health nursing adaptation.
Orem’s (1971) self-care deficit nursing model aims to guide nurses to identify gaps in self-care and respond in a way that optimises individual patients’ behaviour. This is the foundation for three nursing systems (wholly compensatory; partly compensatory; and supportive-educative), which correspond closely to the SEHD portrayal in Fig 1. As such, there would seem much to learn from studying community nursing practice that draws on such an explicit self-care model.
Perhaps the most widely used and adapted nursing model within the community is Roper et al’s (1983) activities of daily living model. This guides nurses to assess, plan, deliver and evaluate care in relation to 12 key activities. Underpinning the model is the notion that individual patients’ abilities to perform these activities will relate to their current level of functioning on a continuum from dependence to independence. Thus, it tends to address support for self-care in a more implicit manner than Orem’s (1971) model.
More recently, the FHN role has been introduced to community nursing in Scotland (Macduff, 2007). The theoretical basis guiding this practice is derived mainly from family systems theory, whereby nurses are guided to assess family resources and coping strategies in response to threats to health. Individual self-care behaviour would be seen to take place within this context. Accordingly, the model addresses support for self-care from a different angle and, again, the approach is less overt than that of Orem. At present the family health nursing model is primarily used in remote and rural regions.
The main aim was to clarify the nature and extent of support for patient self-care recorded in nursing casenotes. The study also sought to compare the potential of three community nursing models to support self-care, and to investigate the extent to which casenotes can inform such a comparison.
This study mainly used qualitative case-study methods to explore these different models in different contexts. The three sites each covered populations of around 8,000-12,000, but varied in nature (one was in a large city while the other two were primarily rural). Patients on district nurse or FHN caseloads who had one or more of six long-term conditions (diabetes, depression, dementia, heart failure, multiple sclerosis (MS) and leg ulcer) and who were not acutely or terminally ill were invited to take part by letter – a total of 124 letters were sent.
The invitation asked patients to give consent for the research team to access their nursing notes. The team was also keen to include scrutiny of the notes of patients with dementia who lacked capacity to consent, but who had a welfare guardian or nearest relative who could do so on their behalf. Ethical approval for this, and for the study as a whole, was obtained from the NHS Research Ethics Service.
A data collection form for extracting information about how nurses support self-care was developed. This was informed by:
- A review of self-care and self-management literature;
- A study of ‘blank’ casenotes from each site;
- General consultations with community nursing educators, managers and practitioners in the participating regions.
The data form used criteria relating to each element of the nursing process in order to help categorisation of self-care consideration in the notes. Similar criteria were also developed to assess elements of Glasgow et al’s (2002) self-management model. This comprises five areas to help patients with action-planning: assessing, advising, agreeing goals, assisting and arranging plans for follow up.
All data collection and analysis from casenotes was done jointly by the authors on visits to sites.
From the 124 patients invited to take part, 54 (44%) consented to their nursing casenotes being accessed. It was possible to analyse 47 of these during site visits. Seven sets of notes were not accessed, mainly because patients had recently become more acutely ill. In one case it was not possible for the notes to be made available on the appropriate day. The relative proportions of particular long-term conditions varied across the sites.
Eighteen casenotes were reviewed in site 1, 17 in site 2 and 12 in site 3. Although FHNs led the care of patients in site 2, they typically used casenotes based on an Orem adaptation, rather than the distinctive notes developed during the Scottish pilot of the role (Macduff, 2007). The latter notes were only used in two of the 17 cases reviewed in site 2. Accordingly, the research only really explored the use of two nursing models: an adaptation of Orem’s (1971) model (site 1 and, in the main, site 2) and an adaptation of Roper et al’s (1983) model (site 3).
Tables 1 and 2 present findings about the nature and extent of evidence of support for self-care. Both show considerable variation with regard to written evidence of support for self-care. This is evident within and across sites, nevertheless some common trends can be seen.
Table 1. Number of casenotes showing evidence of consideration of self-care related to stages of nursing process
|Substantial, developed consideration of self-care (%)||Some consideration of self-care, but little development (%)||Very superficial or no consideration of self-care (%)|
|Site 1||3 (17)||10 (56)||5 (28)|
|Site 2||2 (12)||7 (41)||8 (47)|
|Site 3||0 (0)||6 (50)||6 (50)|
|Site 1||3 (17)||9 (50)||6 (33)|
|Site 2||0 (0)||9 (53)||8 (47)|
|Site 3||0 (0)||4 (33)||8 (67)|
|Site 1||1 (6)||5 (28)||12 (67)|
|Site 2||2 (12)||5 (29)||10 (59)|
|Site 3||0 (0)||5 (42)||7 (58)|
Table 2. Number of casenotes showing evidence of consideration of self-care related to stages of self-management model
|Substantial, developed consideration of self-care (%)||Some consideration of self-care, but little development (%)||Very superficial or no consideration of self-care (%)|
|Site 1||6 (33)||12 (67)||0 (0)|
|Site 2||3 (18)||12 (71)||2 (12)|
|Site 3||1 (8)||5 (42)||6 (50)|
|Site 1||1 (6)||8 (44)||9 (50)|
|Site 2||2 (12)||7 (41)||8 (47)|
|Site 3||1 (8)||5 (42)||6 (50)|
|Site 1||0 (0)||6 (33)||12 (67)|
|Site 2||2 (12)||1 (6)||14 (82)|
|Site 3||0 (0)||2 (17)||10 (83)|
|Site 1||2 (11)||10 (56)||6 (33)|
|Site 2||2 (12)||10 (59)||5 (29)|
|Site 3||1 (8)||6 (50)||5 (42)|
|Site 1||0 (0)||13 (72)||5 (28)|
|Site 2||1 (6)||10 (59)||6 (35)|
|Site 3||1 (8)||8 (67)||3 (25)|
As Tables 1 and 2 suggest, consideration of self-care was usually most evident within assessment structures and processes. Where an assessment structure directly addressed self-care there was more likely to be evidence of it being explicitly considered in both assessment and subsequent planning processes. This typically took the form of considering patients’ and/or carers’ self-care abilities, needs and/or dependencies, but some of the best assessments and plans also addressed patients’ and carers’ understandings, motivations and related consequences for self-care capacities. This brought breadth and depth to these written care plans.
Compared with other phases of the nursing process and of Glasgow et al’s (2002) self-management model, assessment emerged as the activity that most often explicitly considered self-care. However, this often had the quality of a ‘one-off’ episode, with formal reassessment or updates relatively rare. Moreover, this was often the case even when it was clear that the status of the patient and/or carer had changed considerably. In a few casenotes there was no evidence at all of a formal process of assessment.
Evidence of planning that explicitly considered self-care was more mixed. In a few ‘best cases’, there was explicit consideration of patient and/or carers’ roles, aims/goals, and nursing care planned to support related activities. However, there was very rarely evidence of explicit discussion or agreement between nurse and patient or carer (that is, the collaborative goal-setting advocated in the Glasgow et al (2002) self-management model was almost never evidenced). Much more often there was either little or no consideration of patient or carer roles and associated nursing support activities. The predominant characteristic in these plans was a focus on tasks or procedures that the nurse would perform.
The intervention and evaluation aspects of the nursing process were considered together. Evidence relating to self-care tended to be noticeable by its absence in the intervention and evaluation documentation. In some notable exceptions there was substantial consideration of the extent to which interventions impacted on both patient and/or carers’ roles, and the match of these to their aims or goals. These best cases also considered the need for reassessment of goals and/or the nature and extent of related nursing support.
Much more often there was little or no consideration of the impact of nursing support on self-care. Indeed, the written evaluation of the care of these patients was typically a list of task-focused interventions, and it was relatively rare to find any analysis of why a situation or a pattern of events had developed and how this might influence a future care plan. In a few cases the presenting problem seemed to have become the focus and there was considerable need for such evaluation and reassessment.
The advise, assist and arrange stages of Glasgow et al’s (2002) self-management model can be seen as broadly contiguous with the intervention and evaluation phases of the nursing process. As such, it is perhaps not surprising that evidence of the above three stages tended to be patchy.
Perhaps because initial assessment typically seemed to have focused, at best, on behaviour rather than beliefs and knowledge, evidence of providing advice on health risks and benefits of change tended, at best, to focus on instrumental information-giving (for example, on warfarin procedures). Evidence of nursing assistance tended to reflect social or environmental support issues (and sometimes problem-solving techniques) rather than addressing personal barriers and/or strategies. Again, this might fit with a tendency towards short-term practical approaches rather than more in-depth engagement with beliefs and knowledge.
The final stage of follow-up arrangements was one of the most difficult to judge using the data collection form devised. While there was usually at least a minimal plan in place for some kind of patient follow up (such as a blood sample or clinic visit), it was often hard to know to what extent this might be engaging with any self-care needs.
The findings suggest that incorporating specific focus on self-care within community nursing casenotes can be useful, especially in terms of the initial assessment and planning stages. The Orem model adaptation addressed self-care most overtly and frequently, while the Roper et al adaptation did so more implicitly (mainly in terms of considering patient dependencies). Nevertheless, even the presence of an explicit self-care framework was not, in itself, enough to guarantee its initial use, and was certainly not enough to ensure developed and sustained use for individual patients.
At one level this is not surprising. The trend for nursing notes to be deficient in documenting evaluation has been noted elsewhere (Hale et al, 1997). Aside from nursing models, there are many other possible influences on nurses’ behaviour in documenting support for patient self-care.
These include the individual nurse’s motivation and knowledge; staffing levels, case mix and prioritising; team skill mix and morale; team leadership and role-modelling; and the constraints of writing in community nursing notes that are kept in patients’ homes. These and other factors may explain the variability seen within and across the sites studied.
However, this small-scale exploratory study has focused particularly on evidence of support for self-care in community nursing notes. As highlighted earlier, there is little evidence relating to community nursing practice in this area, despite policy drivers and the particular focus on long-term conditions. In such a situation, the priority is to build knowledge of what is actually happening before doing anything else (Hockey, cited by Mason, 2005).
In effect we had to create operational definitions of support for self-care for each of the four stages of the nursing process and of the five stages of an influential self-management model. However, the resulting approach necessarily involved making subjective judgements. As Griffiths et al (2007) highlighted, this is unavoidable, and we identified, discussed and resolved some differences in interpretation and categorisation during data collection and analysis. Nevertheless, the tools developed for this study remain ‘works in progress’ that would benefit from further development and formal testing.
There are also limits to what can be inferred about actual nursing support for self-care from scrutinising nursing notes alone. While the limitations of looking at casenote evidence as a proxy for nursing practice were evident, the ongoing wider study will provide a more rounded picture through interviews with nurses, patients and carers.
In addition to achieving its primary aim, the casenote study has also suggested some sub-themes that generate further questions. There was also variation across different long-term conditions. However, one noticeable tendency was for casenotes of patients with MS to contain more explicit consideration of self-care across more phases of the nursing process. This group of patients was typically the ‘highest scoring’ of all the long-term conditions that were taken into consideration. As they were on average a younger group, it may be that this factor influenced nursing considerations. Moreover, it was also noted that some of these patients with MS had (or had developed) considerable self-advocacy skills that influenced their expectations of service. While these observations remain speculative, there is some opportunity to explore them further in subsequent interviews with nurses.
The example of patients with MS also raises questions about whether their notes tended to ‘score higher’ simply because they, typically, had complex health issues and an uncertain disease process. However, some of these patients were relatively independent of trained nursing input (despite substantially debilitated health). In turn, this raises a question that was also evident from some patients’ notes at the other end of the scoring spectrum (that is, with patients with long-term conditions who had one focal problem such as heart failure or diabetes and who tended to have minimal engagement with nursing services). This question is: what sort of self-care consideration (nature, frequency and depth of engagement) should nurses be expected to give to patients and their carers who function relatively independently but who are in a fragile situation? On the one hand there is the view that assessment then purposive engagement will prevent future problems – arguably, this is the essence of anticipatory care from trained community nurses. Although we noted some written evidence of this sort, there often seemed much more scope for explicit anticipatory care approaches, especially with families. The other side of this argument sees self-care as signifying the point at which nursing input should be stopping (‘self-caring’ = independent = ‘off the books’).
These questions about the nature and extent of support for self-care and related anticipatory care are highlighted when the rhetoric of current policy and the reality of current service provision come together. To date, the focus has mostly been on case-management approaches for patients with relatively complex care needs through initiatives such as community matrons (Hudson, 2005).
There is significant potential for community nurses to support more patients at levels 1 and 2 (Fig 1) to self-care to prevent further health problems, but it is not at all clear whether there is, or will be, service capacity to engage substantively at these levels. The family health nursing development in Scotland included this aspiration, but the reality of trying to engage with significant numbers of families on matters of health and ill health was often problematic (Macduff, 2007). In effect, more explicit consideration needs to be given to the criteria for engaging with patients to support self-care and to enable anticipatory care approaches.
This small-scale study analysed a sample of casenotes related to different long-term conditions, different nursing models and different community nursing contexts. While the nature and extent of evidence of support for self-care was found to vary quite considerably across and within three sites, two clear implications for practice emerged:
- The incorporation of an explicit self-care framework, such as an adaptation of Orem’s model, can make consideration of support for self-care more evident in initial assessments;
- There is a need to consider support for self-care more overtly when interventions are being evaluated and/or care plans reassessed.
These measures would counteract the tendency in documented care to focus on patients’ personal needs to shift towards an almost ritualistic citation of nursing actions. They could also provide nurses with useful evidence in relation to this key element of community nursing care.
Finally, the study has highlighted further research opportunities. The operational definitions of support for self-care that have been developed may be usefully adapted and refined in future research with community nursing records. Future research might also address some of the more fundamental questions raised about community nurses’ engagement with people who have long-term conditions.
This study is funded by the Queen’s Nursing Institute Scotland. The other study team members are: Dr Peter Wimpenny, lecturer; Dr Bernice J.M. West senior lecturer; Simon Naji, reader; all at The Robert Gordon University and Thora Baeyens, district nurse, NHS Grampian.
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