problem solving approach in care of patient

What is Problem-Solving in Nursing? (With Examples, Importance, & Tips to Improve)

Whether you have been a nurse for many years or you are just beginning your nursing career, chances are, you know that problem-solving skills are essential to your success. With all the skills you are expected to develop and hone as a nurse, you may wonder, “Exactly what is problem solving in nursing?” or “Why is it so important?” In this article, I will share some insight into problem-solving in nursing from my experience as a nurse. I will also tell you why I believe problem-solving skills are important and share some tips on how to improve your problem-solving skills.

What Exactly is Problem-Solving in Nursing?

5 reasons why problem-solving is important in nursing, reason #1: good problem-solving skills reflect effective clinical judgement and critical thinking skills, reason #2: improved patient outcomes, reason #3: problem-solving skills are essential for interdisciplinary collaboration, reason #4: problem-solving skills help promote preventative care measures, reason #5: fosters opportunities for improvement, 5 steps to effective problem-solving in nursing, step #1: gather information (assessment), step #2: identify the problem (diagnosis), step #3: collaborate with your team (planning), step #4: putting your plan into action (implementation), step #5: decide if your plan was effective (evaluation), what are the most common examples of problem-solving in nursing, example #1: what to do when a medication error occurs, how to solve:, example #2: delegating tasks when shifts are short-staffed, example #3: resolving conflicts between team members, example #4: dealing with communication barriers/lack of communication, example #5: lack of essential supplies, example #6: prioritizing care to facilitate time management, example #7: preventing ethical dilemmas from hindering patient care, example #8: finding ways to reduce risks to patient safety, bonus 7 tips to improve your problem-solving skills in nursing, tip #1: enhance your clinical knowledge by becoming a lifelong learner, tip #2: practice effective communication, tip #3: encourage creative thinking and team participation, tip #4: be open-minded, tip #5: utilize your critical thinking skills, tip #6: use evidence-based practices to guide decision-making, tip #7: set a good example for other nurses to follow, my final thoughts, list of sources used for this article.

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Evidence-Based Practice, Step by Step: Asking the Clinical Question

A key step in evidence-based practice.

Stillwell, Susan B. DNP, RN, CNE; Fineout-Overholt, Ellen PhD, RN, FNAP, FAAN; Melnyk, Bernadette Mazurek PhD, RN, CPNP/PMHNP, FNAP, FAAN; Williamson, Kathleen M. PhD, RN

Susan B. Stillwell is clinical associate professor and program coordinator of the Nurse Educator Evidence-Based Practice Mentorship Program at Arizona State University in Phoenix, where Ellen Fineout-Overholt is clinical professor and director of the Center for the Advancement of Evidence-Based Practice, Bernadette Mazurek Melnyk is dean and distinguished foundation professor of nursing, and Kathleen M. Williamson is associate director of the Center for the Advancement of Evidence-Based Practice.

Contact author: Susan B. Stillwell, [email protected] .

This is the third article in a series from the Arizona State University College of Nursing and Health Innovation's Center for the Advancement of Evidence-Based Practice. Evidence-based practice (EBP) is a problem-solving approach to the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise and patient preferences and values. When delivered in a context of caring and in a supportive organizational culture, the highest quality of care and best patient outcomes can be achieved.

The purpose of this series is to give nurses the knowledge and skills they need to implement EBP consistently, one step at a time. Articles will appear every two months to allow you time to incorporate information as you work toward implementing EBP at your institution. Also, we've scheduled "Ask the Authors" call-ins every few months to provide a direct line to the experts to help you resolve questions. Details about how to participate in the next call will be published with May's Evidence-Based Practice, Step by Step.

In this third article on implementing evidence-based practice, the authors discuss how to create a well-formulated clinical question.

To fully implement evidence-based practice (EBP), nurses need to have both a spirit of inquiry and a culture that supports it. In our first article in this series ("Igniting a Spirit of Inquiry: An Essential Foundation for Evidence-Based Practice," November 2009), we defined a spirit of inquiry as "an ongoing curiosity about the best evidence to guide clinical decision making." A spirit of inquiry is the foundation of EBP, and once nurses possess it, it's easier to take the next step—to ask the clinical question. 1 Formulating a clinical question in a systematic way makes it possible to find an answer more quickly and efficiently, leading to improved processes and patient outcomes.

In the last installment, we gave an overview of the multistep EBP process ("The Seven Steps of Evidence-Based Practice," January). This month we'll discuss step one, asking the clinical question. As a context for this discussion we'll use the same scenario we used in the previous articles (see Case Scenario for EBP: Rapid Response Teams ).

In this scenario, a staff nurse, let's call her Rebecca R., noted that patients on her medical–surgical unit had a high acuity level that may have led to an increase in cardiac arrests and in the number of patients transferred to the ICU. Of the patients who had a cardiac arrest, four died. Rebecca shared with her nurse manager a recently published study on how the use of a rapid response team resulted in reduced in-hospital cardiac arrests and unplanned admissions to the critical care unit. 2 She believed this could be a great idea for her hospital. Based on her nurse manager's suggestion to search for more evidence to support the use of a rapid response team, Rebecca's spirit of inquiry led her to take the next step in the EBP process: asking the clinical question. Let's follow Rebecca as she meets with Carlos A., one of the expert EBP mentors from the hospital's EBP and research council, whose role is to assist point of care providers in enhancing their EBP knowledge and skills.

Types of clinical questions. Carlos explains to Rebecca that finding evidence to improve patient outcomes and support a practice change depends upon how the question is formulated. Clinical practice that's informed by evidence is based on well-formulated clinical questions that guide us to search for the most current literature.

There are two types of clinical questions: background questions and foreground questions. 3-5 Foreground questions are specific and relevant to the clinical issue. Foreground questions must be asked in order to determine which of two interventions is the most effective in improving patient outcomes. For example, "In adult patients undergoing surgery, how does guided imagery compared with music therapy affect analgesia use within the first 24 hours post-op?" is a specific, well-defined question that can only be answered by searching the current literature for studies comparing these two interventions.

Background questions are considerably broader and when answered, provide general knowledge. For example, a background question such as, "What therapies reduce postoperative pain?" can generally be answered by looking in a textbook. For more information on the two types of clinical questions, see Comparison of Background and Foreground Questions . 4-6

Ask the question in PICOT format. Now that Rebecca has an understanding of foreground and background questions, Carlos guides her in formulating a foreground question using PICOT format.

PICOT is an acronym for the elements of the clinical question: patient population (P), intervention or issue of interest (I), comparison intervention or issue of interest (C), outcome(s) of interest (O), and time it takes for the intervention to achieve the outcome(s) (T). When Rebecca asks why the PICOT question is so important, Carlos explains that it's a consistent, systematic way to identify the components of a clinical issue. Using the PICOT format to structure the clinical question helps to clarify these components, which will guide the search for the evidence. 6 , 7 A well-built PICOT question increases the likelihood that the best evidence to inform practice will be found quickly and efficiently. 5-8

To help Rebecca learn to formulate a PICOT question, Carlos uses the earlier example of a foreground question: "In adult patients undergoing surgery, how does guided imagery compared with music therapy affect analgesia use within the first 24 hours post-op?" In this example, "adult patients undergoing surgery" is the population (P), "guided imagery" is the intervention of interest (I), "music therapy" is the comparison intervention of interest (C), "pain" is the outcome of interest (O), and "the first 24 hours post-op" is the time it takes for the intervention to achieve the outcome (T). In this example, music therapy or guided imagery is expected to affect the amount of analgesia used by the patient within the first 24 hours after surgery. Note that a comparison may not be pertinent in some PICOT questions, such as in "meaning questions," which are designed to uncover the meaning of a particular experience. 3 , 6 Time is also not always required. But population, intervention or issue of interest, and outcome are essential to developing any PICOT question.

Carlos asks Rebecca to reflect on the clinical situation on her unit in order to determine the unit's current intervention for addressing acuity. Reflection is a strategy to help clinicians extract critical components from the clinical issue to use in formulating the clinical question. 3 Rebecca and Carlos revisit aspects of the clinical issue to see which may become components of the PICOT question: the high acuity of patients on the unit, the number of cardiac arrests, the unplanned ICU admissions, and the research article on rapid response teams. Once the issue is clarified, the PICOT question can be written.

Because Rebecca's issue of interest is the rapid response team—an intervention—Carlos provides her with an "intervention or therapy" template to use in formulating the PICOT question. (For other types of templates, see Templates and Definitions for PICOT Questions . 5 , 6 ) Since the hospital doesn't have a rapid response team and doesn't have a plan for addressing acuity issues before a crisis occurs, the comparison, or (C) element, in the PICOT question is "no rapid response team." "Cardiac arrests" and "unplanned admissions to the ICU" are the outcomes in the question. Other potential outcomes of interest to the hospital could be "lengths of stay" or "deaths."

Rebecca proposes the following PICOT question: "In hospitalized adults (P), how does a rapid response team (I) compared with no rapid response team (C) affect the number of cardiac arrests (O) and unplanned admissions to the ICU (O) during a three-month period (T)?"

Now that Rebecca has formulated the clinical question, she's ready for the next step in the EBP process, searching for the evidence . Carlos congratulates Rebecca on developing a searchable, answerable question and arranges to meet with her again to mentor her in helping her find the answer to her clinical question. The fourth article in this series, to be published in the May issue of AJN , will focus on strategies for searching the literature to find the evidence to answer the clinical question.

Now that you've learned to formulate a successful clinical question, try this exercise: after reading the two clinical scenarios in Practice Creating a PICOT Question , select the type of clinical question that's most appropriate for each scenario, and choose a template to guide you. Then formulate one PICOT question for each scenario. Suggested PICOT questions will be provided in the next column.

Case Scenario for EBP: Rapid Response Teams

You're a staff nurse on a busy medical–surgical unit. Over the past three months, you've noticed that the patients on your unit seem to have a higher acuity level than usual, with at least three cardiac arrests per month, and of those patients who arrested, four died. Today, you saw a report about a recently published study in Critical Care Medicine on the use of rapid response teams to decrease rates of in-hospital cardiac arrests and unplanned ICU admissions. The study found a significant decrease in both outcomes after implementation of a rapid response team led by physician assistants with specialized skills. 2 You're so impressed with these findings that you bring the report to your nurse manager, believing that a rapid response team would be a great idea for your hospital. The nurse manager is excited that you have come to her with these findings and encourages you to search for more evidence to support this practice and for research on whether rapid response teams are valid and reliable.

Practice Creating a PICOT Question

Scenario 1: You're a recent graduate with two years' experience in an acute care setting. You've taken a position as a home health care nurse and you have several adult patients with various medical conditions. However, you've recently been assigned to care for hospice patients. You don't have experience in this area, and you haven't experienced a loved one at the end of life who's received hospice care. You notice that some of the family members or caregivers of patients in hospice care are withdrawn. You're wondering what the family caregivers are going through, so that you might better understand the situation and provide quality care.

Scenario 2: You're a new graduate who's accepted a position on a gerontology unit. A number of the patients have dementia and are showing aggressive behavior. You recall a clinical experience you had as a first-year nursing student in a long-term care unit and remember seeing many of the patients in a specialty unit for dementia walking around holding baby dolls. You're wondering if giving baby dolls to your patients with dementia would be helpful.

What type of PICOT question would you create for each of these scenarios? Select the appropriate templates and formulate your questions.

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What is Problem Solving in Health and Social Care?

May 28, 2024

Table of Contents

Problem solving in health and social care is a systematic process employed to address and overcome challenges that arise in the provision of care to individuals and communities.

This process is integral to ensuring effective, efficient, and high-quality services that meet the varying needs of patients and service users.

This often involves several key steps:

• Identifying the Problem: The first step is to clearly recognise and define the issue. This might be a clinical problem, such as a recurrent infection in a patient, or a systemic issue, like delays in service delivery. Defining the problem accurately helps in understanding its scope and impact.
• Gathering Information: This involves collecting all relevant data and information related to the problem. It could include patient health records, staff observations, service user feedback, and statistical data. Gathering comprehensive information ensures that all aspects of the problem are considered.
• Analysing the Information: Once the data is collected, it needs to be thoroughly analysed to identify patterns, root causes, and potential contributing factors. Tools such as SWOT analysis (Strengths, Weaknesses, Opportunities, Threats), fishbone diagrams , and flowcharts can be utilised to visualise and dissect the problem.
• Generating Solutions: Based on the analysis, various potential solutions are brainstormed. It’s important to consider multiple approaches and evaluate their feasibility, effectiveness, and resource implications. Solutions should be evidence-based and tailored to the specific context of the problem.
• Implementing Solutions: This stage involves putting the chosen solution into action. It may require changes in procedures , the introduction of new technologies, training for staff, or adjustments in resource allocation. Implementation should be planned carefully to ensure smooth execution and minimal disruption to services.
• Monitoring and Evaluating: After the solution is implemented, it is critical to monitor its impact and evaluate its effectiveness. This can be done through regular assessments, patient feedback, performance metrics, and follow-up studies. Monitoring helps to ensure that the problem is resolved and that the solution is sustainable.
• Adjusting as Necessary: If the solution is not achieving the desired outcomes, adjustments may be necessary. This step involves being flexible and adaptive, ready to make modifications or, if required, to reconsider alternative solutions.

Examples of Problem Solving in Care Settings

Let’s consider several care settings and provide examples of how problem solving can be applied in each:

Hospital Setting

Problem: High Rates of Hospital-Acquired Infections (HAIs)

• Identifying the Problem: Observing an increase in infection rates over the past six months.
• Gathering Information: Collecting data on infection cases, reviewing hygiene protocols, interviewing staff, and analysing patient records.
• Analysing the Information: Identifying common factors such as specific wards with higher infection rates, lapses in hand hygiene practices, and issues with sterilisation of equipment.
• Generating Solutions: Introducing rigorous hand hygiene training, revising sterilisation procedures, increasing availability of hand sanitisers, and more frequent cleaning schedules.
• Implementing Solutions: Rolling out new hygiene training programmes, updating sterilisation guidelines, and ensuring compliance through regular audits.
• Monitoring and Evaluating: Regularly assessing infection rates to measure the impact of these measures.
• Adjusting as Necessary: Making tweaks to the strategy based on feedback and infection rate data, such as focusing on high-risk areas or re-evaluating cleaning products used.

Care Home Setting

Problem: Residents Experiencing Social Isolation

• Identifying the Problem: Noticing lower morale among residents, a decline in participation in social activities , and increased reports of loneliness .
• Gathering Information: Speaking with residents, staff, and families, as well as reviewing activity participation records and mental health reports.
• Analysing the Information: Recognising patterns suggesting that certain residents are more isolated due to factors like physical mobility issues or lack of family visits.
• Generating Solutions: Introducing more inclusive social activities, utilising technology to facilitate virtual family interactions, and implementing a buddy system among residents.
• Implementing Solutions: Organising a range of activities that cater to different interests and abilities, setting up video call stations, and pairing residents for mutual support.
• Monitoring and Evaluating: Tracking participation in activities, conducting regular resident satisfaction surveys, and evaluating changes in mental health metrics.
• Adjusting as Necessary: Refining activities based on resident preferences, providing additional training for staff to facilitate social interactions, and enhancing technological solutions.

Community Health Setting

Problem: Low Uptake of Preventative Health Services (e.g., Vaccinations)

• Identifying the Problem: Observing lower than expected vaccination rates in the community.
• Gathering Information: Conducting surveys and focus groups , reviewing demographic data, and consulting with community leaders.
• Analysing the Information: Identifying barriers such as misinformation, lack of awareness, logistical issues (e.g., clinic hours), and cultural beliefs impacting vaccination rates.
• Generating Solutions: Launching an awareness campaign, extending clinic hours, partnering with local leaders to build trust , and providing mobile vaccination units.
• Implementing Solutions: Executing communication strategies through various media, organising community events, and ensuring flexible and accessible vaccination services.
• Monitoring and Evaluating: Measuring vaccination rates periodically, collecting feedback from the community, and monitoring attendance at mobile clinics.
• Adjusting as Necessary: Tweaking the communication strategy, perhaps via more targeted messaging or additional outreach efforts, and adjusting the operational hours of vaccination services based on community needs.

Mental Health Service Setting

Problem: High Wait Times for Mental Health Services

• Identifying the Problem: Realising that individuals seeking mental health support face significantly long wait times for appointments.
• Gathering Information: Reviewing appointment schedules, patient records, and input from mental health professionals.
• Analysing the Information: Finding bottle-necks such as limited number of professionals, inefficiencies in booking systems, and high no-show rates for appointments.
• Generating Solutions: Increasing staffing levels, enhancing the efficiency of the booking system, implementing reminder systems, and offering group therapy sessions.
• Implementing Solutions: Recruiting additional mental health professionals, upgrading IT systems to streamline booking, and introducing automated reminders.
• Monitoring and Evaluating: Tracking wait times, measuring patient satisfaction, and analysing attendance rates.
• Adjusting as Necessary: Making adjustments such as redistributing workloads, further improving the appointment system, or offering additional support in high-demand periods.

Primary Care Setting

Problem: Medication Non-Adherence Among Patients

• Identifying the Problem: Recognising that a significant number of patients are not adhering to their prescribed medication regimens.
• Gathering Information: Reviewing patient records, conducting surveys, and discussing with healthcare providers and pharmacists.
• Analysing the Information: Identifying reasons for non-adherence such as side effects, complexity of medication regimens, lack of understanding, and patient forgetfulness.
• Generating Solutions: Simplifying medication regimens where possible, providing patient education, using pill organisers, and implementing reminder systems.
• Implementing Solutions: Working with healthcare providers to streamline prescriptions, developing educational materials, distributing pill organisers, and initiating SMS or app-based reminders.
• Monitoring and Evaluating: Checking adherence rates through follow-up appointments, pharmacy refill rates, and patient feedback.
• Adjusting as Necessary: Adjusting educational approaches, enhancing reminder systems, and offering more personalised support as needed.

In each of these settings, the problem-solving approach not only addresses immediate issues but also supports continuous improvement , ensuring high standards of care and better outcomes for all involved.

Final Thoughts

In the health and social care sector, problem solving often requires collaboration across multidisciplinary teams , encompassing doctors, nurses, social workers, care managers, and other healthcare professionals. Effective communication , shared decision-making, and a person-centred approach are crucial elements in this collaborative effort.

Moreover, problem solving in this sector must be aligned with national standards and regulations, such as those set out by the Care Quality Commission (CQC) and the National Institute for Health and Care Excellence (NICE) . Compliance with these standards ensures that solutions not only address individual problems but also contribute to the overarching goals of safety, quality, and equity in care provision.

In summary, problem solving in health and social care is a dynamic and multi-faceted process aimed at improving outcomes for both service users and care providers. By adhering to systematic methods and collaborative practices, the sector can more effectively navigate the complexities and challenges it faces.

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The website may be down at times on Saturday, August 24, and Sunday, August 25, for maintenance. 

MARY THOESEN COLEMAN, M.D., PH.D., AND KAREN S. NEWTON, M.P.H.

Am Fam Physician. 2005;72(8):1503-1510

See editorial on page 1454.

Author disclosure: Nothing to disclose.

Support of patient self-management is a key component of effective chronic illness care and improved patient outcomes. Self-management support goes beyond traditional knowledge-based patient education to include processes that develop patient problem-solving skills, improve self-efficacy, and support application of knowledge in real-life situations that matter to patients. This approach also encompasses system-focused changes in the primary care environment. Family physicians can support patient self-management by structuring patient-physician interactions to identify problems from the patient perspective, making office environment changes that remove self-management barriers, and providing education individually and through available community self-management resources. The emerging evidence supports the implementation of practice strategies that are conducive to patient self-management and improved patient outcomes among chronically ill patients.

A global rise in life expectancy and an increase in cultural and environmental risks such as smoking, unhealthy diet, lack of physical activity, and air pollution are associated with an epidemic of chronic illness. Approximately 120 million Americans have one or more chronic illnesses, accounting for 70 to 80 percent of health care costs. Twenty-five percent of Medicare recipients have four or more chronic conditions, accounting for two thirds of Medicare expenditures. 1 , 2 Most patients with chronic conditions such as hypertension, diabetes, hyperlipidemia, congestive heart failure, asthma, and depression are not treated adequately, and the burden of chronic illness is magnified by the fact that chronic conditions often occur as comorbidities. 3

Physician support of patient self-management is one of the key elements of a systems-oriented chronic care model. 4 Increasing evidence shows that self-management support reduces hospitalizations, emergency department use, and overall managed care costs, although the cost of self-management interventions in individual nonmanaged care practices has yet to be determined. 3 , 5 – 7 A review 7 of 41 studies assessing interventions to improve diabetes outcomes in primary care revealed that adding patient-oriented interventions can lead to improvements in outcomes such as glycemic control. In 36 trials focused on adult asthma, self-management (self-monitoring coupled with medical review and a written action plan) produced greater reductions in nocturnal symptoms, hospitalizations, and emergency department use than did usual care. 8 Another community-based group program, designed to increase self-efficacy among patients with diabetes, resulted in improved self-efficacy and A1C levels. 9 Despite this encouraging evidence, self-management is the least implemented and most challenging area of chronic disease management. 10

Although the terms patient self-management, self-management support, and patient education often are used interchangeably, they do not have the same meaning. Self-management is the ability of the patient to deal with all that a chronic illness entails, including symptoms, treatment, physical and social consequences, and lifestyle changes. 11 With effective self-management, the patient can monitor his or her condition and make whatever cognitive, behavioral, and emotional changes are needed to maintain a satisfactory quality of life. 11 Self-management support is the process of making multilevel changes in health care systems and the community to facilitate patient self-management. 10 , 12 Patient education generally refers to knowledge-based instructions for a specific disease. Self-management education differs from traditional patient education in what is taught, how problems are formulated, the relation of what is taught to the disease, and the theory underlying the goal ( Table 1 ) . 13

The theory underlying patient education is that increasing a patient’s knowledge about a disease leads to behavioral change that improves clinical outcomes. An underlying theory of self-management education is that self-efficacy, or the patient’s belief in his or her own ability to accomplish a specific behavior or achieve a reduction in symptoms, leads to improved clinical outcomes. Self-management support expands the role of health care professionals from delivering information to include helping patients build confidence and make choices that lead to improved self-management and better outcomes. Patient education typically is given by a health care professional; self-management can be taught and supported by health care professionals, office support staff, peer leaders, and other patients.

The self-management challenges for persons with chronic conditions can be divided into three types: medical management, role management, and emotional management. 13 – 15 Physicians who want to provide increased support of their patients’ self-management are advised to address three areas: structuring patient-physician interactions to include goal-setting and problem-solving strategies, making office system changes, and providing self-management education by linking patients to community self-management programs. 10

Practical Applications for Physicians

There are many ways that physicians can translate this evidence for self-management support into daily practice. Primarily, this involves a shift of focus away from clinical outcomes (e.g., reducing A1C levels) and toward providing help with the day-today problems of living with chronic illness (e.g., making healthful food selections in restaurants). It may be useful for physicians making this shift to remind themselves that, for the patient, self-management is inevitable and already occurring. 10 , 16 More specific methods are discussed below, and summarized in Table 2 .

MOTIVATIONAL INTERVIEWING

Motivational interviewing is an in-depth approach to decision making intended to help patients come to their own decisions by exploring their uncertainties. The interviewer uses directive questions and reflective listening to encourage the patient to participate ( Figure 1 ) . 17 This style of interview, asking the patient provocative questions and discussing the responses, often can help uncover important self-management issues, and has been proven effective for preventing relapse in patients with alcohol dependence. 18

IDENTIFYING BARRIERS

A common barrier to successful self-management is that chronic conditions often occur as comorbidities. Patients with chronic diseases who are asked to identify barriers to self-management often cite examples such as aggravation of one condition by the symptoms or treatment of another, and problems created by multiple medication regimens. 16 , 19 , 20 Physicians can help patients set goals that will affect real-life challenges, rather than disease-oriented goals. For example, a patient with diabetes and asthma has limited ability to do the exercise needed for diabetes control; rather than focusing on reducing A1C levels, the patient could focus on breathing exercises to improve daily comfort. Additionally, the physician can address barriers that have medical treatment options. For example, if a patient with diabetes has untreated depression, this may create a barrier to effective self-management; treating the depression would help the patient cope more effectively with diabetes. Physicians could include depression assessment and treatment in diabetic care protocols as part of self-management support.

A low level of literacy is another potential barrier to active participation, and addressing health literacy in chronic illness has been associated with better outcomes. 21 Asking the patient to repeat information that has been given them is an easy way to identify any misunderstanding. 21 Additionally, giving patients clear instructions and information about how to monitor symptoms, use measurement tools, schedule appointments, and take medications makes it much easier for them to participate in setting goals and planning their actions.

PRACTICE CHANGES

Physicians can further support patient self-management by making changes in practice systems. Group visits could be scheduled for interested patients with comparable chronic illnesses (e.g., diabetes, heart disease) so that they can discuss self-managing their illnesses with others who are in similar situations. 22 The scheduling of 30- to 45-minute planned individual visits would allow patients and physicians time to address medical management issues such as symptom control and potential complications. This also would allow time for setting goals, creating plans to reach those goals, and solving the challenges of role and emotional management. 15 Office staff or other health care professionals can assist patients with planned visit tasks. Self-management support is most effective when it is consistently available from all members of the family practice. 10 Disease management guidelines could be used as prompts for patient reminders and to structure planned visits.

Systematic follow-up is another means of providing patients with support. In one controlled study, 5 weekly phone calls from a nurse manager and monthly calls from a physician were shown to improve blood sugar control and weight loss in patients with diabetes. In another trial 23 involving patients with diabetes, feedback from a touch-screen computer assessment was used to identify key barriers, which were then checked at regular intervals; this was found to increase the efficacy of dietary self-management. It also provides an example of how technology can be used to support self-management of chronic conditions.

Simple time-saving devices, such as ensuring laboratory values are available when patients arrive, reminding patients with diabetes to remove footwear while they are waiting for the physician, having self-management materials on hand, or having ready access to Web-based resources also help support patients.

COMMUNITY INTERVENTIONS

Family physicians can support patient self-management by providing information about community resources such as the local health department, chamber of commerce, and YMCA, as well as local chapters of societies such as the Arthritis Foundation and the American Lung Association. Patients with arthritis have reported improved pain control and mood through participation in programs emphasizing four efficacy-enhancing strategies: mastery of skills through learning and practice, modeling by inspirational role leaders, encouraging participants to attempt more than they are currently doing, and reinterpretation of symptoms to distinguish pain caused by disease from that caused by therapeutic exercise. 24 Many community organizations offer exercise programs, self-help groups, patient education classes, and self-management programs. The physician can serve as a conduit for directing patients to these resources, and could make office space available to community groups.

Self-management support tools are available to guide discussion between physician and patient in such a way that the patient determines his or her goal, identifies steps to achieve the goal, identifies barriers to reaching the goal, and plans for overcoming the barriers, including obtaining needed resources. 20 The Target Practice model ( Figure 2 ) 25 , 26 can be used to guide the goal-setting conversation and lead the patient toward developing a personal action plan. If the patient reports a low confidence level in accomplishing the action steps (i.e., less than 7 on a scale of zero to 10, with 10 being extremely high confidence and zero being extremely low), the physician-as-partner works with the patient to modify the plan until the patient has a confidence level of 7 or higher.

The Personal Action Plan ( Figure 3 ) 27 helps patients with chronic illness to develop a personal plan for learning a new behavior, such as starting a program to increase their physical activity. “Stoplight” tools, such as the Diabetes Zones for Management guide ( Figure 4 ) , 28 divide various signs and symptoms into green, yellow, and red management zones. Green indicates stability and good control over the condition; yellow indicates caution and suggests steps for regaining control; and red indicates a medical crisis that requires a physician’s attention.

Tools such as these may be particularly important when community resources are limited. Additional guidelines and tools for self-management are available at the Web site of the Institute for Healthcare Improvement (http://www.ihi.org/IHI/Topics/Chronic-Conditions/AllConditions/Tools) and the Improving Chronic Illness Care Web site (http://www.improvingchroniccare.org/tools/criticaltools.html).

Hoffman C, Rice D, Sung HY. Persons with chronic conditions. Their prevalence and costs. JAMA. 1996;276:1473-9.

Wagner EH. Meeting the needs of chronically ill people. BMJ. 2001;323:945-6.

Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA. 2002;288:1775-9.

Robert Wood Johnson Foundation. Improving chronic illness care. Accessed online July 20, 2005, at: http://www.improvingchroniccare.org .

Whitlock WL, Brown A, Moore K, Pavliscsak H, Dingbaum A, Lacefield D, et al. Telemedicine improved diabetic management. Mil Med. 2000;165:579-84.

Lorig KR, Ritter P, Stewart AL, Sobel DS, Brown BW, Bandura A, et al. Chronic disease self-management program: 2-year health status and health care utilization outcomes. Med Care. 2001;39:1217-23.

Renders CM, Valk GD, Griffin SJ, Wagner EH, Eijk Van JT, Assendelft WJ. Interventions to improve the management of diabetes in primary care, outpatient, and community settings: a systematic review. Diabetes Care. 2001;24:1821-33.

Gibson PG, Powell H, Coughlan J, Wilson AJ, Abramson M, Haywood P, et al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database Syst Rev. 2004;4:CD001117.

Anderson RM, Funnell MM, Butler PM, Arnold MS, Fitzgerald JT, Feste CC. Patient empowerment. Results of a randomized controlled trial. Diabetes Care. 1995;18:943-9.

Glasgow RE, Davis CL, Funnell MM, Beck A. Implementing practical interventions to support chronic illness self-management. Jt Comm J Qual Saf. 2003;29:563-74.

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Critical Thinking in Nursing: Tips to Develop the Skill

4 min read • February, 09 2024

Critical thinking in nursing helps caregivers make decisions that lead to optimal patient care. In school, educators and clinical instructors introduced you to critical-thinking examples in nursing. These educators encouraged using learning tools for assessment, diagnosis, planning, implementation, and evaluation.

Nurturing these invaluable skills continues once you begin practicing. Critical thinking is essential to providing quality patient care and should continue to grow throughout your nursing career until it becomes second nature. 

What Is Critical Thinking in Nursing?

Critical thinking in nursing involves identifying a problem, determining the best solution, and implementing an effective method to resolve the issue using clinical decision-making skills.

Reflection comes next. Carefully consider whether your actions led to the right solution or if there may have been a better course of action.

Remember, there's no one-size-fits-all treatment method — you must determine what's best for each patient.

How Is Critical Thinking Important for Nurses? 

As a patient's primary contact, a nurse is typically the first to notice changes in their status. One example of critical thinking in nursing is interpreting these changes with an open mind. Make impartial decisions based on evidence rather than opinions. By applying critical-thinking skills to anticipate and understand your patients' needs, you can positively impact their quality of care and outcomes.

Elements of Critical Thinking in Nursing

To assess situations and make informed decisions, nurses must integrate these specific elements into their practice:

• Clinical judgment. Prioritize a patient's care needs and make adjustments as changes occur. Gather the necessary information and determine what nursing intervention is needed. Keep in mind that there may be multiple options. Use your critical-thinking skills to interpret and understand the importance of test results and the patient’s clinical presentation, including their vital signs. Then prioritize interventions and anticipate potential complications. 
• Patient safety. Recognize deviations from the norm and take action to prevent harm to the patient. Suppose you don't think a change in a patient's medication is appropriate for their treatment. Before giving the medication, question the physician's rationale for the modification to avoid a potential error. 
• Communication and collaboration. Ask relevant questions and actively listen to others while avoiding judgment. Promoting a collaborative environment may lead to improved patient outcomes and interdisciplinary communication. 
• Problem-solving skills. Practicing your problem-solving skills can improve your critical-thinking skills. Analyze the problem, consider alternate solutions, and implement the most appropriate one. Besides assessing patient conditions, you can apply these skills to other challenges, such as staffing issues . 

How to Develop and Apply Critical-Thinking Skills in Nursing

Critical-thinking skills develop as you gain experience and advance in your career. The ability to predict and respond to nursing challenges increases as you expand your knowledge and encounter real-life patient care scenarios outside of what you learned from a textbook. 

Here are five ways to nurture your critical-thinking skills:

• Be a lifelong learner. Continuous learning through educational courses and professional development lets you stay current with evidence-based practice . That knowledge helps you make informed decisions in stressful moments.  
• Practice reflection. Allow time each day to reflect on successes and areas for improvement. This self-awareness can help identify your strengths, weaknesses, and personal biases to guide your decision-making.
• Open your mind. Don't assume you're right. Ask for opinions and consider the viewpoints of other nurses, mentors , and interdisciplinary team members.
• Use critical-thinking tools. Structure your thinking by incorporating nursing process steps or a SWOT analysis (strengths, weaknesses, opportunities, and threats) to organize information, evaluate options, and identify underlying issues.
• Be curious. Challenge assumptions by asking questions to ensure current care methods are valid, relevant, and supported by evidence-based practice .

Critical thinking in nursing is invaluable for safe, effective, patient-centered care. You can successfully navigate challenges in the ever-changing health care environment by continually developing and applying these skills.

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• Faye Abdellah: 21 Nursing Problems Theory

Faye Abdellah is a celebrated nurse theorist, military nurse, and leader in nursing research. Get to know the major concepts of her “ 21 Nursing Problems ” nursing theory, its application, and its impact on nursing.

Table of Contents

Early life of faye abdellah, as an educator, as a researcher, established nursing standards, military nursing service, abdellah’s typology of 21 nursing problems, awards and honors, assumptions, nursing problems, problem solving, basic needs, sustenal care needs, remedial care needs, restorative care needs, patient-centered approaches to nursing, 21 nursing problems and the nursing process, recommended resources, external links, biography of faye glenn abdellah.

Faye Glenn Abdellah (March 13, 1919 – present) is a nursing research pioneer who developed the “Twenty-One Nursing Problems.” Her nursing model was progressive for the time in that it refers to a nursing diagnosis during a time in which nurses were taught that diagnoses were not part of their role in health care.

She was the first nurse officer to rank a two-star rear admiral, the first nurse, and the first woman to serve as a Deputy Surgeon General.

On March 13, 1919, Faye Abdellah was born in New York to a father of Algerian heritage and a Scottish mother. Her family subsequently moved to New Jersey, where she attended high school.

Years later, on May 6, 1937, the German hydrogen-fueled airship Hindenburg exploded over Lakehurst.

Abdellah and her brother witnessed the explosion, destruction, and fire after the ignited hydrogen killed many people. That incident became the turning point in Abdellah’s life. It was that time when she realized that she would never again be powerless to assist when people were in such a dire need of assistance. It was at that moment she vowed that she would learn to nurse and become a professional nurse.

Faye Abdellah earned a nursing diploma from Fitkin Memorial Hospital’s School of Nursing, now known as Ann May School of Nursing.

It was sufficient to practice nursing during her time in the 1940s, but she believed that nursing care should be based on research, not hours of care.

Abdellah went on to earn three degrees from Columbia University: a bachelor of science degree in nursing in 1945, a master of arts degree in physiology in 1947, and a doctor of education degree in 1955.

With her advanced education, Abdellah could have chosen to become a doctor. However, as she explained in one of her interviews that she wanted to be an M.D. because she could do all she wanted to do in nursing, which is a caring profession.

Career and Appointments

In her early twenties, Faye Abdellah worked as a health nurse at a private school, and her first administrative position was on the faculty of Yale University from 1945-1949. At that time, she was required to teach a class called “120 Principles of Nursing Practice,” using a standard nursing textbook published by the National League for Nursing. The book included guidelines that had no scientific basis, which challenged Abdellah to explain everything she called the “brilliant” students.

After a year, Abdellah became so frustrated that she gathered her colleagues in the Yale courtyard and burned the textbooks. The next morning the school’s dean told her she would have to pay for the destroyed texts. It took a year for Abdellah to settle the debt, but she never regretted her actions because it started her on the long road to pursue the scientific basis of the nursing practice .

In 1949, she met Lucile Petry Leone, the first Nurse Officer, and decided to join the Public Health Service. Her first assignment was with the division of nursing that focused on research and studies. They performed studies with numerous hospitals to improve nursing practice .

Abdellah was an advocate of degree programs for nursing. Diploma programs, she believes, were never meant to prepare nurses at the professional level. Nursing education, she argued, should be based on research; she herself became among the first in her role as an educator to focus on theory and research. Her first studies were qualitative; they simply described situations. As her career progressed, her research evolved to include physiology, chemistry, and behavioral sciences.

In 1957, Abdellah spearheaded a research team in Manchester, Connecticut, that established the groundwork for what became known as progressive patient care . In this framework, critical care patients were treated in an intensive care unit, followed by a transition to immediate care and then home care. The first two segments of the care program proved very popular within the caregiver profession. Abdellah is also credited with developing the first nationally tested coronary care unit as an outgrowth of her work in Manchester.

Home care, which is the third phase of the progressive patient care equation, was not widely accepted in the mid-twentieth century. Abdellah explained that people at the time kept saying home care would mean having a maid or a nurse in everyone’s home. They could not figure out that home care with nurses teaching self-care would help patients regain independent function. Forty years later, home care had become an essential part of long-term health care.

In another innovation within her field, Abdellah developed the Patient Assessment of Care Evaluation (PACE), a system of standards used to measure the relative quality of individual health-care facilities that were still used in the healthcare industry into the 21st century. She was also one of the first people in the healthcare industry to develop a classification system for patient care and patient-oriented records.

Classification systems have evolved in different ways within the health-care industry, and Abdellah’s work was foundational in developing the most widely used form: Diagnostic related groups, or DRGs. DRGs, which became the standard coding system used by Medicare, categorize patients according to particular primary and secondary diagnoses. This system keeps health-care costs down because each DRG code includes the maximum amount Medicare will payout for a specific diagnosis or procedure while also taking into account patient age and length of stay in a healthcare facility. Providers are given an incentive to keep costs down because they only realize a profit if costs are less than the amount specified by the relevant DRG category.

During her 40-year career as a Commissioned Officer in the U.S. Public Health Service from 1949 to 1989, Abdellah was assigned to work with the Korean people during the Korean War. As a senior officer, she was alternatively assigned to Japan, China , Russia, Australia, and the Scandinavian countries to identify the Public Health Service’s role in dealing with various health problems. She was able to assist and initiate, in an advisory role, numerous studies in those countries.

She served as Chief Nurse Officer from 1970 to 1987 and was the first nurse to achieve the rank of a two-star Flag Officer named by U.S. Surgeon General C. Everett Koop as the first woman and nurse Deputy Surgeon General from 1982 to 1989. After retirement, Abdellah founded and served as the first dean in the Graduate School of Nursing, GSN, Uniformed Services University of the Health Sciences (USUHS).

Faye Abdellah is well known for developing the “Twenty-One Nursing Problems Theory” that has interrelated the concepts of health, nursing problems, and problem-solving.

She views nursing as an art and a science that molds the attitude, intellectual competencies, and technical skills of the individual nurse into the desire and ability to help individuals cope with their health needs, whether they are ill or well.

She used Henderson’s 14 basic human needs and nursing research to establish the classification of nursing problems.

Faye Abdellah’s theory is further discussed below.

As a consultant and educator, Faye Abdellah shared her nursing theories with caregivers around the world. She led seminars in France, Portugal, Israel, Japan, China, New Zealand, Australia, and the former Soviet Union. She also served as a research consultant to the World Health Organization. From her global perspective, Abdellah learned to appreciate nontraditional and complementary medical treatments and developed the belief such non-Western treatments deserved scientific research.

Also, she has been active in professional nursing associations and is a prolific author, with more than 150 publications. Her publications include Better Nursing Care Through Nursing Research and Patient-Centered Approaches to Nursing . She also developed educational materials in many areas of public health, including AIDS , hospice care , and drug addiction.

Abdellah considers her greatest accomplishment being able to “play a role in establishing a foundation for nursing research as a science.” Her book, Patient-Centered Approaches to Nursing , emphasizes nursing science and has elicited changes throughout nursing curricula. Her work, which is based on the problem-solving method, serves as a vehicle for delineating nursing (patient) problems as the patient moves toward a healthy outcome.

Faye Abdellah is recognized as a leader in nursing research and nursing as a profession within the Public Health Service (PHS) and as an international expert on health problems. She was named a “living legend” by the American Academy of Nursing in 1994 and was inducted into the National Women’s Hall of Fame in 2000 for a lifetime spent establishing and leading essential health care programs for the United States. In 2012, Abdellah was inducted into the American Nurses Association Hall of Fame for a lifetime of contributions to nursing.

Her contributions to nursing and public health have been recognized with almost 90 professional and academic honors, such as the Allied Signal Achievement Award for pioneering research in aging and Sigma Theta Tau’s Lifetime Achievement Award.

Abdellah’s leadership , her publications, and her lifelong contributions have set a new standard for nursing and health care. Her legacy of more than 60 years of extraordinary accomplishments lives nationally and globally.

Aside from being the first nurse and the first woman to serve as a Deputy Surgeon General, Faye Glenn Abdellah also made a name in the nursing profession to formulate her “21 Nursing Problems Theory.” Her theory changed the focus of nursing from disease-centered to patient-centered and began to include the care of families and the elderly in nursing care. The Patient Assessment of Care Evaluation developed by Abdellah is now the standard used in the United States.

Abdellah’s 21 Nursing Problems Theory

According to Faye Glenn Abdellah’s theory, “Nursing is based on an art and science that molds the attitudes, intellectual competencies, and technical skills of the individual nurse into the desire and ability to help people, sick or well, cope with their health needs.”

The patient-centered approach to nursing was developed from Abdellah’s practice, and the theory is considered a human needs theory. It was formulated to be an instrument for nursing education , so it most suitable and useful in that field. The nursing model is intended to guide care in hospital institutions but can also be applied to community health nursing, as well.

The assumptions Abdellah’s “21 Nursing Problems Theory” relate to change and anticipated changes that affect nursing; the need to appreciate the interconnectedness of social enterprises and social problems; the impact of problems such as poverty, racism, pollution, education, and so forth on health and health care delivery; changing nursing education ; continuing education for professional nurses; and development of nursing leaders from underserved groups.

• Learn to know the patient.
• Sort out relevant and significant data.
• Make generalizations about available data concerning similar nursing problems presented by other patients.
• Identify the therapeutic plan.
• Test generalizations with the patient and make additional generalizations.
• Validate the patient’s conclusions about his nursing problems.
• Continue to observe and evaluate the patient over a period of time to identify any attitudes and clues affecting this behavior.
• Explore the patient’s and family’s reaction to the therapeutic plan and involve them in the plan.
• Identify how the nurse feels about the patient’s nursing problems.
• Discuss and develop a comprehensive nursing care plan .

Major Concepts of 21 Nursing Problems Theory

The model has interrelated concepts of health and nursing problems and problem-solving, which is inherently logical in nature.

She describes nursing recipients as individuals (and families), although she does not delineate her beliefs or assumptions about the nature of human beings.

Health, or the achieving of it, is the purpose of nursing services. Although Abdellah does not define health, she speaks to “total health needs” and “a healthy state of mind and body.”

Health may be defined as the dynamic pattern of functioning whereby there is a continued interaction with internal and external forces that results in the optimal use of necessary resources to minimize vulnerabilities.

Society is included in “ planning for optimum health on local, state, and international levels.” However, as Abdellah further delineates her ideas, the focus of nursing service is clearly the individual.

The client’s health needs can be viewed as problems, overt as an apparent condition, or covert as a hidden or concealed one.

Because covert problems can be emotional, sociological, and interpersonal in nature, they are often missed or misunderstood. Yet, in many instances, solving the covert problems may solve the overt problems as well.

Quality professional nursing care requires that nurses be able to identify and solve overt and covert nursing problems. The problem-solving process can meet these requirements by identifying the problem, selecting pertinent data, formulating hypotheses, testing hypotheses through collecting data, and revising hypotheses when necessary based on conclusions obtained from the data.

Subconcepts

The following are the subconcepts of Faye Abdellah’s “21 Nursing Problems” theory and their definitions.

The 21 nursing problems fall into three categories: physical, sociological, and emotional needs of patients; types of interpersonal relationships between the patient and nurse; and common elements of patient care . She used Henderson’s 14 basic human needs and nursing research to establish the classification of nursing problems. Abdellah’s 21 Nursing Problems are the following:

• To maintain good hygiene and physical comfort .
• To promote optimal activity: exercise, rest, sleep
• To promote safety by preventing accidents, injuries, or other trauma and preventing the spread of infection .
• To maintain good body mechanics and prevent and correct the deformity.
• To facilitate the maintenance of a supply of oxygen to all body cells.
• To facilitate the maintenance of nutrition for all body cells.
• To facilitate the maintenance of elimination.
• To facilitate the maintenance of fluid and electrolyte balance.
• To recognize the physiologic responses of the body to disease conditions—pathologic, physiologic, and compensatory.
• To facilitate the maintenance of regulatory mechanisms and functions.
• To facilitate the maintenance of sensory function.
• To identify and accept positive and negative expressions, feelings, and reactions.
• To identify and accept interrelatedness of emotions and organic illness.
• To facilitate the maintenance of effective verbal and nonverbal communication .
• To promote the development of productive interpersonal relationships.
• To facilitate progress toward achievement and personal spiritual goals.
• To create or maintain a therapeutic environment.
• To facilitate awareness of self as an individual with varying physical, emotional, and developmental needs.
• To accept the optimum possible goals in the light of limitations, physical and emotional.
• To use community resources as an aid in resolving problems that arise from an illness.
• To understand the role of social problems as influencing factors in the cause of illness.

Moreover, patients’ needs are further divided into four categories: basic to all patients , sustenance care needs , remedial care needs , and restorative care needs .

The basic needs of an individual patient are to maintain good hygiene and physical comfort ; promote optimal health through healthy activities, such as exercise, rest, and sleep ; promote safety through the prevention of health hazards like accidents, injury , or other trauma and the prevention of the spread of infection; and maintain good body mechanics and prevent or correct deformity.

Sustenal care needs to facilitate the maintenance of a supply of oxygen to all body cells; facilitate the maintenance of nutrition of all body cells; facilitate the maintenance of elimination; facilitate the maintenance of fluid and electrolyte balance; recognize the physiological responses of the body to disease conditions; facilitate the maintenance of regulatory mechanisms and functions, and facilitate the maintenance of sensory function.

Remedial care needs to identify and accept positive and negative expressions, feelings, and reactions; identify and accept the interrelatedness of emotions and organic illness; facilitate the maintenance of effective verbal and non- verbal communication ; promote the development of productive interpersonal relationships; facilitate progress toward achievement of personal spiritual goals; create and maintain a therapeutic environment; and facilitate awareness of the self as an individual with varying physical, emotional, and developmental needs.

Restorative care needs include the acceptance of the optimum possible goals in light of limitations, both physical and emotional; the use of community resources as an aid to resolving problems that arise from an illness; and the understanding of the role of social problems as influential factors in the case of illness.

Abdellah’s work, based on the problem-solving method, serves as a vehicle for delineating nursing (patient) problems as the patient moves toward a healthy outcome. The theory identifies ten steps to identify the patient’s problem and 11 nursing skills to develop a treatment typology.

The ten steps are:

• Validate the patient’s conclusions about his nursing problems.
• Continue to observe and evaluate the patient over a period of time to identify any attitudes and clues affecting his or her behavior.
• Explore the patient and their family’s reactions to the therapeutic plan and involve them in the plan.
• Identify how the nurses feel about the patient’s nursing problems.

The 11 nursing skills are:

• observation of health status
• skills of communication
• application of knowledge
• the teaching of patients and families
• planning and organization of work
• use of resource materials
• use of personnel resources
• problem-solving
• the direction of work of others
• therapeutic uses of the self
• nursing procedure

Abdellah also explained nursing as a comprehensive service, which includes:

• Recognizing the nursing problems of the patient
• Deciding the appropriate course of action to take in terms of relevant nursing principles
• Providing continuous care of the individual’s total needs
• Providing continuous care to relieve pain and discomfort and provide immediate security for the individual
• Adjusting the total nursing care plan to meet the patient’s individual needs
• Helping the individual to become more self- directing in attaining or maintaining a healthy state of body and mind
• Instructing nursing personnel and family to help the individual do for himself that which he can within his limitations
• Helping the individual to adjust to his limitations and emotional problems
• Working with allied health professions in planning for optimum health on local, state, national, and international levels
• Carrying out continuous evaluation and research to improve nursing techniques and to develop new techniques to meet people’s health needs

Faye Abdellah’s work is a set of problems formulated in terms of nursing-centered services used to determine the patient’s needs. The nursing-centered orientation to client care appears to be contradicting the client-centered approach that Abdellah professes to support. This can be observed by her desire to move away from a disease-centered orientation.

In her attempt to bring the nursing practice to its proper relationship with restorative and preventive measures for meeting total client needs, she seems to swing the pendulum to the opposite pole, from the disease orientation to nursing orientation, while leaving the client somewhere in the middle.

The nursing process in Abdellah’s theory includes assessment , nursing diagnosis , planning, implementation , and evaluation.

In the assessment phase , the nursing problems implement a standard procedure for data collection . A principle underlying the problem-solving approach is that for each identified problem, pertinent data is collected. The overt or covert nature of problems necessitates a direct or indirect approach, respectively.

The outcome of the collection of data in the first phase concludes the patient’s possible problems, which can be grouped under one or more of the broader nursing problems. This will further lead to the nursing diagnosis .

After formulating the diagnosis, a nursing care plan is developed, and appropriate nursing interventions are determined. The nurse now sets those interventions in action, which complete the implementation phase of the nursing process .

The evaluation takes place after the interventions have been carried out. The most convenient evaluation would be the nurse’s progress or lack of progress toward achieving the goals established in the planning phase.

With Faye Abdellah’s aim in formulating a clear categorization of patient’s problems as health needs, she rather conceptualized nurses’ actions in nursing care, which is contrary to her aim. Nurses’ roles were defined to alleviate the problems assessed through the proposed problem-solving approach.

The problem-solving approach introduced by Abdellah has the advantage of increasing the nurse’s critical and analytical thinking skills since the care to be provided would be based on sound assessment and validation of findings.

One can identify that the framework is strongly applied to individuals as the focus of nursing care. The inclusion of an aggregate of people such as the community or society would make the theory of Abdellah more generalizable since nurses do not only provide one-person service, especially now that the community healthcare level is sought to have higher importance than curative efforts in the hospital.

The following are the strengths of Faye Abdellah’s “21 Nursing Problems” theory.

• The problem-solving approach is readily generalizable to the client with specific health needs and specific nursing problems.
• With the model’s nature, healthcare providers and practitioners can use Abdellah’s problem-solving approach to guide various activities within the clinical setting. This is true when considering a nursing practice that deals with clients with specific needs and specific nursing problems.
• The language of Faye Abdellah’s framework is simple and easy to comprehend.
• The theoretical statement greatly focuses on problem-solving, an activity that is inherently logical in nature.

The following are the limitations of Faye Abdellah’s “21 Nursing Problems” theory.

• The major limitation to Abdellah’s theory and the 21 nursing problems is their robust nurse-centered orientation. She rather conceptualized nurses’ actions in nursing care which is contrary to her aim.
• Another point is the lack of emphasis on what the client is to achieve was given in client care.
• The framework seems to focus quite heavily on nursing practice and individuals. This somewhat limits the generalizing ability, although the problem-solving approach is readily generalizable to clients with specific health needs and specific nursing.
• Also, Abdellah’s framework is inconsistent with the concept of holism. The nature of the 21 nursing problems attests to this. As a result, the client may be diagnosed with numerous problems leading to fractionalized care efforts. Potential problems might be overlooked because the client is not deemed to be in a particular illness stage.

Abdellah’s typology of 21 nursing problems is a conceptual model mainly concerned with patient’s needs and nurses’ role in problem identification using a problem analysis approach.

According to the model, patients are described as having physical, emotional, and sociological needs. People are also the only justification for the existence of nursing. Without people, nursing would not be a profession since they are the recipients of nursing.

Patient-centered approaches to nursing health are described as a state mutually exclusive of illness. Abdellah does not define health but speaks to “total health needs” and “a healthy state of mind and body” in her nursing description.

However, Abdellah rather conceptualized nurses’ actions in nursing care, contrary to her aim of formulating a clear categorization of patients’ problems as health needs. Nurses’ roles were defined to alleviate the problems assessed through the proposed problem-solving approach.

As a whole, the theory is intended to guide care not just in the hospital setting but can also be applied to community nursing, as well. The model has interrelated concepts of health and nursing problems and problem-solving, which is inherently logical in nature.

Furthermore, the 21 nursing problems progressed to a second-generation development referred to as patient problems and patient outcomes . Abdellah educated the public on AIDS , drug addiction, violence, smoking, and alcoholism. Her work is a problem-centered approach or philosophy of nursing.

Recommended books and resources to learn more about nursing theory:

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy .

• Nursing Theorists and Their Work (10th Edition) by Alligood Nursing Theorists and Their Work, 10th Edition provides a clear, in-depth look at nursing theories of historical and international significance. Each chapter presents a key nursing theory or philosophy, showing how systematic theoretical evidence can enhance decision making, professionalism, and quality of care.
• Knowledge Development in Nursing: Theory and Process (11th Edition) Use the five patterns of knowing to help you develop sound clinical judgment. This edition reflects the latest thinking in nursing knowledge development and adds emphasis to real-world application. The content in this edition aligns with the new 2021 AACN Essentials for Nursing Education.
• Nursing Knowledge and Theory Innovation, Second Edition: Advancing the Science of Practice (2nd Edition) This text for graduate-level nursing students focuses on the science and philosophy of nursing knowledge development. It is distinguished by its focus on practical applications of theory for scholarly, evidence-based approaches. The second edition features important updates and a reorganization of information to better highlight the roles of theory and major philosophical perspectives.
• Nursing Theories and Nursing Practice (5th Edition) The only nursing research and theory book with primary works by the original theorists. Explore the historical and contemporary theories that are the foundation of nursing practice today. The 5th Edition, continues to meet the needs of today’s students with an expanded focus on the middle range theories and practice models.
• Strategies for Theory Construction in Nursing (6th Edition) The clearest, most useful introduction to theory development methods. Reflecting vast changes in nursing practice, it covers advances both in theory development and in strategies for concept, statement, and theory development. It also builds further connections between nursing theory and evidence-based practice.
• Middle Range Theory for Nursing (4th Edition) This nursing book’s ability to break down complex ideas is part of what made this book a three-time recipient of the AJN Book of the Year award. This edition includes five completely new chapters of content essential for nursing books. New exemplars linking middle range theory to advanced nursing practice make it even more useful and expand the content to make it better.
• Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice This book offers balanced coverage of both qualitative and quantitative research methodologies. This edition features new content on trending topics, including the Next-Generation NCLEX® Exam (NGN).
• Nursing Research (11th Edition) AJN award-winning authors Denise Polit and Cheryl Beck detail the latest methodologic innovations in nursing, medicine, and the social sciences. The updated 11th Edition adds two new chapters designed to help students ensure the accuracy and effectiveness of research methods. Extensively revised content throughout strengthens students’ ability to locate and rank clinical evidence.

Recommended site resources related to nursing theory:

• Nursing Theories and Theorists: The Definitive Guide for Nurses MUST READ! In this guide for nursing theories, we aim to help you understand what comprises a nursing theory and its importance, purpose, history, types or classifications, and give you an overview through summaries of selected nursing theories.

Other resources related to nursing theory:

• Betty Neuman: Neuman Systems Model
• Dorothea Orem: Self-Care Deficit Theory
• Dorothy Johnson: Behavioral System Model
• Florence Nightingale: Environmental Theory
• Hildegard Peplau: Interpersonal Relations Theory
• Ida Jean Orlando: Deliberative Nursing Process Theory
• Imogene King: Theory of Goal Attainment
• Jean Watson: Theory of Human Caring
• Lydia Hall: Care, Cure, Core Nursing Theory
• Madeleine Leininger: Transcultural Nursing Theory
• Martha Rogers: Science of Unitary Human Beings
• Myra Estrin Levine: The Conservation Model of Nursing
• Nola Pender: Health Promotion Model
• Sister Callista Roy: Adaptation Model of Nursing
• Virginia Henderson: Nursing Need Theory
• Abdellah, F.G. The federal role in nursing education. Nursing outlook. 1987, 35(5),224-225.
• Abdellah, F.G. Public policy impacting on nursing care of older adults. In E.M. Baines (Ed.), perspectives on gerontological nursing. Newbury, CA: Sage publications. 1991.
• Abdellah, F.G., & Levine, E. Preparing nursing research for the 21st century. New York: Springer. 1994.
• Abdellah, F.G., Beland, I.L., Martin, A., & Matheney, R.V. Patient-centered approaches to nursing (2nd ed.). New York: Mac Millan. 1968.
• Abdellah, F.G. Evolution of nursing as a profession: perspective on manpower development. International Nursing Review, 1972); 19, 3..
• Abdellah, F.G.). The nature of nursing science. In L.H. Nicholl (Ed.), perspectives on nursing theory. Boston: Little, Brown, 1986.
• Craddock, J. (2013). Encyclopedia of world biography supplement. Detroit, Mich.: Gale. https://www.encyclopedia.com/doc/1G2-3435000010.html
• Better Patient Care Through Nursing Research
• Preparing Nursing Research for the 21st Century: Evolution, Methodologies, Challenges

With contributions by Wayne, G. (for Biography), Vera, M. 

6 thoughts on “Faye Abdellah: 21 Nursing Problems Theory”

Thank you for sharing Angelo

I mean no disrespect to RADM Abdellah’s service to our nation, but the USPHS is not part of the military. It is part of the Uniformed Services, but not in the Dept of Defense.

Oh! Good to know! Thanks for clarifying :)

An insightful information 👌

I was a brand new lieutenant US Army and just graduated from college to become a nurse. I had used Faye Abdellah’s Theories as the rationale for nursing care plans in school papers, so I was very familiar. A big professional regret was I had the opportunity to meet Faye at a nursing conference in Germany. I was a timid young nurse and somewhat shy and saw her in one of the conference sessions sitting by herself. I wish I introduced myself and talked to her. I really respected her as a pioneer in nursing theory.

thanks for sharing.

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• Volume 28, Issue 4
• Shared decision-making as a method of care
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• http://orcid.org/0000-0003-0595-2898 Victor M Montori 1 ,
• http://orcid.org/0000-0002-5720-0674 Merel M Ruissen 1 , 2 , 3 ,
• Ian G Hargraves 1 ,
• Juan P Brito 1 ,
• http://orcid.org/0000-0001-5334-1085 Marleen Kunneman 1 , 2
• 1 Knowledge and Evaluation Research Unit , Mayo Clinic , Rochester , Minnesota , USA
• 2 Department of Biomedical Data Sciences, Section of Medical Decision Making , Leiden University Medical Center , Leiden , Netherlands
• 3 Department of Medicine, Division of Endocrinology , Leiden University Medical Center , Leiden , Netherlands
• Correspondence to Dr Juan P Brito, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA; brito.juan{at}mayo.edu

https://doi.org/10.1136/bmjebm-2022-112068

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• Clinical Decision-Making
• Delivery of Health Care
• Evidence-Based Practice
• Patient Care

Care happens in interaction between the patient and the clinician, in conversation where the patient and clinician uncover or develop a shared understanding of the problematic situation of the patient and identify, discover, or invent ways to make that situation better, given what each patient prioritises and seeks. 1 Thus, to get the right care for each patient, patient and clinician collaborate and deliberate together to figure out what to do. 2

Shared decision-making (SDM) has been traditionally defined as a collaborative approach by which, in partnership with their clinician, patients are encouraged to think about the available care options and the likely benefits and harms of each, to communicate their preferences, and help select the best course of action that fits these. 3 This definition is limited to situations in which the problem and the pertinent options to address it can be defined a priori, and the main task is to find the option that best matches the patient’s preferences. Thought in this way, SDM may involve distributing decision aids for patients to come prepared for the consultation and using tools to elicit and document patient preferences. This practice has been proposed as an expression of patient-centred care, a way of involving patients, an antidote to medical paternalism, and as a way to promote high-value care. 3

But anytime, a patient and clinician figure out together what to do about the patient’s situation, they are doing SDM. Although there are multiple models and accounts of what SDM is and is not, 2 4 5 in practice, SDM starts by determining the nature of the problematic situation the patient is experiencing. This often requires considering insights that only the patient and perhaps their family can share, insights about both the patient’s biology and biography. Then clinicians must mobilise their competence and compassion to work with patients to develop a sensible care plan that responds to the situation as understood, is based on relevant evidence, attends to the emotional aspects of the problem, and is feasible and sustainable for the patient. 6 7

Therefore, we believe SDM is not ‘another thing clinicians must do’, that is, to help patients select the best evidence-based option given their preferences, but that it is a method of care, as central to the clinician’s art as history taking, the physical examination, the selection and interpretation of diagnostic tests, and patient education and counselling.

The practical method to implement SDM as a method of care proposed below seeks to make as few demands as possible of both patients, who are taxed by the demands of self-care and of navigating a labyrinthine healthcare system while responding to the demands of living, 8 and of clinicians, who, despite some evidence of the contrary, 9 often express their worries about SDM adding time to their encounters. 10

Practicing SDM as a method of care

Here, we propose a simple method to implement SDM in practice (see summary box 1 ).

Steps for shared decision-making (SDM) in practice

(1) Foster a conversation

Key elements: problem definition, iteration, co-creation

(2) Purposefully select and adapt the SDM process

Matching preferences

Reconciling conflicts

Problem-solving

Meaning making

(3) Support SDM

Protect the space

Make the most of participation, deploy useful tools, advocate for care.

(4) Evaluate and learn SDM

Evaluate beyond outcomes

Share the evaluation.

Seek joint improvement

Foster a conversation

In this conversation, the clinician curiously works to understand which aspect of the patient’s problematic human situation requires action. 4 This could be an unaddressed medical problem, such as a new symptom, concern, sign or complication. It could also be a change in life circumstances that affects how the medical condition manifests or that affects the practicality of the existing plan to address it. It could be signs that the plan of care in place is not helping, or even hurting, or that it has become impractical or unfeasible. The patient and clinician must collaborate to arrive at a useful formulation of the problem. For example, will the change in insurance coverage change the patient’s ability to afford the treatment prescribed given their income and other expenses they must cover? Is the increase in pain in the feet impairing living? Is the increase in pain in the feet impairing living? The inquiry then seeks to uncover the action that the situation requires. 1 It may be necessary to conduct new tests, change the care plan, or provide additional support.

The process of noticing and responding is iterative, 1 11 and continues until a response emerges that makes intellectual sense (ie, it is an evidence-based response 12 to the situation as understood), practical sense (ie, it is feasible and minimally disruptive of personal and social routines) and emotional sense (ie, it accounts for the emotional dimensions of the situation and feels like the right thing to do now) to patients and clinicians. 7 Confronting the actions available to respond to the situation may lead to reframing the situation itself and reformulating the problem to address. For example, a patient facing a cancer with a very poor prognosis and seeking a cure may discover that the treatments have a low likelihood of success and a high likelihood of harm. The unattractiveness of these options may lead to a recasting of the situation as one in which the patient is facing death because of cancer and now seeks ways to die well. The options identified in the first instance fail to be a sensible response to this new formulation of the situation and new options must be identified, uncovered, or invented. As it is cocreated and implemented, the patient is best positioned to provide feedback about the plan, as to its adequacy, its acceptability by itself and in interaction with other treatments and daily routines, and its efficacy in improving the situation.

It may be helpful to be aware of some stumbling blocks to fostering SDM conversations:

In some cases, that is, when there is no one technically correct solution to their problem, patients may not be aware that SDM is an appropriate method of care. Clinicians can helpfully state so and invite the patient into the process of collaborately figuring out together what to do. 13 This renders irrelevant that the patient ‘did not go to medical school’, creating the space and momentum for collaboration.

When made prematurely, a clinician’s recommendation or a patient’s demand can abort the exploration for new insights; when unacceptable to the other party, these can complicate the patient–clinician relationship. 14 Also, a desire to avoid conflict may lead to either party acquiescing, which is why policies (eg, guidelines, pathways, formulary restrictions, preauthorisations) and marketing campaigns (eg, detailing to clinicians, direct-to-consumer advertising and ‘ask your doctor about…’ ads) can unduly shape care. 15 16

Purposefully select and adapt the SDM process

There are four distinct ways in which patients and clinicians can work together to address the patient’s problematic situation: (A) focusing on matching preferences, (B) reconciling conflicts, (C) problem-solving or (D) meaning making. 4 Each of these forms of SDM is best suited to address one of four different kinds of problematic situations ( tables 1 and 2 ). Clinicians need to be aware of these forms of SDM to intentionally select the form best suitable to respond to the situation at hand, avoid selecting the wrong one and nimbly switching to a different form when the situation becomes clearer or changes. 17 In our observations, clinicians and patients who do SDM well, work within a form of SDM until a better one becomes apparent and they flexibly, gracefully and perhaps intuitively switch according to the challenges uncovered during the conversation. 17 For example, a conflict requiring reconciliation (‘I will never use insulin because I am not allowed to use needles at my job’) can become a problem requiring solving (‘Is there a way to use insulin such that it is only administer at home?’).

• View inline

Forms of shared decision-making (SDM)

Practical differences between the forms of shared decision-making (SDM)

Also in our observations, the situations adverse to care emerge when clinicians use an unhelpful SDM form or inflexibly insist on using a particular SDM form after it has proven unsuitable. This can be observed when, for example, a clinician, documenting advanced directives, requires from distressed patients and family members to select what they prefer from a menu of life-sustaining therapies. 18 Selecting the right approach requires clinicians to be present, competent, flexible and attuned to whether the conversation is helping the patient with what they are struggling.

Support SDM

Finding and deploying useful, usable and desirable ways of supporting SDM in each encounter promotes the practice of SDM as a method of care.

SDM is work for both patients and clinicians. 19 The conversation is the workspace within which this work takes place. The space for the conversation must be set up to be supportive of this work. 20 Clinical spaces can be cluttered with visual (posters behind office doors, clinical equipment) and auditory (overhead announcements, ringtones) distractions. Demands for entries from the medical record system can interrupt conversations. Thus, clinicians must be deliberate about protecting the space and the time allocated for these conversations. This is less about new investments in interior design and more about securing agreements and arrangements (eg, team policy to avoid interrupting clinicians when in consultation with patients; minimise pop-up alerts and mandatory data entry in the design of medical records) that eliminate distractions, disruptions and interruptions. The setup should clearly signal the intention: the clinician and patient are here to have an unhurried conversation—not necessarily a long one—to work through what to do about the patient’s problems today and going forward.

Having set the stage for an unhurried conversation, 21 it is necessary to determine who should participate in that conversation. Patients and clinicians in continuous relationships of care may be optimally situated to have unhurried conversations. When the issue requires specialised technical knowledge, or access to educational materials, longer consultations and decision-making tools, it may be optimal to bring into the conversation clinicians specialised in the matter, either to cocreate the plan of care with the patient or to assist the established patient–clinician dyad in their decision-making process. A similar choice needs to be made about the participation of informal caregivers, who in their roles at the patient’s side, often have expertise about and experience with the patient and may be responsible for the plan’s implementation.

Clinicians and patients may want to thoughtfully consider which tools are allowed into the conversation, including specialised tools designed to support specific SDM forms that have shown to be useful, usable, and desirable. Given the situation at hand, different tools can support the decision-making process:

Self-management logs, patient-reported outcome trends, results from ancillary laboratory and imaging tests can all support the problem-solving mode of SDM.

Patients and clinicians could consider using home visits, photographs, narrative accounts of daily living, the ‘My Healthcare, My Life’ conversation tool, 22 23 and other ways to develop a joint understanding of the social and economic challenges the patient faces routinely, and how these conditions promote or hinder health and the implementation of treatments. Stories and accounts of how patients lived their lives may also be helpful to their family and clinicians in determining together whether and for how long to implement intensive life-support interventions in the care of a critically ill patient.

Tools to support SDM conversations can help patients and clinicians select together which treatments to implement to reduce the risk of adverse disease outcomes. 24 25 These tools should be easy to use, use helpful ways to communicate pertinent evidence and numerical risk information, 25 26 and should support the conversation without intruding. Some tools which have been found to be useful in randomised trials are available free of use (see carethatfits.org ).

Teach-back could be used to verify that patients and clinicians understood the information shared by each other. 27

Access and efficiency imperatives abbreviate and accelerate consultations to the point that SDM and other forms of care cannot be adequately implemented. Algorithms and guidelines may enable bypassing the messy process of co-creation, offering a right answer for ‘patients like this’, which may or may not fit ‘this patient’. SDM may get outsourced to third parties, offered to privileged patients (and less to those who need interpreters, racialised patients, patients with cognitive and sensorial challenges, and those seen in high-volume or understaffed clinics), or reduced to the distribution of SDM tools. 28

Like careful and kind care, SDM is not a luxury. And yet, it often seems as if high-quality SDM is a method of care that healthcare cannot afford to offer everyone. Clinicians and patients must play an active role in advocating and working toward healthcare that enables and supports SDM. This work can focus on reprioritising care over efficiency, advancing unhurried care conversations, 21 28 reorienting healthcare innovations to advance rather than replace SDM, and on ensuring SDM for all patients. 29

Evaluate and learn SDM

When done well, SDM should contribute to improve the patient’s problematic situation. Being able to cocreate and jointly revise plans of care may reduce the risk of a poor-quality decision, that is, one that does not respond sensibly to the problem, fails to support patient goals and priorities, and maximally disrupts patient lives and loves. 11 Doing SDM can deepen the relationship between patient and clinician and this relationship can offer resilience to adverse patient outcomes. 30 In turn, joint evaluation of how well the patient and clinician are doing SDM can motivate improvement of SDM skills and further their partnership. In this way, care and learning to care are intertwined, and are both reliant on unhurried conversations and SDM.

It is not adequate to judge the quality of the SDM process by patient outcomes, as the link between decisions and outcomes is weak as many outcomes result from highly complex interactions, multiple decisions over time, and chance. Short of general patient satisfaction questions, to our knowledge, there are no practical means available for external evaluators to assess how well a healthcare system, a clinician and a patient implemented SDM and how well this process contributed to advance the patient’s problematic situation. A way forward may require defining a good decision by the way it was produced (evidence based, cocreated), by the goals that animated the decision-making process (advancing the patient situation in a sensible way), and by the nature of the care plan that emerged from it (maximally supportive of the patient situation and goals, minimally disruptive of the live routines of patients and their community. 11

Beyond external assessments, the most important evaluation needs to take place within the patient–clinician relationship. The patient and clinician may want to ask each other how well the conversation went and to seek feedback from each other about how they went about working out what to do, that is, how well they did SDM. This may be particularly necessary early in the dyad’s decision-making experience so that their performance can improve over time and be increasingly readier to face more difficult situations. By seeking feedback, clinicians exercise their humble commitment to meet the patient where they are and to care well for, about and with the patient.

Seek shared improvement

As with every other aspect of caring for patients, this method of care must continue to be subject of innovation and improvement, 31 including the preparation of both patients and clinicians (and the healthcare systems within which they meet) 32 to better contribute to the joint work of making care fit. 11 The shared work of SDM demands that both parties learn from their experience. Since clinicians and patients with chronic conditions face a lifetime of decisions, this learning is life long and ongoing. Few opportunities exist to improve together. Clinicians can access courses in communication, but often these courses pay limited attention to the co-creation of a plan of care, instead focusing on explaining the plan to the patient. Patients are often trained to ask questions (eg, what are my options, what are their pros and cons, how likely are these pros and cons to happen), 33 but there is little training about the different ways in which they can contribute depending on the forms of SDM used. Resources to improve the performance of both patients and clinicians, including joint skill building opportunities, need to be made available to promote high quality SDM. 27 34

The number of tasks assigned to clinicians seem to increase in inverse proportion to the time allotted to execute them. In this context, SDM may seem like just one more box to tick, or a skill clinicians have no time to learn or use. But SDM is not an add-on. Clinicians are already engaging patients in conversations to work through a plan of action because that is what is required to formulate the best plan. Every consultation with a patient is an opportunity to get care right—intellectually, practically and emotionally—for that person using SDM as a method of care. In these conversations, patients and clinicians can find problems that matter along with possible ways of addressing them, deciding among the possibilities, and putting it all together in a plan that the patient wants, is likely to help, and is feasible and sustainable. Within the constraints of any situation, including systemic constraints, SDM is a method of creating the best care, it is also the human, kind and caring thing to do—the sort of thing that breathes life, joy and purpose into the practice of medicine.

Ethics statements

Patient consent for publication.

Not applicable.

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Twitter @vmontori, @MarleenKunneman

Contributors This article was conceived at a meeting of all the authors. VM prepared the first draft and all listed authors provided critical review and edits. All authors approved the final version.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests The authors participate in research developing, evaluating, and implementing interventions promoting shared decision making in clinical practice. These research is funded by research grants or contracts awarded by governmental and nonprofit organisations to their institutions. They do not derive personal income or have patents related to these activities. MK had financial support from the Dutch Research Council (NWO) and The Netherlands Organisation for Health Research and Development (ZonMw) (#016.196.138).

Provenance and peer review Not commissioned; externally peer reviewed.

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Open Access

Peer-reviewed

Research Article

Helping patients help themselves: A systematic review of self-management support strategies in primary health care practice

Roles Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Current address: Graduate School of Health, University of Technology Sydney, Ultimo, NSW, Australia

Affiliation Graduate School of Health, University of Technology Sydney, Sydney, Australia

Roles Conceptualization, Methodology, Supervision, Validation, Writing – review & editing

Roles Conceptualization, Supervision, Writing – review & editing

Roles Conceptualization, Methodology, Supervision, Writing – review & editing

Affiliation Emeritus Professor, University of Sydney, Sydney, Australia

• Sarah Dineen-Griffin, 
• Victoria Garcia-Cardenas, 
• Kylie Williams, 
• Shalom I. Benrimoj

• Published: August 1, 2019
• https://doi.org/10.1371/journal.pone.0220116
• Reader Comments

Primary health professionals are well positioned to support the delivery of patient self-management in an evidence-based, structured capacity. A need exists to better understand the active components required for effective self-management support, how these might be delivered within primary care, and the training and system changes that would subsequently be needed.

(1) To examine self-management support interventions in primary care on health outcomes for a wide range of diseases compared to usual standard of care; and (2) To identify the effective strategies that facilitate positive clinical and humanistic outcomes in this setting.

A systematic review of randomized controlled trials evaluating self-management support interventions was conducted following the Cochrane handbook & PRISMA guidelines. Published literature was systematically searched from inception to June 2019 in PubMed, Scopus and Web of Science. Eligible studies assessed the effectiveness of individualized interventions with follow-up, delivered face-to-face to adult patients with any condition in primary care, compared with usual standard of care. Matrices were developed that mapped the evidence and components for each intervention. The methodological quality of included studies were appraised.

6,510 records were retrieved. 58 studies were included in the final qualitative synthesis. Findings reveal a structured patient-provider exchange is required in primary care (including a one-on-one patient-provider consultation, ongoing follow up and provision of self-help materials). Interventions should be tailored to patient needs and may include combinations of strategies to improve a patient’s disease or treatment knowledge; independent monitoring of symptoms, encouraging self-treatment through a personalized action plan in response worsening symptoms or exacerbations, psychological coping and stress management strategies, and enhancing responsibility in medication adherence and lifestyle choices. Follow-up may include tailored feedback, monitoring of progress with respect to patient set healthcare goals, or honing problem-solving and decision-making skills. Theoretical models provided a strong base for effective SMS interventions. Positive outcomes for effective SMS included improvements in clinical indicators, health-related quality of life, self-efficacy (confidence to self-manage), disease knowledge or control. An SMS model has been developed which sets the foundation for the design and evaluation of practical strategies for the construct of self-management support interventions in primary healthcare practice.

Conclusions

These findings provide primary care professionals with evidence-based strategies and structure to deliver SMS in practice. For this collaborative partnership approach to be more widely applied, future research should build on these findings for optimal SMS service design and upskilling healthcare providers to effectively support patients in this collaborative process.

Citation: Dineen-Griffin S, Garcia-Cardenas V, Williams K, Benrimoj SI (2019) Helping patients help themselves: A systematic review of self-management support strategies in primary health care practice. PLoS ONE 14(8): e0220116. https://doi.org/10.1371/journal.pone.0220116

Editor: Christophe Leroyer, Universite de Bretagne Occidentale, FRANCE

Received: November 13, 2018; Accepted: July 9, 2019; Published: August 1, 2019

Copyright: © 2019 Dineen-Griffin et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Internationally, healthcare systems are challenged with the rising rates of chronic and complex illness and the clinical and economic burden associated represents a major challenge to the optimal provision of healthcare [ 1 ]. Health systems need to accommodate changes to meet the increasing need for health services. Evidence suggests that leveraging the potential of people to care for themselves and involving patients in decisions affecting their health is beneficial, particularly on the increasing rates of primary care consultations and health system pressures [ 2 ]. A key issue that needs to be addressed is how primary health care professionals (HCPs) can support self-management in an evidence-based, structured way and how self-management processes can be integrated into clinical practice, as models of care evolve to deliver a person-centred approach. Patient participation is suggested to narrow the gap between the dichotomous roles of patient and HCP [ 3 ]. Patient participation involves being engaged in the planning of care and exchanging knowledge, setting own goals and carrying out self-management activities [ 3 ]. This partnership has been suggested as valuable in the support of the management and control of symptoms, particularly for patients with chronic health conditions [ 4 ]. Self-management strategies are increasingly recognized as an essential component of chronic disease management and secondary prevention [ 5 ], individually tailored to patient preferences, prior knowledge and circumstances, supporting patient participation in their care [ 6 ].

Self-management support (SMS) is viewed in two ways: (1) as a portfolio of techniques and tools that help patients choose healthy behaviours, and (2) as a fundamental transformation of the patient-professional relationship into a collaborative partnership [ 7 ]. SMS encompasses more than a didactic, instructional program and goes beyond simple dissemination of information or disease state management. The pivotal objective of SMS is to change behaviour within a collaborative arrangement to produce sustainable effects. This can be achieved by increasing patients’ skills and confidence in managing their disease state through regular assessment of progress and problems, goal setting, and problem-solving support [ 8 ]. Simply put, patients and HCPs work to develop tangible and realistic healthcare goals, while HCPs can assist with the development of the skill set necessary to achieve these goals and monitor for improvements in patient health [ 9 ]. Lorig and Holman [ 10 ] identify a generic set of skills proven successful for effective self-management, including (1) problem-solving; (2) decision-making; (3) resource utilization; (4) forming a patient-health care provider partnership; and (5) taking action. Acquisition of these skills leads to increased self-efficacy. Self-efficacy refers to beliefs in one’s capabilities to execute a behaviour or course of action necessary to reach a desired goal [ 10 , 11 ].

There is a growing body of evidence that shows supporting people to self-manage their health and care can lead to improvements in clinical and humanistic outcomes [ 12 – 18 ], reducing the economic impact of chronic disease and a means of contributing to the sustainability of the global healthcare system. Supporting people to self-manage has resulted in reduced use of general practitioners, reduced admissions to hospital, significant gains in health status and increased symptom control [ 19 , 20 ]. Interventions have targeted patients with arthritis [ 21 ], asthma [ 22 ], chronic heart failure (CHF) [ 23 ], chronic obstructive pulmonary disease (COPD) [ 24 ], type 2 diabetes mellitus (T2DM) [ 25 , 26 ], hypertension (HT) [ 27 ] and patients on oral anticoagulation [ 28 ]. Self-management support interventions vary in the literature with increasing evaluations of peer-led, lay-led, or non-health professional-led, web-based and group-based interventions. For example, the generic Chronic Disease Self-Management Program, a non-health professional group-delivered intervention remains the most widely adopted self-management support program internationally [ 29 ].

Primary HCPs are typically an individuals’ first point of contact with the health system [ 30 ], and are continuing contacts for people with chronic disease. This opens up substantial opportunities to effect sustainable changes through supporting self-management and delivery of more personalized healthcare services. There is an increasing number and uptake of primary care services which require HCPs to be patient-oriented however none of the education provided appears to include any theoretical framework or evidence-based structure for providers to effectively support self-management and facilitate patient behaviour change. Importantly, HCPs need to acquire the competencies not only to identify the techniques and tools for specific patients but to ensure that patients acquire the skills to self-manage. Kennedy et al. recommends a whole systems approach, which integrates SMS at the level of the patient, HCP, and service organizations, which has proven effective in improving outcomes for patients [ 31 ]. Effective implementation is profoundly important to ensure viability and sustainability, and potential scale-up. In some countries, governments have developed health policy and funding alignment for self-management support with the aim of improving health outcomes and alleviating pressures on the wider health system [ 32 ].

While the role of primary HCPs in delivering SMS is highlighted in the literature, there remains a gap in research regarding the specific strategies and active components of interventions used by providers resulting in better health outcomes for patients. A need exists to better understand how these might be delivered within primary care, what outcomes can be achieved, and the training and system changes needed as a result. This gap increases the challenge of providing consistent SMS in primary care, and enabling the appropriate evaluation of SMS trials. Therefore, the objective of this systematic review is to summarize the evidence of effectiveness for SMS interventions delivered face-to-face in primary care practice, and identify evidence-based strategies with active components facilitating positive clinical and humanistic patient outcomes.

A systematic review of randomized controlled trials evaluating SMS interventions was conducted following the Cochrane Handbook for Systematic Reviews of Interventions. We have reported the review according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines [ 33 , 34 ]. Details of the protocol for this systematic review can be found in the PROSPERO international prospective register of systematic reviews database (registration CRD42017062639).

Search strategy

The research question (using PICO) and search strategy were developed and reviewed by three authors (SDG, VGC, SB) to identify studies for this review. In a preliminary scoping search of databases, we as a group of authors identified ten key papers which were suitable to be included in the review. In the multiple search strategies all authors were involved. We tested and refined our strategies as a group, which ensured reproducibility of key papers within search results and a robust search strategy. The detailed search strategy for different electronic databases can be found in S1 Table . A comprehensive search was undertaken in three databases using PubMed, Scopus and Web of Science and search strategies were refined for each individual database. Multiple databases were searched to adequately identify all literature relevant to the research question. Published literature was systematically searched from inception to June 2019. Neither publication date nor publication type filters were used. Citation searching was also conducted to find articles cited by other publications. Searches of grey literature and reference lists of previous systematic reviews complemented our literature search to ensure all relevant studies were captured. The complete results from all databases were imported and managed in a unique EndNote X9 library upon search completion and saved without duplication.

Data extraction, management and synthesis

The review team were responsible for assessing the trials’ eligibility using the methods outlined. The lead reviewer (SDG) screened by title and abstract to select relevant publications. A second and third reviewer (VGC, SB) were consulted throughout this process if an article could not be rejected with certainty. Any disagreement among the reviewers throughout this process were resolved by discussion and consensus. All authors (SDG, VGC, KW, SB) agreed on the final texts for inclusion. Full texts were assessed for eligibility according to inclusion and exclusion criteria. Eligible studies were randomized controlled trials (RCTs) and cluster-randomized controlled trials (c-RCTs) assessing SMS interventions with follow-up, delivered by primary HCPs, face-to-face to adult patients with any condition, compared to usual standard of care. The types of interventions included in the review were multicomponent interventions aimed at supporting patient self-management. Jonkman et al’s definition of SMS interventions was applied for the purposes of selection of interventions for inclusion in this review [ 35 ]. This definition includes the wide range of components considered for ‘self-management interventions’. Self-management interventions are defined as [ 35 ]:

“ Interventions that aim to equip patients with skills to actively participate and take responsibility in the management of their chronic condition . This includes knowledge acquisition , and a combination of at least two of the following : (1) stimulation of independent sign and/or symptom monitoring; (2) medication management; (3) enhancing problem-solving and decision-making skills for treatment or disease management; (4) or changing physical activity , dietary and/or smoking behaviour ”.

Excluded studies were: (1) non-randomized controlled study designs; (2) interventions not meeting Jonkman’s definition of self-management support; (3) interventions not delivered face-to-face (i.e. web-based interventions); (4) group-delivered interventions; (5) study populations under 18 years of age; (6) interventions delivered in settings other than primary care; (7) interventions delivered by non-HCPs (i.e. lay, peer-led); (8) studies without usual standard of care as comparator; (9) studies written in a language other than English or Spanish; or (10) non-primary research articles (i.e. literature reviews, study protocols).

Authors kept a record of the number of trials included or excluded from the review at each stage of the assessment process. Multiple papers of the same study were linked together. Study design, setting, methods, participant characteristics, type of intervention, content, duration and intensity of components, follow up, and study findings were extracted using a tailored data extraction form developed for data retrieval using the Cochrane Handbook for Systematic Reviews of Interventions [ 36 ] and the Cochrane Effective Practice and Organisation of Care Group (EPOC) data collection form [ 37 ] and checklist [ 38 ].

Matrices were developed mapping both evidence and active components for each self-management intervention. Outcome indicators were independently extracted, tabulated and grouped using the following categories of outcome measures, including (1) disease specific indicators; (2) self-efficacy; (3) health-related quality of life; (4) functional status and disability; (5) psychological functioning; (6) disease knowledge; (7) behaviours and self-management activities. Components were categorized according to Jonkman’s definition of SMS interventions [ 35 ], including strategies for: (1) condition or treatment knowledge acquisition; (2) active stimulation of symptom monitoring; (3) self-treatment through the use of an action plan; (4) enhancing resource utilization; (5) enhancing problem-solving and/ or decision-making skills; (6) enhancing stress management or emotional coping with condition; (7) enhancing physical activity; (8) enhancing dietary intake; (9) enhancing smoking cessation; and (10) medication management or adherence. Given the heterogeneity of the studies regarding participants, varying healthcare setting, strategies and outcome measures, no formal quantitative synthesis or meta-analysis could be conducted.

Assessment of risk of bias

The methodological quality of studies were appraised using the ‘Suggested risk of bias criteria for EPOC reviews’ tool in accordance with the Cochrane Handbook [ 39 ]. Domains of bias included in the final assessment, were: (1) random sequence generation; (2) allocation concealment; (3) similarities on baseline outcome measurements; (4) similarities on baseline characteristics; (5) completeness of outcome data; (6) blinding (participants, personnel); (7) protection against contamination; (8) selective outcome reporting; and (9) other risks of bias. Studies were assessed by domain as 'low risk' or 'high risk' of bias. Domains were ‘unclear risk’ if too few details were available to make an acceptable judgement of ‘high’ or ‘low’ risk. A second and third reviewer (VGC, SB) were consulted throughout this process if decisions could not be made with certainty. Any disagreement among the reviewers throughout this process were resolved by discussion and consensus. Three categories of study quality were identified by study authors according to each study’s methodological characteristics. In high-quality studies, the majority of criteria were fulfilled and done well (low risk of bias in at least six criterion), while in low-quality studies, the majority of criteria were not done or done poorly (high risk of bias in at least five criterion); other situations were considered medium quality [ 40 ]. No papers were excluded as a result of quality assessment.

Study selection

6,510 citations were retrieved. After the removal of duplicates, 4,831 records were screened by title and abstract. After review of full texts, fifty-eight RCTs/c-RCTs (reported in 80 citations) fulfilled the review criteria and were included in this systematic review (see flow diagram in Fig 1 ). A completed PRISMA checklist can be found in S2 Table . Descriptive characteristics of individual studies are provided in S3 Table .

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https://doi.org/10.1371/journal.pone.0220116.g001

Description of studies

The included studies originated from 18 countries, predominantly the United Kingdom (UK) and the United States (US). The conditions most frequently targeted included T2DM (37.9%; n = 22), COPD (20.7%; n = 12) and depression (13.8%; n = 8) ( Table 1 ). Settings primarily reported were general practice (48.3%; n = 28), primary care clinics (25.9%; n = 15) and community pharmacies (10.3%; n = 6). Interventions were delivered largely by general practitioners or nurses, commonly specialising in areas such as respiratory, diabetes and mental health. SMS interventions in fourteen studies were delivered in primary care teams involving more than one health care professional from different disciplines (24.1%; n = 14).

https://doi.org/10.1371/journal.pone.0220116.t001

Study outcomes

Ninety-three different outcome measures were adopted by studies. Clinical outcome measures associated with a particular condition were typically reported (e.g. clinical outcomes such as changes in blood pressure or HbA1c levels). Humanistic outcomes sought to measure physical, social and psychological functioning and changes in health-related quality of life (HRQOL). Others captured changes in self-efficacy. Results were classified by outcome and method of assessment (summarised in S4 Table relative to key findings).

Impact of interventions on outcomes

The overall impact of interventions on clinical and humanistic outcomes are illustrated in Table 2 .

https://doi.org/10.1371/journal.pone.0220116.t002

Disease specific outcomes.

Forty four RCTs examined the impact of interventions on disease specific outcomes [ 42 – 57 , 60 , 70 , 71 , 76 , 78 , 79 , 82 , 85 – 87 , 102 , 106 , 107 , 109 , 110 , 112 , 114 , 115 , 118 ]. Disease specific outcomes were most commonly reported in studies evaluating interventions targeting patients with T2DM (e.g. changes in HbA1c, weight, blood pressure and lipids), COPD (e.g. changes in Peak Expiratory Flow (PEF)), courses of antibiotics, oral corticosteroids and frequency of exacerbations), asthma (e.g. PEF, symptoms, inhalation technique, number of exacerbations and nocturnal awakenings), binge eating disorders (e.g. frequency of episodes and purging) and osteoarthritis (OA) (e.g. pain intensity, level of fatigue and use of pain medication). Seventeen studies targeting diabetes reported mean changes in HbA1c, with seven reporting significant improvements in the intervention compared to usual care [ 42 , 46 , 47 , 50 , 52 , 53 , 56 , 109 , 112 ]. Goudswaard et al. [ 42 ] reported a decrease in HbA1c at six weeks by 0.7% more (95% CI 0.1, 1.4) in those receiving the intervention when compared with control. The intervention evaluated by Adachi et al. [ 50 ] for patients with T2DM resulted in a 0.7% decrease in HbA1c at six months in the intervention group (n = 100) compared with a 0.2% decrease in the control group (n = 93) (difference −0.5%, 95% CI: -0.2%, −0.8%; p = 0.004).

Three RCTs reported on the level of asthma control and symptoms [ 80 – 82 ]. Mehuys et al. measured the level of asthma control using the Asthma Control Test (ACT), a clinically validated measure [ 81 ]. While mean ACT scores did not change from baseline for both study groups, a subgroup analysis of patients having insufficiently controlled asthma at baseline showed the intervention group had significantly increased ACT scores after six months (mean ACT change from baseline in the intervention group was +2.3 and +0.3 in the control group (mean difference 2.0, 95% CI: 0.1, 3.9; p = 0.038). The need for rescue medication was reduced in both groups from baseline, however a significantly higher reduction in the intervention group (-0.56 and -0.57 inhalations per day at three and six-month follow-up, respectively) was reported against control (-0.03 and -0.43 inhalations per day at three and six-month follow-up, respectively; p = 0.012) [ 81 ]. Six studies reported on COPD-specific outcomes [ 64 , 65 , 68 – 71 , 111 ]. McGeoch et al. [ 64 ] reported no significant change in St. George’s Respiratory Questionnaire (SGRQ) as the primary outcome measure. The intervention also showed no effect on self-reported outcomes including the frequency of use of antibiotic courses and oral corticosteroids over 12 months [ 64 ].

Interventions targeting eating disorders were evaluated in four RCTs [ 41 , 92 , 93 , 97 , 103 , 117 ]. Banasiak et al. [ 97 ] explored primary outcome measures of eating pathology derived from the Eating Disorder Examination Questionnaire (EDE-Q). Intention-to-treat (ITT) analyses revealed significant improvements in psychological symptoms at the end of the intervention compared with control, reduction in mean frequency of binge-eating episodes by 60% in intervention and 6% in control, and remission from all binge-eating and compensatory behaviours in 28% of the intervention and 11% of control. Treatment gains were maintained at three and six-month follow-up [ 97 ].

An intervention targeting patients with OA measured primary outcomes of pain intensity, physical functioning, self-efficacy, psychological distress, use of pain coping strategies, catastrophizing and HRQOL [ 84 ]. ITT analyses were performed on primary outcomes at baseline, post-treatment, 6 and 12 month follow-up which yielded significant group differences, indicating improvement in pain intensity (F(3,233) = 2.75, p = 0.044), physical functioning (F(3,233) = 3.11, p = 0.027), psychological distress (F(3,233) = 2.83, p = 0.039), use of pain coping strategies (F(3,233) = 4.97, p = 0.002), and self-efficacy (F(3,232) = 10.59, p< 0.001) in intervention, compared with control. All outcomes, except for self-efficacy, were maintained at 12-month follow-up while effects on self-efficacy degraded over time [ 84 ].

Health-related quality of life.

Twenty-four RCTs examined the impact of interventions on HRQOL [ 31 , 54 , 56 , 57 , 60 , 61 , 64 – 66 , 69 , 71 , 73 , 74 , 76 , 81 – 84 , 90 – 92 , 94 , 96 , 98 , 101 , 102 , 108 , 113 , 117 ]. The method of assessment varied and included general HRQOL questionnaires such as the SF-12 survey questionnaire and EuroQoL EQ-5D questionnaire. Disease specific QOL measures were also identified including the Arthritis Impact Measurement Scales Short Form questionnaire (AIMS2-SF) [ 119 ], Irritable Bowel Syndrome Quality of Life Questionnaire (IBSQOL) [ 120 ], Audit of Diabetes Dependent Quality of Life (ADDQOL) [ 121 ] and the standardised Asthma Quality of Life Questionnaire (AQLQ) [ 122 ]. Eight studies reported significant improvements in HRQOL [ 56 , 66 , 71 , 82 , 90 – 92 , 96 , 113 , 117 ]. Efraimsson et al. [ 66 ] evaluated the effects of COPD self-management delivered at a nurse-led primary health care clinic. HRQOL, measured using the SGRQ, was improved by an average value of 8.2 units (from 30.6) in the intervention group, whereas no change was noted in control. Differences between groups were clinically relevant and statistically significant (p = 0.00030) [ 66 ]. Heitkemper et al. [ 91 ] examined the effect of an IBS SMS intervention on HRQOL using the Irritable Bowel Syndrome Quality of Life questionnaire (IBSQOL), a 30-item questionnaire. Compared to usual care, participants receiving the intervention demonstrated statistically significant improvements in QOL, increasing by 10.6 units, 12.8 units and 12.2 units at nine weeks, six and twelve-months, respectively. Changes persisted at 12-month follow-up (p<0.001) [ 91 ].

Physical, psychological or social functioning.

Physical, mental or social functioning were measured in 25 RCTs [ 31 , 43 , 44 , 47 , 54 , 56 – 58 , 60 – 64 , 68 , 72 – 76 , 79 , 84 – 97 , 100 , 102 , 108 , 111 – 115 , 117 ]. Psychological symptoms and social functioning using the CORE-OM scale [ 123 ] were measured in three studies [ 74 , 75 , 100 ]. Psychological functioning was measured using the Beck Depression Inventory (BDI) and Beck Depression Inventory-II (BDI-II) scale [ 124 ] in eight studies [ 72 , 75 , 84 , 92 – 94 , 97 , 100 , 108 , 117 ]. Williams et al. [ 75 ] reported lower mean BDI-II scores in the intervention group at four months (2.6 to 7.9; mean difference 5.3 points, p<0.001). At twelve-month follow-up, there were also significantly higher proportions of participants achieving a 50% reduction in BDI-II in the intervention arm compared to control [ 75 ]. The Problem Areas in Diabetes Scale (PAID), a brief self-report scale [ 125 ], was used to evaluate diabetes-related distress. Sturt et al. [ 44 ] reported a reduction by 4.5 points in mean PAID scores at follow-up (95% CI: −8.1, −1.0), indicating lowered diabetes-related distress after a nurse-delivered intervention compared with control (p = 0.012), however this difference was considered a small effect [ 44 ]. Physical functioning was assessed with the SF-36PF scale [ 126 ] by Friedberg et al. [ 94 , 108 ] evaluating a chronic fatigue self-management intervention. No significant changes in scores by time, treatment group, or diagnostic group were revealed (p>0.05) [ 94 , 108 ].

Patient self-efficacy.

Self-efficacy was assessed using a number of validated instruments including the General Self Efficacy Scale (GSES-12) [ 127 ], Diabetes Management Self Efficacy Scale (DMSE) [ 128 ] and the Arthritis Self Efficacy Scale (an eight item scale measuring patients’ perceived ability to perform specific behaviours aimed at controlling arthritis pain and disability) [ 129 ], the COPD self-efficacy scale (CSES) [ 130 ], among others. Self-management and patient enablement were measured by the Patient Enablement Instrument (PEI) [ 87 ]. Changes in perceived self-efficacy were reported in 14 studies [ 31 , 44 , 54 , 57 , 68 , 69 , 73 , 76 – 78 , 84 , 87 , 98 , 99 , 102 , 104 , 110 , 111 , 116 ]. Sturt et al. showed self-efficacy scores were 11.2 points higher on the DMSE (95% CI: 4.4, 18.0) in the intervention group compared with the control group following a structured intervention delivered by practice nurses in the UK (p = 0.0014) [ 44 ]. Broderick et al. [ 84 ] reported significant improvement in self-efficacy (F(3,232) = 10.59, p = 0.001) following a nurse-practitioner delivered intervention for OA patients, however this was not maintained at 12-month follow up (p = 0.158). Seven RCTs reported non-significant improvements in self-efficacy [ 54 , 57 , 59 , 68 , 69 , 77 , 78 , 98 , 102 , 105 , 110 , 111 , 116 ]. Bischoff et al. found no statistically significant changes in CSES scores at 24 months [ 69 ]. Smit et al. [ 77 , 116 ] assessed self-efficacy in controlling depressive symptoms and preventing future episodes, using the Depression Self-Efficacy Scale (DSES) [ 131 ]. No statistically significant differences between groups were revealed at 12-month follow-up [ 77 , 116 ]. Eikelenboom et al. reported no significant difference in PAM-13 scores (measure of patient activation [ 132 ]) between control and intervention arms at six-month follow-up [ 59 , 105 ].

Self-management behaviours.

Behaviours commonly measured were diet, physical activity, medication adherence and smoking. Five studies reported on level of physical activity [ 41 , 59 , 83 , 88 , 103 , 105 ]. A range of measures included the International Physical Activity Questionnaire short form (IPAQ-SF) [ 133 ], Rapid Assessment of Physical Activity questionnaire (RAPA) [ 134 ] and The Physician-based Assessment and Counselling for Physical Activity (PACE) questionnaire [ 135 ]. No significant between group differences were reported for physical activity in 4 RCTs [ 41 , 59 , 65 , 83 , 103 , 105 ]. There was evidence in one study to suggest self-reported exercise participation was higher 1-week post-intervention (p<0.001) however differences were no longer significant at seven-week follow-up [ 88 ]. Self-care activities within 7 days were measured in 4 RCTs [ 41 , 52 , 54 , 60 , 102 , 103 ] using the Summary of Diabetes Self-Care Activities (SDSCA) questionnaire, a brief self-report instrument for measuring levels of self-management in diabetes (‘general diet’, ‘specific diet’, ‘physical exercise’, ‘foot care’ and ‘smoking’) [ 136 ]. Mehuys et al. reported significant improvements in self-management activities in the domains of ‘specific diet’ (+0.5 day/week, p = 0.008), ‘physical exercise’ (+0.4 day/week, p = 0.006), and ‘foot care’ (+1.0 day/week, p<0.001) for intervention patients. There were significant between-study group differences in the domains ‘physical exercise’ (p = 0.045) and ‘foot care’ (p<0.001), however the between-group difference for ‘specific diet’ were non-significant [ 52 ].

Disease knowledge.

Nine studies reported disease knowledge as an outcome [ 52 , 66 – 68 , 71 , 81 , 82 , 88 , 93 , 111 ]. Two RCTs [ 67 , 68 , 111 ], measured COPD disease knowledge using the Bristol COPD Knowledge Questionnaire (BCKQ) [ 137 ]. Hill et al. reported the results of the BCKQ for each domain in both groups. Compared with baseline measures, the total Bristol COPD knowledge Questionnaire score increased from 27.6 ± 8.7 to 36.5 ± 7.7 points (p<0.001) in the intervention group, and unchanged in the control group (29.6 ± 7.9 to 30.2 ± 7.2; p = 0.51) [ 67 ].

Intervention components and theoretical underpinnings

Each of the studies described interventions including multiple core components (see S5 Table for full component breakdown). Providing knowledge about the condition or treatment (100%; n = 58), enhancing patients role in making lifestyle changes (71.9%; n = 41), development of a self-management or action plan (45.6%; n = 26), keeping logs of self-monitoring (43.9%; n = 25), strategies for psychological coping with conditions (43.9%; n = 25), enhancing problem-solving and/or decision-making skills (42.1%; n = 24) and medication adherence or management (36.8%; n = 21) were most prominently detected ( Table 3 ). Interventions targeting heart disease, irritable bowel disease (IBD) and asthma reported the highest number of self-management components. Self-treatment through the use of an action plan, enhancing medication adherence and smoking cessation components were frequently seen in studies evaluating interventions targeting COPD. Similarly, SMS components targeting T2DM commonly included strategies to stimulate symptom monitoring, making positive lifestyle improvements with physical activity or dietary improvements. In contrast, interventions for depression included components focusing on patients’ role in managing stress, problem-solving and strategies for coping with conditions.

https://doi.org/10.1371/journal.pone.0220116.t003

Overall, sixteen studies explicitly reported a theoretical framework underpinning the intervention (28.1%; n = 16) including Cognitive Behavioural Theory (17.5%; n = 10) [ 58 , 74 , 75 , 84 , 90 – 94 , 100 ], Social Cognitive Theory (3.5%; n = 2) [ 79 , 104 ], Prochaska and DiClementes’ Transtheoretical model of the Stages of Change (3.5%; n = 2) [ 51 , 55 , 66 , 82 ], Social Learning Theory (1.8%, n = 1) [ 44 ], Normalization Process Theory [ 31 ] and Implementation Intention Theory (1.8%; n = 1) [ 104 ]. Intervention fidelity was reported in 21 studies (27.6%; n = 16).

Training of primary care provider to deliver SMS.

70.7% (n = 41) of studies included upskilling of HCPs to deliver the intervention. Training aimed at enhancing aspects of patient self-efficacy including mastery achievements, positive learning, adjustment to stress, verbal encouragement and outcome expectations. Intervention approaches were underpinned by the use of core communication skills to build trust and rapport in the patient-provider relationship, and as such providers were trained in areas including active listening, non-verbal communication, reflection, empathy and affirmation. Studies reported the provision of HCP resources to support self-management, e.g. written material or manuals, feedback on care reports, video demonstrations or case studies, and tools to assess patient support needs and priorities (PRISMS).

Interventions reporting positive findings for clinical and humanistic measures

Thirteen RCTs targeting a range of conditions including asthma, T2DM, COPD, recurrent binge eating, chronic fatigue, major depression, low self-esteem, IBS and depression reported positive findings for all clinical and humanistic outcome measures ( Table 4 ) [ 42 , 66 , 67 , 72 , 75 , 80 , 91 , 92 , 95 , 100 , 117 ].

https://doi.org/10.1371/journal.pone.0220116.t004

A mean of five self-management components (SD 1.7) were included in effective interventions. Elements most frequently reported to enhance the patient’s role in self-management included information provision (100.0%; n = 13), enhancing problem-solving or decision-making skills (76.9%; n = 10), active stimulation of symptom monitoring (46.2%; n = 6), medication management or adherence (46,2%; n = 6), strategies for stress or psychological management of condition (46.2%; n = 6) or enhancing dietary intake (46.2%; n = 6). The total duration of interventions ranged from 4 to 52 weeks. Initial consultations were on average 62 minutes (SD 13.8). Follow-up was delivered face-to-face in 11 interventions (84.6%; n = 11), and two studies reported telephone follow up (15.4%; n = 2). Studies reported mean of five follow-up sessions (SD 3.6) on average, ranging from 1 to 12 sessions. Mean duration of follow up sessions were 57 minutes (SD 18.5). Individuals were provided self-help support materials or resources in majority of interventions (92.3%; n = 12). Accompanying patient materials provided in addition to face-to-face sessions included manuals, information or educational booklets to work through at home, personalized treatment or action plans, devices and diaries for self-monitoring, goal setting forms or individualized dietary plans. Six RCTs incorporated a theoretical underpinning in their intervention: cognitive behavioral theory (30.8%; n = 4) and Prochaska and DiClementes’ transtheoretical model of the stages of change (15.4%; n = 2). Five integrated cognitive behavioral therapy (CBT) into their intervention (38.5%; n = 5).

Barbanel et al. [ 80 ] and Goudswaard et al. [ 42 ] targeted asthma and T2DM respectively and produced positive improvements in clinical outcomes. The SMS intervention evaluated by Barbanel et al. [ 80 ] examined the impact of a self-management program delivered by community pharmacists on asthma control. Intervention participants received self-management support from the pharmacist with weekly telephone follow-up for 3 months. This included a review of inhaler technique, skills including monitoring of peak flow, and a personalized action plan for worsening symptoms or exacerbations. Symptom scores improved in the intervention group and marginally worsened in the control group to 20.3 (4.2) and 28.1 (3.5), respectively (p<0.001; adjusted difference = 7.0 (95% CI: 4.4, 9.5). Goudswaard et al. [ 42 ] evaluated long-term effects of nurse-delivered self-management education in type 2 diabetics. The intervention focused on medication adherence, enhancing physical exercise, dietary intake and self-monitoring blood glucose at home. Six sessions were provided at intervals of 3–6 weeks, resulting in contact time of approximately 2.5 hours with HCPs over 6 months. HbA1c levels improved from 8.2% to 7.2% in the intervention group and 8.8% to 8.4% in usual care at 6 weeks, however this result was not sustained at 18 months [ 42 ].

Efraimsson et al. [ 66 ] examined effects of nurse-led COPD intervention. Patients received education on self-care ability to cope with disease and treatment. Patients were scheduled for two visits with nurses lasting 60 minutes during a 5-month period. A statistically significant increase was noted in the intervention group on QOL, the proportion of patients who ceased smoking, and patients’ knowledge about COPD at 3–5 month follow up, compared with usual care. Heitkemper et al. [ 91 ] examined an intervention delivered to women with IBS. Women in the intervention received eight weekly 1-hour individual sessions. The intervention included education, dietary counselling, symptom monitoring, relaxation training and cognitive-behavioral strategies including anger management, cognitive restructuring, assertiveness and social skills training [ 91 ]. Hill et al. [ 67 ] examined an intervention in people with COPD. Intervention participants attended two one-to-one 60-minute sessions, focusing on enhancing self-efficacy. Sessions were accompanied by a written manual adapted from the "Living Well with COPD" program. COPD knowledge increased from 27.6 (+/- 8.7) to 36.5 (+/- 7.7) in the intervention group, which was greater than any difference seen in the control group. Waite et al. [ 100 ] examined an individualized intervention for patients with low self-esteem. This included goal setting, learning skills to re-evaluate anxious and self-critical thoughts and beliefs through cognitive techniques. All participants were given a three-part self-help workbook in addition to individual treatment sessions. The intervention showed significantly better functioning than control on measures of overall functioning and depression and had fewer psychiatric diagnoses at the end of treatment. All treatment gains were maintained at follow-up assessment. Williams et al. [ 75 ] evaluated a guided self-help intervention for depression in primary care. The first appointment focused on an introduction to the use of the self-help materials. Three additional face-to-face support sessions of approximately 40 minutes were provided on a weekly or fortnightly basis. Mean Beck Depression Inventory (BDI-II) scores were lower in the intervention group at 4 months by 5.3 points, compared with control (2.6 to 7.9, p = 0.001). There were also significantly higher proportions of intervention participants achieving a 50% reduction in BDI-II scores at 4 and 12 months.

McLean et al. [ 82 ] involved a pharmacist-delivered intervention for asthma self-management. The intervention involved education surrounding the basic concepts of disease, medications, trigger identification and avoidance, and an asthma action plan. Patients were taught to use a peak flow meter, spacer devices, calendars/diaries were provided and asked to record peak expiratory flow rates (PEFRs) regularly for the course of the study period. Patients received appointments of approximately one hour in length with a pharmacist in a private counselling area every two to three weeks for at least three appointments, and then follow-up appointments at least quarterly for 12 months [ 82 ]. Symptom scores decreased by 50% (p<0.05) and peak flow readings increased by 11% (p = 0.0002) for intervention patients, compared to those receiving usual care. Chalder et al. [ 95 ] evaluated the efficacy of a self‐help booklet and advice delivered by a nurse in reducing chronic fatigue in adult patients. The intervention reiterated self-monitoring and maintaining symptom diaries. Basic cognitive techniques such as identifying and challenging unhelpful thoughts were also introduced. The self‐help group showed significantly greater improvements in fatigue (p = 0.01) and psychological distress (p<0.01) than controls. Striegel-Moore et al. [ 92 , 117 ] evaluated cognitive behavioural guided self-help for the treatment of recurrent binge eating. Intervention participants received 8 sessions over 12 weeks. The primary focus of this intervention was on developing a regular pattern of moderate eating using self-monitoring and problem-solving. The main outcome, abstinence from binge eating differed significantly between the groups: the initial improvement in abstinence from baseline was greater for the intervention group than usual care (p<0.001). Watkins et al. [ 72 ] evaluated guided self-help concreteness training as an intervention for major depression. During the initial session of the self-help intervention, psycho-education and training exercises were provided. During the follow-up telephone sessions, feedback, guidance and encouragement was provided to ensure accurate use of exercises, and progress monitored. The intervention resulted in significantly fewer depressive symptoms post-treatment, relative to treatment as usual (ITT, p = 0.006, effect size d for change in Hamilton Rating Scale for Depression (HAMD) = 0.76; PP, p<0.0001, d = 1.06).

Quality risk of bias assessment of individual studies

The overall methodological quality was considered high (lower risk of bias) in 41.4% of studies (n = 24 RCTs), and of medium quality in 58.6% of studies (n = 34 RCTs). The domains considered lowest risk of bias were selective reporting (96.6%; n = 56), baseline outcome measures (84.5%; n = 49), random sequence generation (79.3%; n = 46) and baseline characteristics (79.3%; n = 46). The domains with higher risk of bias were ‘blinding of outcome assessment’ (25.9% of studies; n = 15). Reporting bias was judged low for more than 95% of studies. Half of studies (51.7%; n = 30) presented low risk for the domain ‘other bias’. Reasons for other risk of bias included not meeting recruitment targets for assumed power. Fig 2 shows aggregate appraisal of risk of bias of included studies and visual representation of each domain.

https://doi.org/10.1371/journal.pone.0220116.g002

This systematic review has synthesized evidence from 58 randomized controlled trials examining the effectiveness of primary HCP delivered self-management support interventions for adult patients, with any condition, compared to usual standard of care. We describe effective SMS interventions and have highlighted their active elements, identified trends in combinations of intervention strategies, range of outcomes measured and the magnitude of effect size. This review demonstrates that SMS interventions delivered face-to-face by primary HCPs, which are multicomponent and tailored to explicitly enhance patient self-management skill set can lead to improvements in clinical and humanistic outcomes. The various tools and strategies that provide a structure to interventions delivered face-to-face include adapting interventions according to patients’ readiness to change, action planning and goal setting by collaboratively breaking down individual health goals into small achievable actions. The effectiveness of multicomponent SMS interventions is not surprising. But it raises the question of how to focus efforts on the best combination of active components within interventions. The variation in context, outcome measures, training methodology used across the 58 studies, in addition to the high degree of autonomy given to providers, deem the evaluation of SMS interventions more difficult.

Ninety-three different outcome measures were adopted to demonstrate evaluated impact of the various interventions and presumably were selected to reflect expected outcomes or processes of self-management. These include different measures of health-related quality of life, overall functioning, self-efficacy, health behaviours, disease knowledge, symptoms and disease control. Disease specific clinical indicators were mostly included as primary outcomes, and QoL indicators generally served as secondary or ancillary outcomes to primary outcome criteria. Generic HRQOL measures varied across different types of diseases, interventions and groups (i.e. EQ5D, SF-12), and specific HRQOL disease measures were also utilized. (i.e. IBSQOL questionnaire was used to measure changes in HRQOL for IBS patients). Further examination of studies producing positive improvements in HRQOL revealed use of disease specific measures (i.e. Ferrone et al. [ 71 ] reported positive changes in HRQOL using the Clinical COPD Questionnaire (CCQ)—a 10-item, health-related quality of life questionnaire). Interestingly, studies using more generic HRQOL measures (i.e. EQ5D, SF scales) mostly reported insignificant differences in their interventions. S4 Table provides a summary of the various instruments used in studies.

Our findings reveal a structured patient-provider exchange is required in primary care (including a one-on-one patient-provider consultation, ongoing follow up and provision of self-help materials). A systematic and tailored patient-primary care provider exchange is needed to provide individuals with the portfolio of techniques and tools to effectively self-manage. Various combinations of strategies were used to achieve this and adapted to the individuals’ condition, health literacy, skills and confidence in managing their own health. Strategies containing several interacting components and varying dimensions of complexity produce favourable effects when tailored to the individual. No one intervention solution is suitable for all patient groups and the selection of combinations of strategies should support patients’ needs relevant to both primary care and HCP. The strategy of enhancing the patient’s decision-making skills or ability to problem-solve was reported in the highest percentage of studies (53.8%) with positive results, after knowledge acquisition. Active stimulation of symptom monitoring (46.2%) and having specific, clear and accepted treatment or healthcare goals was also commonly identified. This involved setting measurable, clear and accepted treatment or healthcare goals on a per patient basis with a specific action or self-management plan detailing these. Tailored, written information and care plans that are mutually agreed upon have previously been identified as helpful [ 138 ]. Strategies to improve responsibility in medication adherence and lifestyle choices were also reported within effective interventions.

Interestingly, strategies for stress or psychological coping of conditions (46.2%) were commonly identified in effective interventions. Changing the patient’s cognitive approach to their illness was commonly incorporated into the intervention to deal with the physical and emotional symptoms resulting from a chronic illness. Effective interventions integrated cognitive behavioral therapy (CBT) into the intervention in 40% of studies. Multiple cognitive strategies were raised, such as identifying and challenging unhelpful thoughts [ 95 ], relaxation training and cognitive-behavioral strategies including anger management, cognitive restructuring, assertiveness and social skills training [ 91 ]. A 2014 systematic review of qualitative literature identified patients often express difficulties in dealing with the physical and emotional symptoms of their chronic conditions [ 138 ]. As such, undesirable physical and emotional symptoms and impaired physical functioning can directly prevent patients from carrying out normal daily activities, including tasks required to appropriately and successfully self-manage [ 139 – 141 ]. Self-management of chronic conditions should therefore be examined not only from the clinical perspective, but also the patient perspective with a focus on humanistic outcomes. Importantly, the theory of SMS drawn for effective studies included Cognitive Behavioral Theory and Prochaska and DiClementes’ transtheoretical model of the stages of change. Follow-up by HCPs included tailored feedback, monitoring of progress with respect to patient set healthcare goals, or honing problem-solving and decision-making skills. Self-help tools and assistance with locating resources were commonly provided during the patient-provider exchange.

The scope of the terms ‘self-management’, ‘self-management support’ and ‘self-management support interventions’ in literature and the large heterogeneity in terminology has repeatedly been highlighted in previous systematic reviews and meta-analyses [ 27 , 142 – 144 ]. This is a key limitation, as very broad or very narrow definitions of what constitutes “self-management support” have been applied. Lorig and Holman [ 10 ] previously underlined the need to explore interventions beyond the label of self-management to define if interventions actually address the necessary support strategies required to change behaviour. Subtle variations in self-management definitions can result in substantial differences in selected studies. Using Jonkman’s operational definition [ 35 ] to define our interventions has shown highly important in distinguishing self-management interventions from other types of interventions (ie. patient education or disease management) without being too restrictive. The definition clearly defines the elements or strategies that constitute a self-management support intervention, with the pivotal objective of changing behaviour. This has guided the selection of studies on which our review conclusions have been based.

A notable gap identified in the literature was a lack of focus on multimorbidity. This is understood to pose challenges for self-management, as many individuals have more than one health condition [ 138 ]. The effects of multimorbidity on a person are not always linear. Interestingly enough, some studies have found that patients with multimorbidity consider themselves better at self-management because they had already developed skills such as self-monitoring and self-advocacy [ 145 ].

In acknowledging that SMS is a multidimensional topic, we aimed to create a broader picture of the landscape of SMS in primary care. This was achieved by evaluating the patterns of intervention components comprehensively across all conditions, by not limiting our research to a clinical condition, or specific intervention strategies. Although including different clinical conditions in the review may be considered as a drawback due the potential heterogeneity induced, in our research, there was a clear distinction of strategies across the conditions studied. Findings from this review add further detail to this body of knowledge, while providing HCPs with a number of evidence-based strategies that can be utilized in practice. These findings pave the way to explore further SMS strategies targeting patient’s behaviour change, effective patterns of strategies, and develop a more evidence-based model for optimum SMS service design. Primary care providers (e.g. general practitioners, nurses, pharmacists) can play a foundational role in supporting patient self-management, especially for people with multiple chronic conditions. Fig 3 sets the foundation for an evidence-based SMS primary care model for face-to-face interventions, allowing for a more efficient and effective process to evaluate and implement SMS interventions in primary care.

Modelled on the definition of self-management interventions by Jonkman et al. 2016 [ 35 ].

https://doi.org/10.1371/journal.pone.0220116.g003

For this collaborative partnership approach to be more widely applied, there should be a strong focus on upskilling primary care providers to deliver SMS strategies in health care, which are both integrated and coordinated to improve the patient-provider encounter in practice [ 5 ]. The total duration of the intervention and the correlation of intervention duration with the number of strategies delivered are important aspects when considering the sustainability within primary care. Policy and funding alignment will also be a major determinant for future sustainability. Therefore, we must determine where the best compromise in SMS interventions lie for cost-effective and resource-limited approaches. Future high-quality evaluations of consistent interventions will be of value to practitioners, policy-makers and researchers in terms of collecting clinical, humanistic and economic outcome measures to generate a robust evidence base of primary care providers impact in the area. This will also allow determination of ineffective combinations of strategies.

Future research efforts should continue to expand on this landscape to (1) examine the patterns of strategies within effective multicomponent interventions for various conditions; (2) examine the weighting of each strategy (ie. determine intervention components which are more or less effective) within effective multicomponent interventions; (3) determine if certain types of patient populations could be targeted most effectively by certain combinations of strategies; (4) develop a core SMS outcome set in primary care; (5) examine the patient’s ability to self-manage over time as well as aiming to achieve the goal of long-term sustainability for improved self-management; and (6) determine training requirements for the upskilling of health care providers for sustained patient behaviour change.

Furthermore, sustainability of improved SMS first requires an understanding of the implementation of SMS enhancing interventions [ 146 ]. Sustainability can be challenging if not embedded into everyday clinical practice [ 31 ], and achieving the potential of primary care as a platform to effectively deliver SMS and achieve the stated outcomes means overcoming known barriers, such as limited time, skills and confidence among health professionals [ 31 , 147 ]. We know changes in health care professional practice requires exhaustive planning and testing to increase the probability that they are successfully and sustainably implemented. The adoption of Intervention Mapping has been widely used in health care settings to plan changes in the behaviour and practice of health care professionals, and should be applied to ensure SMS interventions are both effective and successfully implemented in practice [ 148 ].

There are limitations to this review. A number of studies did not report sufficient detail to their interventions which hampered the assessment of possible effective combinations of strategies being evaluated. The methodological quality domains of the included trials were in a lot of cases unclear, with a lack of poor description of the study methodology and intervention fidelity in evaluations. This was mitigated by contacting authors for further relevant information, searching for study protocols or further examining supplementary data online. With the growing recognition of the importance of assessing treatment fidelity in multicomponent interventions [ 149 – 151 ] (ie. compliance to treatment protocols by HCPs, or compliance to treatment by patients), it is important to note most trials (72%) did not include this in their design and few provided data on treatment fidelity to the intervention. Only 38% of effective interventions reported an assessment of intervention fidelity. The methodological quality domains of the included trials were in a lot of cases unclear. Four high-quality studies provided positive evidence that SMS interventions delivered in primary care dominate usual standard of care, by improving patients’ clinical outcomes, HRQOL or psychological functioning [ 72 , 91 , 92 , 100 ]. Similar trends have been found in existing literature in several contexts that self-management is essential to optimizing clinical and humanistic outcomes for patients with chronic conditions [ 13 , 15 , 18 , 152 – 155 ].

Although multiple databases were extensively searched using clear, specific and appropriate terms, the search may not have yielded all published relevant studies given the ambiguity of what constitutes “self-management support” and the variation in terminology for “self-management” identified in the literature. Unsurprisingly, with the rising burden of chronic disease, the nomenclature of “self-management” has become more prevalent in both published and grey literature. We recognize the use of different search terms and definitions to guide the development of the search strategy may lead to variation in the identification of studies, and affect a review's conclusions. This is identified as a limitation of our review. Search terms were sourced from previous systematic reviews, primary studies and grey literature. Our search included general terms for “self-management” and was not limited to specific illnesses or outcomes.

Systematic reviews are at risk for bias from a number of sources [ 156 ]. We sought to reduce potential sources of bias within the inclusion and synthesis of studies. One of our main goals was developing inclusion criteria to minimize ambiguity and reduce bias in study selection decisions. We have defined our inclusion and exclusion criteria by PICO clearly and have documented and reported all decisions made in the study selection process for transparency. Since we restricted our review to face-to-face interventions, there may be other SMS interventions that may be effective that are not covered by this review. We decided to categorize the comparator as usual standard of care and understand the definition of usual standard of care may vary by country or healthcare system.

In conclusion, this review highlights core components of successful interventions showing positive clinical and/or humanistic outcomes. Whilst it was difficult to directly correlate individual strategies to outcomes and effectiveness, there was a clear distinction of strategies across the conditions studied. This review provides encouraging groundwork for the design and evaluation of practical strategies for evidence-based practice and the construction of self-management support processes in primary healthcare practice. This review may assist in determining the breadth and focus of the support primary care professionals provide. Application of a theoretical perspective provides a strong base for the development of SMS interventions. The developed model sets the foundation for the design and evaluation of practical strategies for the construct of self-management support in primary healthcare practice. These results may be used to justify additional research investigating self-management interventions delivered in the primary care setting. In response, primary care providers can begin to deeply reflect on current practice and become involved in a dialogue to improve self-management support. Critically, these results should stimulate informed discussion for the future delivery of self-management support in primary care and the requirements for upskilling healthcare providers to effectively support patients in this collaborative process.

Supporting information

S1 data. database..

https://doi.org/10.1371/journal.pone.0220116.s001

S1 Table. Search strategy.

https://doi.org/10.1371/journal.pone.0220116.s002

S2 Table. PRISMA checklist.

https://doi.org/10.1371/journal.pone.0220116.s003

S3 Table. Descriptive characteristics of included studies.

https://doi.org/10.1371/journal.pone.0220116.s004

S4 Table. Summary of findings and extracted outcomes.

https://doi.org/10.1371/journal.pone.0220116.s005

S5 Table. Mapping of intervention components.

https://doi.org/10.1371/journal.pone.0220116.s006

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When Health Care Providers Look at Problems from Multiple Perspectives, Patients Benefit

• Jemima A. Frimpong,
• Christopher G. Myers,
• Kathleen M. Sutcliffe,
• Yemeng Lu-Myers

Specialization has its limits.

Health care providers have vastly different ways of seeing and treating patients, as differences in profession, specialty, experience, or background lead them to pay attention to particular signals or cues, and influence how they approach problems. While diverse perspectives and approaches to care are important, if they are not managed appropriately, they can cause misunderstandings, bias decision-making, and get in the way of the best care. Two things can help health professionals get better at communicating with each other and adopting multiple perspectives themselves: 1) creating an environment that supports perspective sharing and effective communication among team members; and 2) building people’s capacity to adopt multiple perspectives.

Mr. Smith was ready to be discharged home after his laryngectomy, an extensive operation that removes a patient’s throat due to cancer. In the opinion of Dr. Lu-Myers, he was a capable man who had passed his physical and occupational therapy evaluations with flying colors. Mr. Smith had fulfilled the doctor’s list of clinical discharge criteria, and she was eager to send him home. She planned to entrust him and his family to manage his dressing changes, as well as his tracheostomy and drain care, with the support of frequent outpatient nursing visits — all very routine protocol, especially for someone who seemed alert and capable.

• Jemima A. Frimpong is an assistant professor at the Johns Hopkins University Carey Business School and Armstrong Institute for Patient Safety & Quality. Her research focuses on the adoption and sustainability of innovations, development and testing of organization-level interventions, and performance improvement, centered primarily on health care organizations.
• Christopher G. Myers is an assistant professor at Johns Hopkins University on the faculty of the Carey Business School, School of Medicine, and Armstrong Institute for Patient Safety & Quality. His research explores interpersonal processes of learning, development, and innovation in health care and other knowledge-intensive work environments. Follow him  @ChrisGMyers .
• KS Kathleen M. Sutcliffe is a Bloomberg Distinguished Professor at Johns Hopkins University. Her research examines how organizations manage the unexpected and the dynamics of organizational reliability and resilience.
• Yemeng Lu-Myers is a resident surgeon specializing in otorhinolaryngology (ENT) at the University of Maryland Medical Center. Her research explores how patient demographics influence health outcomes and examines the effects of differential access to care.

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What Is Problem-Solving Therapy?

Verywell / Madelyn Goodnight

Problem-Solving Therapy Techniques

How effective is problem-solving therapy, things to consider, how to get started.

Problem-solving therapy is a brief intervention that provides people with the tools they need to identify and solve problems that arise from big and small life stressors. It aims to improve your overall quality of life and reduce the negative impact of psychological and physical illness.

Problem-solving therapy can be used to treat depression , among other conditions. It can be administered by a doctor or mental health professional and may be combined with other treatment approaches.

At a Glance

Problem-solving therapy is a short-term treatment used to help people who are experiencing depression, stress, PTSD, self-harm, suicidal ideation, and other mental health problems develop the tools they need to deal with challenges. This approach teaches people to identify problems, generate solutions, and implement those solutions. Let's take a closer look at how problem-solving therapy can help people be more resilient and adaptive in the face of stress.

Problem-solving therapy is based on a model that takes into account the importance of real-life problem-solving. In other words, the key to managing the impact of stressful life events is to know how to address issues as they arise. Problem-solving therapy is very practical in its approach and is only concerned with the present, rather than delving into your past.

This form of therapy can take place one-on-one or in a group format and may be offered in person or online via telehealth . Sessions can be anywhere from 30 minutes to two hours long. 

Key Components

There are two major components that make up the problem-solving therapy framework:

• Applying a positive problem-solving orientation to your life
• Using problem-solving skills

A positive problem-solving orientation means viewing things in an optimistic light, embracing self-efficacy , and accepting the idea that problems are a normal part of life. Problem-solving skills are behaviors that you can rely on to help you navigate conflict, even during times of stress. This includes skills like:

• Knowing how to identify a problem
• Defining the problem in a helpful way
• Trying to understand the problem more deeply
• Setting goals related to the problem
• Generating alternative, creative solutions to the problem
• Choosing the best course of action
• Implementing the choice you have made
• Evaluating the outcome to determine next steps

Problem-solving therapy is all about training you to become adaptive in your life so that you will start to see problems as challenges to be solved instead of insurmountable obstacles. It also means that you will recognize the action that is required to engage in effective problem-solving techniques.

Planful Problem-Solving

One problem-solving technique, called planful problem-solving, involves following a series of steps to fix issues in a healthy, constructive way:

• Problem definition and formulation : This step involves identifying the real-life problem that needs to be solved and formulating it in a way that allows you to generate potential solutions.
• Generation of alternative solutions : This stage involves coming up with various potential solutions to the problem at hand. The goal in this step is to brainstorm options to creatively address the life stressor in ways that you may not have previously considered.
• Decision-making strategies : This stage involves discussing different strategies for making decisions as well as identifying obstacles that may get in the way of solving the problem at hand.
• Solution implementation and verification : This stage involves implementing a chosen solution and then verifying whether it was effective in addressing the problem.

Other Techniques

Other techniques your therapist may go over include:

• Problem-solving multitasking , which helps you learn to think clearly and solve problems effectively even during times of stress
• Stop, slow down, think, and act (SSTA) , which is meant to encourage you to become more emotionally mindful when faced with conflict
• Healthy thinking and imagery , which teaches you how to embrace more positive self-talk while problem-solving

What Problem-Solving Therapy Can Help With

Problem-solving therapy addresses life stress issues and focuses on helping you find solutions to concrete issues. This approach can be applied to problems associated with various psychological and physiological symptoms.

Mental Health Issues

Problem-solving therapy may help address mental health issues, like:

• Chronic stress due to accumulating minor issues
• Complications associated with traumatic brain injury (TBI)
• Emotional distress
• Post-traumatic stress disorder (PTSD)
• Problems associated with a chronic disease like cancer, heart disease, or diabetes
• Self-harm and feelings of hopelessness
• Substance use
• Suicidal ideation

Specific Life Challenges

This form of therapy is also helpful for dealing with specific life problems, such as:

• Death of a loved one
• Dissatisfaction at work
• Everyday life stressors
• Family problems
• Financial difficulties
• Relationship conflicts

Your doctor or mental healthcare professional will be able to advise whether problem-solving therapy could be helpful for your particular issue. In general, if you are struggling with specific, concrete problems that you are having trouble finding solutions for, problem-solving therapy could be helpful for you.

Benefits of Problem-Solving Therapy

The skills learned in problem-solving therapy can be helpful for managing all areas of your life. These can include:

• Being able to identify which stressors trigger your negative emotions (e.g., sadness, anger)
• Confidence that you can handle problems that you face
• Having a systematic approach on how to deal with life's problems
• Having a toolbox of strategies to solve the issues you face
• Increased confidence to find creative solutions
• Knowing how to identify which barriers will impede your progress
• Knowing how to manage emotions when they arise
• Reduced avoidance and increased action-taking
• The ability to accept life problems that can't be solved
• The ability to make effective decisions
• The development of patience (realizing that not all problems have a "quick fix")

Problem-solving therapy can help people feel more empowered to deal with the problems they face in their lives. Rather than feeling overwhelmed when stressors begin to take a toll, this therapy introduces new coping skills that can boost self-efficacy and resilience .

Other Types of Therapy

Other similar types of therapy include cognitive-behavioral therapy (CBT) and solution-focused brief therapy (SFBT) . While these therapies work to change thinking and behaviors, they work a bit differently. Both CBT and SFBT are less structured than problem-solving therapy and may focus on broader issues. CBT focuses on identifying and changing maladaptive thoughts, and SFBT works to help people look for solutions and build self-efficacy based on strengths.

This form of therapy was initially developed to help people combat stress through effective problem-solving, and it was later adapted to address clinical depression specifically. Today, much of the research on problem-solving therapy deals with its effectiveness in treating depression.

Problem-solving therapy has been shown to help depression in: 

• Older adults
• People coping with serious illnesses like cancer

Problem-solving therapy also appears to be effective as a brief treatment for depression, offering benefits in as little as six to eight sessions with a therapist or another healthcare professional. This may make it a good option for someone unable to commit to a lengthier treatment for depression.

Problem-solving therapy is not a good fit for everyone. It may not be effective at addressing issues that don't have clear solutions, like seeking meaning or purpose in life. Problem-solving therapy is also intended to treat specific problems, not general habits or thought patterns .

In general, it's also important to remember that problem-solving therapy is not a primary treatment for mental disorders. If you are living with the symptoms of a serious mental illness such as bipolar disorder or schizophrenia , you may need additional treatment with evidence-based approaches for your particular concern.

Problem-solving therapy is best aimed at someone who has a mental or physical issue that is being treated separately, but who also has life issues that go along with that problem that has yet to be addressed.

For example, it could help if you can't clean your house or pay your bills because of your depression, or if a cancer diagnosis is interfering with your quality of life.

Your doctor may be able to recommend therapists in your area who utilize this approach, or they may offer it themselves as part of their practice. You can also search for a problem-solving therapist with help from the American Psychological Association’s (APA) Society of Clinical Psychology .

If receiving problem-solving therapy from a doctor or mental healthcare professional is not an option for you, you could also consider implementing it as a self-help strategy using a workbook designed to help you learn problem-solving skills on your own.

During your first session, your therapist may spend some time explaining their process and approach. They may ask you to identify the problem you’re currently facing, and they’ll likely discuss your goals for therapy .

Keep In Mind

Problem-solving therapy may be a short-term intervention that's focused on solving a specific issue in your life. If you need further help with something more pervasive, it can also become a longer-term treatment option.

Get Help Now

We've tried, tested, and written unbiased reviews of the best online therapy programs including Talkspace, BetterHelp, and ReGain. Find out which option is the best for you.

Shang P, Cao X, You S, Feng X, Li N, Jia Y. Problem-solving therapy for major depressive disorders in older adults: an updated systematic review and meta-analysis of randomized controlled trials .  Aging Clin Exp Res . 2021;33(6):1465-1475. doi:10.1007/s40520-020-01672-3

Cuijpers P, Wit L de, Kleiboer A, Karyotaki E, Ebert DD. Problem-solving therapy for adult depression: An updated meta-analysis . Eur Psychiatry . 2018;48(1):27-37. doi:10.1016/j.eurpsy.2017.11.006

Nezu AM, Nezu CM, D'Zurilla TJ. Problem-Solving Therapy: A Treatment Manual . New York; 2013. doi:10.1891/9780826109415.0001

Owens D, Wright-Hughes A, Graham L, et al. Problem-solving therapy rather than treatment as usual for adults after self-harm: a pragmatic, feasibility, randomised controlled trial (the MIDSHIPS trial) .  Pilot Feasibility Stud . 2020;6:119. doi:10.1186/s40814-020-00668-0

Sorsdahl K, Stein DJ, Corrigall J, et al. The efficacy of a blended motivational interviewing and problem solving therapy intervention to reduce substance use among patients presenting for emergency services in South Africa: A randomized controlled trial . Subst Abuse Treat Prev Policy . 2015;10(1):46. doi:doi.org/10.1186/s13011-015-0042-1

Margolis SA, Osborne P, Gonzalez JS. Problem solving . In: Gellman MD, ed. Encyclopedia of Behavioral Medicine . Springer International Publishing; 2020:1745-1747. doi:10.1007/978-3-030-39903-0_208

Kirkham JG, Choi N, Seitz DP. Meta-analysis of problem solving therapy for the treatment of major depressive disorder in older adults . Int J Geriatr Psychiatry . 2016;31(5):526-535. doi:10.1002/gps.4358

Garand L, Rinaldo DE, Alberth MM, et al. Effects of problem solving therapy on mental health outcomes in family caregivers of persons with a new diagnosis of mild cognitive impairment or early dementia: A randomized controlled trial . Am J Geriatr Psychiatry . 2014;22(8):771-781. doi:10.1016/j.jagp.2013.07.007

Noyes K, Zapf AL, Depner RM, et al. Problem-solving skills training in adult cancer survivors: Bright IDEAS-AC pilot study .  Cancer Treat Res Commun . 2022;31:100552. doi:10.1016/j.ctarc.2022.100552

Albert SM, King J, Anderson S, et al. Depression agency-based collaborative: effect of problem-solving therapy on risk of common mental disorders in older adults with home care needs . The American Journal of Geriatric Psychiatry . 2019;27(6):619-624. doi:10.1016/j.jagp.2019.01.002

By Arlin Cuncic, MA Arlin Cuncic, MA, is the author of The Anxiety Workbook and founder of the website About Social Anxiety. She has a Master's degree in clinical psychology.

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The Effectiveness of Problem-Solving Therapy for Primary Care Patients' Depressive and/or Anxiety Disorders: A Systematic Review and Meta-Analysis

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Background: There is increasing demand for managing depressive and/or anxiety disorders among primary care patients. Problem-solving therapy (PST) is a brief evidence- and strength-based psychotherapy that has received increasing support for its effectiveness in managing depression and anxiety among primary care patients.

Methods: We conducted a systematic review and meta-analysis of clinical trials examining PST for patients with depression and/or anxiety in primary care as identified by searches for published literature across 6 databases and manual searching. A weighted average of treatment effect size estimates per study was used for meta-analysis and moderator analysis.

Results: From an initial pool of 153 primary studies, 11 studies (with 2072 participants) met inclusion criteria for synthesis. PST reported an overall significant treatment effect for primary care depression and/or anxiety ( d = 0.673; P < .001). Participants' age and sex moderated treatment effects. Physician-involved PST in primary care, despite a significantly smaller treatment effect size than mental health provider only PST, reported an overall statistically significant effect ( d = 0.35; P = .029).

Conclusions: Results from the study supported PST's effectiveness for primary care depression and/or anxiety. Our preliminary results also indicated that physician-involved PST offers meaningful improvements for primary care patients' depression and/or anxiety.

• Anxiety Disorders
• Depressive Disorder
• Mental Health
• Primary Health Care
• Problem Solving
• Psychotherapy

Depressive and anxiety disorders are the 2 leading global causes of all nonfatal burden of disease 1 and the most prevalent mental disorders in the US primary care system. 2 ⇓ – 4 The proportion of primary care patients with a probable depressive and/or anxiety disorder ranges from 33% to 80% 2 , 5 , 6 ; primary care patients also have alarmingly high levels of co-/multi-morbidity of depressive, anxiety, and physical disorders. 7 Depression and anxiety among primary care patients contribute to: poor compliance with medical advice and treatment 8 ; deficits in patient–provider communication 9 ; reduced patient engagement in healthy behaviors 10 ; and decreased physical wellbeing. 11 , 12 Given the high prevalence of primary care depression and anxiety, and their detrimental effects on the qualities of primary care treatments and patients' wellbeing, it is important to identify effective interventions suitable to address primary care depression and anxiety.

Primary care patients with depression and/or anxiety are often referred out to specialty mental health care. 13 , 14 However, outcomes from these referrals are usually poor due to patients' poor adherence and their resistance to mental health treatment 15 , 16 . Therefore, it is critical to identify effective mental health interventions that can be delivered in primary care for patients' depression and/or anxiety. 17 , 18 During the past decade, a plethora of clinical trials have investigated different mental health interventions for depression and anxiety delivered in primary care. One of the most promising interventions that has received increasing support for managing depression and anxiety in primary care is Problem-Solving Therapy (PST).

Holding that difficulties with problem solving make people more susceptible to depression, PST is a nonpharmacological, competence-based intervention that involves a step-by-step approach to constructive problem solving. 19 , 20 Developed from cognitive-behavioral-therapy, PST is a short-term psychotherapy approach delivered individually or in group settings. The generic PST manual 19 contains 14 training modules that guides PST providers working with patients from establishing a therapeutic relationship to identifying and understanding patient-prioritized problems; from building problem-solving skills to eventually solving the problems. Focused on patient problems in the here-and-now, a typical PST treatment course ranges from 7 to 14 sessions and can be delivered by various health care professionals such as physicians, clinical social workers or nurse practitioners. Because the generic PST manual outlines the treatment formula in detail, providers may deliver PST after receiving 1 month of training. For example, 1 feasibility study on training residents in PST found that residents can provide fidelious PST after 7 weeks' training and reach moderate to high competence after 3 years of practicing PST. 21 PST also has a self-help manual available to clients when needed.

PST is a well-established, evidence-based intervention for depression in specialty mental health care and is receiving greater recognition for its effectiveness in treating depression and anxiety in primary care. Systematic and meta-analytic reviews of PST for depression consistently reported moderate to large treatment effects, ranging from d = 0.4 to d = 1.15. 22 ⇓ – 24 Several clinical trials indicated PST's clinical effectiveness in alleviating anxiety as well. 25 , 26 Most importantly, PST has been adapted for primary care settings (PST-PC) and can be delivered by a variety of health care providers with fewer number of sessions and shorter session length. These unique features make PST(-PC) an ideal psychotherapy for depressive and/or anxiety disorders in primary care.

Previous reviews of PST focused on its effectiveness for depression care, but with little attention to PST's effect on anxiety or comorbid depression anxiety. In addition, to our knowledge, no previous reviews of PST have focused on managing depressive and/or anxiety disorders in primary care. Although research demonstrates that PST has a strong evidence base for treating depression and/or anxiety in specialty mental health care settings, more research is needed to determine whether PST remains effective for treating depressive and/or anxiety disorders when delivered in primary care. To address this gap, we conducted a systematic review and meta-analysis on the effectiveness of PST for treating depressive and/or anxiety disorders with primary care patients.

Search Strategies

This review included searches in 6 electronic databases (Academic Search Complete, CINAHL, Medline, PsychINFO, PUBMED, and the Cochrane Library/Database) and 3 professional Web sites (Academy of Cognitive Therapy, IMPACT, Anxiety and Depression Association of America) for primary care depression and anxiety studies published between January 1900 and September 2016. We also E-mailed major authors of PST studies for feedback and input. Search terms of title and/or abstract searches included: [“PST” or “Problem-Solving Therapy” or “Problem Solving Therapy” or “Problem Solving”] AND [“Depression” or “Depressive” or “Anxiety” or “Panic” or “Phobia”] AND [“primarycare” or “primary care” or “PCP” or “Family Medicine” or “Family Doctor”]. We supplemented the procedure described above with a manual search of study references.

Eligibility Criteria

For inclusion in analyses, a study needed to be 1) a randomized-controlled-trial of 2) PST for 3) primary care patients' 4) depressive and/or anxiety disorders. For studies that examined face-to-face, in-person PST, the intervention must be delivered in primary care for inclusion. If studies examined tele-PST (eg, telephone delivery, video conferencing, computer-based), the intervention must be connected to patients' primary care services for a study to be included. For example, when a primary care physician prescribed computer-based PST at home for their patients, the study met inclusion criteria (as it was still considered managing depression “in primary care” in the present review). However, studies would be excluded if a primary care physician referred patients to an external mental health intervention. Finally, studies must document and report sufficient statistical information for calculating effect size for inclusion in the final analysis.

Data Abstraction and Coding

Two authors (AZ and JES) reviewed an initial pool of 153 studies and agreed to remove 65 studies based on title and 68 studies based on abstract, resulting in 20 studies for full-text review. To develop the final list, we excluded 6 studies after closer review of full-text and consultation with a third reviewer who is an established PST researcher. Lastly, we excluded 2 studies due to 1) a study with a design that blurred the effect of PST with other treatments and 2) unsuccessful contact with a study author to request data needed for calculating effect size. We used a final sample of 11 studies for meta-analysis. The PRISMA chart is presented in Figure 1 .

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Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) chart of literature search for Problem-solving therapy (PST) studies for treating primary care patients' depression and/or anxiety.

Statistical Analysis

This study conducted meta-analysis with the following procedures: 1) calculated a weighted average of effect size estimates per study for depression and anxiety separately (to ensure independence) 27 ; 2) synthesized an overall treatment effect estimate using fixed- or random-effects model based on a heterogeneity statistic (Q-statistic) 28 ; and 3) performed univariate meta-regression with a mixed-effects model for moderator analysis. 29 Although other more advanced statistical approaches allow inclusion of multiple treatment effect size estimates per study for data synthesis, like the Generalized Least Squares method 30 or the Robust Variance Estimation method 31 , this study employed a typical approach because of the relatively small sample and absence of study information required to conduct more advanced methods. Following procedures outlined by Cooper and colleagues 32 , we conducted all analyses with R software. 33 We chose to conduct analyses in R, rather than software specific to meta-analysis (eg, RevMan), because R allowed for more flexibility in statistical modeling (eg, small sample size correction). 34 Sensitivity analysis using Robust Variance Estimation did not significantly alter results estimated with the typical approach. And so this study presents results from only the typical approach for purposes of parsimony and clarity.

Publication Bias, Risk of Bias and Quality of Studies

To detect publication bias, we used a funnel plot of effect size estimates graphed against their standard errors for visual investigation. To evaluate risk of bias, we used the Cochrane Collaboration's tool for assessing risk of bias in randomized trials 35 and the Quality Assessment of Controlled Intervention Studies to evaluate study quality. 36

Primary Studies

Eleven PST studies for primary care depression and/or anxiety reported a total sample size of 2072 participants. Participants' age averaged 50.1 and ranged from 24.5 to 71.8 years old. Ten studies reported participants' sex with an average of 35.6% male participants across all studies. Seven studies (63.6%) reported participants' racial background with most identified as non-Hispanic white (83.6%). Other racial/ethnic groups were poorly reported for meaningful summary. Five studies used active medication as a comparison, including 3 studies that used both active medication and placebo medication. The rest compared PST with treatment-as-usual while 2 studies used active control group (eg, video education material). Four studies involved physicians in some component of intervention delivery. PCPs provided PST in 2 studies; supervised and collaborated with depression care manager in 1 study, and collaborated with a primary care nurse in another. Ten studies reported an average of 6 PST sessions ( M = 6.1) ranging from 3 to 12 sessions. All but 1 study (n = 10) used individual PST and 2 studies used tele-health modalities to provide PST. All studies used standardized measures of depression and anxiety. Examples of the most common measures included: PHQ-9, CES-D, HAM-D, and BDI-II. Table 1 presents a detailed description of study characteristics.

• View inline

Study Characteristics for Problem-Solving Therapy as Intervention for Treating Depression and/or Anxiety Among Primary Care Patients ( n = 11)

Publication Bias, Risk of Bias, and Quality of Studies

The funnel plot ( Figure 2 ) did not indicate any clear sign of publication bias. Risk of bias ( Table 4 ) indicated an overall acceptable risk across studies included for review with blinding of participants and personnel, blinding of outcome assessment and incomplete outcome data most vulnerable to risk of bias. Quality of study assessment ( Table 5 ) indicated an overall satisfactory study quality with over half of studies (n = 6) achieving ratings of “Good” study quality.

Funnel Plot for Publication Bias in Problem-solving therapy (PST) Studies for Treating Primary Care Patients' Depression an/or Anxiety.

Meta-analysis and moderator analysis

Figure 3 presents a forest plot of treatment effects per study, including depression and anxiety measures. Table 3 presents subgroup analysis of overall treatment effect by moderator and Table 2 presents the results of meta-analysis and moderator analysis. Meta-analysis revealed an overall significant treatment effect of PST for primary care depression and/or anxiety ( d = 0.67; P < .001). Further investigation revealed no significant difference between the mean treatment effect of PST for depression versus anxiety in primary care ( d ( diff .) = −0.25; P = .317) while subgroup analysis revealed the overall treatment effect for anxiety was not significant ( d = 0.35; P = .226). Age was found to be a significant moderator (β 1 = 0.02; P = .012) for treatment outcomes, indicating that for each unit increase in participants' age, the overall treatment effect for primary are depression and/or anxiety are expected to increase by 0.02 (standard deviations). Neither participants' ethnic or racial backgrounds nor marital status significantly moderated the overall treatment outcome.

Forest Plot of PST Treatment Effect Size Estimates for Treating Primary Care Patients' Depression and/or Anxiety per Study.

PST for Treating Primary Care Patients' Depression and/or Anxiety; Results of Univariate Meta-regression

Results of Subgroup Analysis of Overall Treatment Effect (by Moderator) of PST for Treating Primary Care Patients' Depression and/or Anxiety

PST for Treating Primary Care Patients' Depression and/or Anxiety; Results of the Cochrane Collaboration's Tool for Assessing Risk of Bias *

Quality Assessment of Controlled PST Intervention Studies for Primary Care Patients' Depression and/or Anxiety ( n =11)

The overall treatment effect was not moderated by any treatment characteristics including: treatment modality (individual vs group PST), delivery methods (face-to-face vs tele-health PST), number of PST sessions and length of individual PST sessions. Subgroup analysis indicated an overall significant treatment effect of in-person PST ( d = 0.72; P < .001) but not of tele-PST ( d = 0.53; P = .097). However, the difference between the 2 was not statistically significant.

PST providers background and primary care physician's involvement significantly moderated the overall treatment effect size. Master's-level providers reported an overall treatment effect ( d = 1.57; P < .001) significantly higher than doctoral-level providers ( d = −1.33; P = .007). Both physician-involved and nonphysician involved PST reported significant overall treatment effect of PST for depression and/or anxiety in primary care ( d = 1.06; P < .001 and d = 0.35; P = .029, respectively). Moderator analysis further revealed that PST without physician involvement reported significantly greater treatment effects compared with physician-involved PST in primary care ( d = −0.71; P = .005). Results of subgroup and moderator analyses indicated that while the difference (in treatment effect) between physician and nonphysician involved PST in primary care were statistically significant, physician-involved PST was also statistically significant, thus practically meaningful.

Results of the study demonstrated a statistically significant overall treatment effect in outcomes of depression and/or anxiety for primary care patients receiving PST compared with patients in control groups. The outcome type—depression versus anxiety—failed to moderate treatment effect; only PST for depression reported a significant overall effect size. This could indicate that many studies primarily targeted depression and included anxiety measures as secondary outcomes. For this reason, we expect to find a greater treatment effect for primary care depression. It was unsurprising that treatment characteristics failed to moderate treatment effect size because most primary studies used PST-PC or its modified version; there was insufficient variation between studies (and moderators), yielding insignificant moderating coefficients.

Although delivery method did not moderate treatment effect reported in studies included in this review, significant effect was only reported by studies using face-to-face in-person PST but not by those with tele-PST modalities (n = 2). Although evidence for the effectiveness of tele-PST is established or increasing in a variety of settings 37 ⇓ – 39 most PST studies for primary care patients have used face-to-face, in-person PST. Our study further supported the use of face-to-face in-person PST for treating depression and anxiety among primary care patients. We recognize, however, that current and projected shortages in specialty mental health care provision, felt acutely in subspecialties such as geriatric mental health, necessitate more trials with PST tele-health modalities. 40

It is salient to note that, while nonphysician-involved PST studies reported significantly greater treatment effect than those involving physicians, PCP-involved studies also reported an overall significant effect size. Closer examination indicated that studies with physician-involved PST were either delivered by physicians or other nonmental health professionals (eg, registered nurses or depression care managers). Lack of sufficient PST training might explain the difference in treatment effect sizes being statistically significant. Yet, the fact that physician-involved PST studies reported an overall statistically significant effect size for primary care depression and/or anxiety suggested a meaningful treatment effect for clinical practice. When faced with a shortage of mental health professionals (eg, psychologists, clinical social workers, licensed professional counselors), our findings suggest physician-led or -supervised PST interventions could still improve primary care patients' depression and/or anxiety. Researchers are encouraged to further examine the treatment effect of PST delivered by mental health professionals in collaboration with primary care physicians.

This study has several weaknesses that are inherent to meta-analyses. There is no way to assure we included all studies despite adopting a comprehensive search and coding strategy (ie, file drawer problem). Second, while all studies in this meta-analysis seemed to have satisfactory methodological rigor, it is possible that internal biases within some studies may influence results. This study takes a quantitative meta-analysis approach which inherently neglects other study designs and methodologies that also provide valuable information about the effectiveness, feasibility, and acceptability of PST for treating primary care patients with depression. To ensure independence of data, this study used a weighted average of effect size estimates per study in synthesizing an overall treatment effect and conducting moderator analysis. While sensitivity analysis did not reveal significant differences from the reported results, we will not know for sure how our choice of statistical method might affect the results.

• Acknowledgments

The authors are grateful to Dr. Namkee Choi, Professor and the Louis and Ann Wolens Centennial Chair in Gerontology at the University of Texas at Austin Steve Hicks School of Social Work, for her mentorship and insightful comments during preparation of the manuscript.

This article was externally peer reviewed.

Funding: none.

Conflict of interest: none declared.

Ethics Review: This is a systematic review and meta-analysis based on de-identified aggregate study data. No human participants or animals were involved in this study. No ethics review was required.

To see this article online, please go to: http://jabfm.org/content/31/1/139.full .

• Received for publication July 5, 2017.
• Revision received September 14, 2017.
• Accepted for publication September 27, 2017.
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Use of EBP as a Problem‐Solving Approach to Improve Patient Satisfaction While Overcoming the COVID Pandemic Barriers

Jeri berryman.

1 Nursing Excellence, Columbus OH, USA

The Centers for Medicare & Medicaid Services requires hospitals to meet rigorous patient satisfaction requirements for reimbursement. One metric used for patient satisfaction is call light responsiveness within a unit.

To meet target call light responsiveness benchmarks at a 45‐bed telemetry, medical–surgical nursing unit within a Magnet ® designated hospital.

An evidence‐based practice (EBP) project model was utilized. The chief nursing officer worked with an EBP nurse mentor. A PICOT (Population, Intervention, Comparison, Outcome, and Time) question was developed to guide the literature search. Literature was critically appraised, and a resulting intervention was established. Nurse educators taught the unit nurses how to perform the intervention, and intervention integration was assessed via direct observation. Call light responsiveness data were collected to assess whether targets were met.

Five articles were deemed as applicable to the PICOT question, and the best evidence determined that using the 4Ps (pain, presence, “potty,” and positioning) during structured registered nurse (RN) care rounding every 2 h improved patient outcomes. After RN education and implementation, hospital call light responsiveness began to improve.

Linking Evidence to Action

Rounding without intention increases RN workload and does not result in improved patient outcomes or a satisfied patient. RN rounding every 2 h is effective and efficient when done with intention (i.e., adhering to the 4Ps). RN patient rounds done every 2 h with intention improved patient satisfaction and other patient outcomes such as a decrease in call light usage.

Hospitals in the United States must meet rigorous patient satisfaction metrics to satisfy the Centers for Medicare & Medicaid Services requirements. One Magnet ® hospital in our large health system, a 45‐bed nursing unit, was challenged with meeting target call light responsiveness benchmarks (Table  1 ). The chief nursing officer contacted the system’s evidence‐based practice (EBP) nurse mentor to help find a solution to this dilemma. The nursing unit setting is a telemetry, medical–surgical nursing unit that recently hired a large number of new registered nurses (RNs). Their current practice was that the nursing leadership completed patient intentional rounding 90% of the time. Leadership rounds included toileting and pain assessment at 5 a.m. and 5 p.m. to decrease call light usage during shift change. However, the nurse responses to call light statistics continued to decline. The staff nurses were generally in the patient rooms at a minimum of every 2 h, but no structured patient care rounding was noted. The health system’s nursing strategic plan values every nurse as a leader and is committed to the use of EBP to improve the health of those they serve. The nursing leadership strategic plan supports that problem‐solving is done best when it is closest to and completed with the patient.

Pre‐EBP Uptake Data

PICOT (POPULATION, INTERVENTION, COMPARISON, OUTCOME, AND TIME) QUESTION

In hospitalized patients, how does hourly rounding compared with bi‐hourly rounding affect patient satisfaction?

SEARCH STRATEGY

Search terms included (Hospitalized patients OR inpatients OR patients OR admitted) AND (hourly rounding OR hourly checks OR rounds) AND (bi‐hourly OR routine OR every two hours) AND (patient satisfaction OR patient experiences OR patient perceptions OR patient attitudes). CINAHL full text, MEDLINE full text, and Healthsource: Consumer Edition databases resulted in 208 articles returned. Filters applied in these databases were peer‐reviewed (66 articles), date limited to 2009–2019 (52 articles), English‐language only (52 articles), and United States (23 articles). Based upon the setting and patient population identified in the PICOT question, four articles were relevant, and three articles were applicable. The Cochrane Database resulted in zero articles. The PubMed database resulted in 46 articles. Filters for PubMed were free full text (19 articles) and publication dates limited to 2009–2019 (17 articles). From these articles, three were found to be relevant, and two were noted as applicable based upon the setting and patient population identified in the PICOT question.

CRITICAL APPRAISAL OF THE EVIDENCE

The literature synthesis revealed that intentional RN rounding every 2–3 hours significantly impacted patient satisfaction. The team discovered that what occurs and how patients perceive the presence of the nurse doing the rounding mattered (Sims et al., 2018 ). Our team further discovered that the uptake of the structured use of the 4Ps (pain, presence, “potty,” and positioning) by the RN every 2 h improves patient outcomes (Woodard, 2009 ). The patient outcomes impacted were an increase in patient satisfaction scores, the patient’s perception of quality nursing care, pain management, and a measurable decrease in call light use and falls.

INTEGRATION OF THE EVIDENCE WITH CLINICAL EXPERTISE AND PATIENT PREFERENCES

The nursing leadership completed 16 direct observation audits of RN rounding (both day and night shift) to determine current practice. The key stakeholders planned implementation strategies to promote uptake of every 2‐h RN rounds. These rounds focused on the 4Ps (Woodard, 2009 ). The stakeholders used simulation to teach the best practices in a convenient staff space on the unit, thus permitting the nurses to attend the simulation at their convenience.

The nurse educator used the simulated environment to promote the knowledge, skills, and attitudes needed for successful practice change (Field, Booth, Ilott, & Gerish, 2014 ). The nurse leaders used a variety of evidence‐based implementation strategies to support the change in rounding behaviors. These leaders shared data and EBP progress daily on the unit’s Key Process Indicator board (Richardson & Richardson, 2016 ). Progress was also discussed at staff meetings and huddles during all shifts. Nurse leaders posted flyers in strategic locations to keep the care goals in front of the team. As nurse leaders made rounds, they used just‐in‐time coaching techniques to assess the nurses’ understanding and uptake of the 4Ps intervention. Coaching was used to role model the implementation of 4Ps in real time.

In June 2020, rounding with the 4Ps intervention began and, consistent with what is reported in the literature, call light responsiveness began to improve (Table  2 ). Leaders celebrated by distributing Hershey Kisses and Hugs drinks to signify a job well done while honoring COVID‐19 restrictions on the nursing unit. Ongoing sustainability strategies for this best practice include strategic communication between the nurse leaders and RNs.

Pre‐ and Post‐EBP Uptake Data

DISSEMINATION

Plans are in place to disseminate this EBP project at the local hospital Nursing Grand Rounds and at the System Nurse Practice Advisory Council to encourage lateralization across the care sites. A virtual poster presentation was presented at the STTI: Rho‐Nu‐at‐Large Chapter #419 Fall Scholarly Event. Lastly, the organization is considering showcasing this EBP project at an upcoming Magnet ® conference.

• Rounding done without intention increases RN workload that does not result in improved patient outcomes or a satisfied patient.
• Hourly rounding on a high fall risk patient is current practice; however, every 2‐hour RN rounding is effective and efficient if done with intention, that is, 4Ps.
• RN patient rounds done every 2 h with intention improve patient satisfaction and other patient outcomes such as decrease in call light usage.
• Field, B. , Booth, A. , Ilott, I. , & Gerish, K. (2014). Using the knowledge to action framework in practice: A citation analysis and systematic review . Implementation Science , 9 , 172. 10.1186/s13012-014-0172-2 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Richardson, E. , & Richardson, T. (2016). The value of key performance indicators in a Lean transformation . https://www.lean.org/LeanPost/Posting.cfm?LeanPostId=531
• Sims, S. , Leamy, M. , Davies, N. , Schnitzler, K. , Levenson, R. , Mayer, F. , … Harris, R. (2018). Realist synthesis of intentional rounding in hospital wards: Exploring the evidence of what works, for whom, in what circumstances and why . BMJ Quality and Safety , 27 , 743–757. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Woodard, J. (2009). Effects of rounding on patient satisfaction and patient safety on a medical‐surgical unit . Clinical Nurse Specialist , 23 ( 4 ), 200–206. [ Google Scholar ]

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Evidence-based practice, step by step: searching for the evidence

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• 1 Nurse Educator Evidence-Based Practice Mentorship Program at Arizona State University in Phoenix, USA. [email protected]
• PMID: 20520115
• DOI: 10.1097/01.NAJ.0000372071.24134.7e

This is the fourth article in a series from the Arizona State University College of Nursing and Health Innovation's Center for the Advancement of Evidence-Based Practice. Evidence-based practice (EBP) is a problem-solving approach to the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise and patient preferences and values. When delivered in a context of caring and in a supportive organizational culture, the highest quality of care and best patient outcomes can be achieved. The purpose of this series is to give nurses the knowledge and skills they need to implement EBP consistently, one step at a time. Articles will appear every two months to allow you time to incorporate information as you work toward implementing EBP at your institution. Also, we've scheduled "Chat with the Authors" calls every few months to provide a direct line to the experts to help you resolve questions. See details below.

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• Published: 19 August 2024

Updating a conceptual model of effective symptom management in palliative care to include patient and carer perspective: a qualitative study

• Emma J. Chapman 1 ,
• Carole A. Paley 1 ,
• Simon Pini 2 &
• Lucy E. Ziegler 1  

BMC Palliative Care volume  23 , Article number:  208 ( 2024 ) Cite this article

114 Accesses

Metrics details

A conceptual model of effective symptom management was previously developed from interviews with multidisciplinary healthcare professionals (HCP) working in English hospices. Here we aimed to answer the question; does a HCP data-derived model represent the experience of patients and carers of people with advanced cancer?

Semi-structured interviews were undertaken with six patients with advanced cancer and six carers to gain an in-depth understanding of their experience of symptom management. Analysis was based on the framework method; transcription, familiarisation, coding, applying analytical framework (conceptual model), charting, interpretation. Inductive framework analysis was used to align data with themes in the existing model. A deductive approach was also used to identify new themes.

The experience of patients and carers aligned with key steps of engagement, decision making, partnership and delivery in the HCP-based model. The data aligned with 18 of 23 themes. These were; Role definition and boundaries, Multidisciplinary team decision making, Availability of services/staff, Clinician-Patient relationship/rapport, Patient preferences, Patient characteristics, Quality of life versus treatment need, Staff time/burden, Psychological support -informal, Appropriate understanding, expectations, acceptance and goals- patients, Appropriate understanding, expectations, acceptance and goals-HCPs, Appropriate understanding, expectations, acceptance and goals- family friends, carers, Professional, service and referral factors, Continuity of care, Multidisciplinary team working, Palliative care philosophy and culture, Physical environment and facilities, Referral process and delays. Four additional patient and carer-derived themes were identified: Carer Burden, Communication, Medicines management and COVID-19. Constructs that did not align were Experience (of staff), Training (of staff), Guidelines and evidence, Psychological support (for staff) and Formal psychological support (for patients).

Conclusions

A healthcare professional-based conceptual model of effective symptom management aligned well with the experience of patients with advanced cancer and their carers. Additional domains were identified. We make four recommendations for change arising from this research. Routine appraisal and acknowledgement of carer burden, medicine management tasks and previous experience in healthcare roles; improved access to communication skills training for staff and review of patient communication needs. Further research should explore the symptom management experience of those living alone and how these people can be better supported.

Peer Review reports

A conceptual model of effective symptom management was previously developed from qualitative data derived from interviews with healthcare professionals working in English hospices to elicit their views about the barriers and facilitators of effective symptom management [ 1 ]. The model delineated the successful symptom management experience into four steps of: engagement, decision-making, partnership and delivery. Constructs contributing to these were identified (Table 1 ).

Our original model was based solely on Healthcare professional (HCP) input. However, the perception of professionals may vary from that of patients and carers. A recent patient and professional survey of needs assessments in an oncology inpatient unit showed discrepancies between perception of unmet needs between staff and patients [ 2 ]. For this reason, we were concerned that what was deemed important by HCP working in palliative care may not mirror the concerns and experience of patients and carers.

Here we aimed to answer the question; does an HCP data-derived model represent the experience of patients and carers of people with advanced cancer?. If necessary, the original conceptual model of effective symptom management will be updated.

Qualitative, semi-structured interviews were chosen to gain an in-depth understanding of the experience from the perspective of a range of patients and carers. All methods were carried out in accordance with the principles of the Declaration of Helsinki. Ethical approval was granted by a UK research ethics committee ( North of Scotland [ 2 ] Research Ethics Committee (20/NS/0086)). Verbal, recorded informed consent was given using a verbal consent script (Supplementary information 1). Our original intention had been to conduct interviews face to face facilitated by a set of laminated prompt cards based upon those used in the HCP interviews. However, adaptation to telephone interviews in patient’s homes was necessary due to COVID-19 restrictions and it became apparent that the card exercise did not work well remotely. We continued interviews based on the interview schedule but without the use of prompt cards. EC is a female, non-clinical senior research fellow in palliative care. She has experience of qualitative interviews and led the development of the original HCP-based model of effective symptom management [ 1 ]. Audio recordings were transcribed verbatim by a senior academic secretary.

Recruitment

Participants who met the inclusion criteria were identified by a research nurse at the participating hospice. Eligible patients were those who met all 5 criteria:

Diagnosed with advanced disease (i.e., cancer that is considered to be incurable).

Had been referred to the participating hospice.

Were 18 years of age or over.

Were able to speak and understand English.

Were able to give informed consent.

Eligible carers were people who met all 4 criteria:

Were the informal carer of an eligible patient (who may or may not also be participating in the study).

Patients or carers were excluded if they:

Exhibited cognitive dysfunction which would impede their being able to give informed consent and take part in the study.

Were deemed by hospice staff to be too ill or distressed.

Access to the inpatient unit was not possible at this time due to Covid-19 restrictions. The research nurse introduced the study, provided a participant information sheet and completed a consent to contact form. The first contact with the researcher was made by telephone to confirm (or not) interest in participation and answer questions. An interview time not less than 48 h after provision of the participant information sheet, was scheduled. The researcher and the participant information sheet explained the overall aim of the RESOLVE research programme to improve health status and symptom experience for people living with advanced cancer (Supplementary information 2). The verbal consent statements made it clear that this was a conversation for research purposes only and would not have any impact on the care the patient received (Supplementary information 3). Permission was granted that the researcher may contact the clinical team at the hospice if there was a serious concern for welfare that required urgent attention. Verbal informed consent was collected, and audio recorded at the start of the interview with participants answering yes or no to each of the statements in the verbal consent script (Supplementary information 3). Participants were told that we had already interviewed HCPs about what helped or hindered effective symptom management and now we wanted to understand their perspective too.

Data Collection

Interview topic guides (Supplementary information 4 and 5) were used. Interviews were conducted by EC over the telephone and audio recorded onto an encrypted Dictaphone. Files were downloaded onto a secure University of Leeds drive and then deleted from the Dictaphone. No video was recorded. The researcher made brief field notes directly after the interview on impression, emotion and participant backgrounds that were disclosed.

An Excel spreadsheet was used to facilitate data management. We explored the constructs of patient and carer experience as defined by our existing model. An inductive framework analysis was used to align data with themes in the existing conceptual model. A deductive approach was also used to identify new themes not included in the original model. Two researchers (EC and CP) independently conducted framework analysis on all transcripts. Data was then compared and discussed until a consensus data set was developed. The study is reported in accordance with Standards for Reporting Qualitative Research (SRQR) recommendations [ 11 ].

Twelve participants were interviewed in their own homes by telephone. In five interviews a family member or friend was also present, and they were interviewed as a dyad. One interview was with a carer of a patient (patient not interviewed) and one interview was with a patient alone. Interviews lasted between 21 and 45 min. Basic self-declared demographic information was collected (Table 2 ).

One person was approached by a research nurse and provided with participant information sheet. However, when they spoke with the researcher on the telephone it was clear that they had not read the participant information sheet. The individual declined for the information to be read out loud with them. Informed consent could therefore not be given and an interview was not carried out. Upon reflection, this person was keen to informally chat to the researcher but was perhaps seeking social interaction rather than research participation. All other participants completed the interview as planned.

Participant background was relevant as one carer and one patient, had experience of working in healthcare and this may have shaped their experience and understanding. Analysis was based on the framework method; transcription, familiarisation, coding, applying analytical framework (conceptual model), charting, interpretation.

Data aligned with 18 of 23 constructs in the professional based model (Table 3 ). Pseudonyms are used to protect confidentiality.

Four constructs that had featured in the healthcare professional based model did not feature in the patient and carer derived data. These were perhaps not unexpectedly related to characteristics of staff; Experience (of staff), Training (of staff), Psychological support (for staff) and the provision of formal psychological support (for patients). One construct ‘Guidelines and Evidence’ was not explicitly mentioned by patients and carers. However, a carer did comment that at time of referral to the hospice, the patient had been on two different does of co-codamol simultaneously ‘ You were on co-codamol, the 500/8 plus co-codamol 500/30’ (Patricia, carer) which suggested to the researchers that the patient had been taking the medication in a way contrary to guidelines. Medications were then optimised by hospice staff. Four additional patient and carer-derived themes were identified: Carer Burden, Communication, Medicines management and Impact of COVID-19 (Fig. 1 ).

The conceptual model of effective symptom management in palliative care was updated to also reflect patient and carer perspective. Specifically, the need for support with communication and medicines management plus consideration of the carer burden were included

Carer burden

Our HCP-based conceptual model identified a role for the carer in shaping symptom management experience in either a positive or negative way [ 1 ]. The patient and carer derived data presented here provides additional insight into their role and the activities required of them. Carer burden is a multifaceted experience, however our interview schedule specifically asked about symptom management experience.

The carer was sometimes responsible for raising concerns and initiating the referral for specialist palliative cares support ‘it was at some stage earlier in this year when I was a little anxious about your health and contacted the chemo wing at (hospital) and one of the nurses there thought it would be helpful to me and Patient to put us in touch with (the hospice) (Kathleen, carer).

Carers were enmeshed into the disease and symptom experience of the patient, referring to ‘we’ when talking about the patient’s cancer treatment, pain and referral to hospice.

Olivia (carer): Immune therapy we’d had a reaction to and we’d resolved the reaction but it concluded in stopping any treatment and we then went to a situation where we were not able to manage the pain from the cancer successfully and it was recommended by our oncologist that (the hospice) may have some expertise that we could….

Olivia (carer): Tap into…as I say that was a difficult decision for us to agree for Anthony to go into (the hospice).

However, on occasion the insight from the carer was not acted upon leading to a delay in support for distressing symptoms ‘ I kept saying to people, he’s losing weight, he’s in pain and they just kept saying well he shouldn’t be in this amount of pain ‘cos of what his bloods are like. And I kept saying well what you’re saying he should be like, I can tell you he’s not like and we’re not ones to you know erm (he) isn’t one to be bothering the doctor.’ (Sandra, carer).

Once the patient was receiving palliative care the carer took responsibility for obtaining and retaining knowledge either because the patient could not, due to memory problems from medication, or their condition, or they were not willing to do this for themselves.

Martin (patient): ‘she knows better than me ‘cos I’m always, I’m not very good at remembering stuff’

Martin (patient): I’m not interested no I understand you do have a very important role and she’s taken the lead on it now, that’s definitely the case’

And with another couple

Terry (patient): Sorry I’ve got my wife at the side of me ‘cos she knows better than me ‘cos I’m always, I’m not very good at remembering stuff.

Stacey (carer): I’m usually present yeah, I’m usually around. I tend to be the one that asks more questions.

However, in our interviews occasionally discordance between patient and carer opinion was seen with the carer rating the symptoms more troublesome than the patient’s recollection.

Interviewer: So was it (the pain) stopping you doing any activities that you had been able to do?

Marti, (patient): Oh I see, not particularly no

Mary (carer): I would probably disagree with that sorry. I would say that Martin’s management of the pain and our management of the pain and everything was kind of a constant thing, that’s all we, you know if felt like we were talking about it all the time, his pain’.

Despite an integral role in facilitating effective symptom management carers could feel unacknowledged, specifically by hospital staff. ‘ at the same time they’re telling me I’m not a carer and yet you know Wendy would be in a very sorry state if I wasn’t on the ball all the time’ (Patricia, carer). Specialist palliative care staff were better at providing acknowledgement and consideration of individual capabilities.

Patricia (carer): ‘So they understand that I’m not sort of hale and hearty and I’ve got my limitations….and it’s just lovely them knowing and actually accepting that I am caring for patient, we are doing the best that we can and that they are there for us.’. This simple step of acknowledgement was appreciated and a factor in allowing the carer to continue to support the patient.

Olivia (carer): ‘You know I do feel that it’s about me as well, it’s not just about Anthony which, it is really all about Anthony but you know it’s important that I continue with my wellbeing in order that I can support and look after him’ .

Communication

The impact of communication of effective symptom management occurred at different levels. As would be expected, communication needed to be tailored to the background, previous experience and outlook of the individual. In particular, we noted that a patient who had a healthcare background themselves welcomed more in-depth discussion and input into decision making.

Andrew (patient): I’ve dealt with people with cancers and terminal illnesses. Yeah, I know about syringe drives and everything…The important thing is to be able to discuss it and with my knowledge of medication as well, I mean I can discuss it in depth.’ .

Interestingly, this person also equated being admitted to the hospice with the use of a syringe driver and end of life, illustrating that regardless of the patient’s professional background, a thorough explanation without any assumptions on understanding would still be necessary. Andrew (patient):  ‘I mean I could go into (the hospice) at any time knowing this but with my work record and everything else, I know what it all entails I mean I’d probably go in and they’d probably want to put me on a syringe drive with Oramorph and Midazolam and Betamethasone and everything else and I know that is the beginning of the end once you start on the syringe driver and everything because it just puts you to sleep and just makes you comfortable and you don’t really have no quality of life’ .

Patients and carers valued being able to get in contact with someone when difficulties arose. Kathleen (carer): ‘Ease of communication is important to us so it’s easy to get in touch with somebody’ .

For some people, at the earlier stages after referral to the palliative care team, the only support that they required was just telephone contact.

Kathleen (carer): ‘What we have at the moment is a phone number to call and another lady, a nurse who actually rings us probably about once a fortnight yeah to check if we have any anxieties, problems.’ .

Palliative care professionals had a key role in mediating communication between patients and carers and other services. Kathleen (carer):  ‘she said yes, do you think Harry would mind us contacting the GP you know and I said I’m sure he would, if I think it’s a good idea he’d go along with it so that’s what we did, she did, she contacted our GP which meant that we got a telephone appointment and something happened very quickly’ .

This extended to explaining the purpose and results of tests such as X-rays.

Stacey (carer): Yeah he went when he was admitted he went for an Xray and that was the hospice, it was (clinical nurse specialist) that had organised that. We didn’t really know what was happening in the hospital but we came home again and he didn’t really know why he’d had the Xray or anything.

So when he spoke to the nurse at (the hospice), she sort of went through it all with him and talked him through it and that was really informative and helpful

There was a feeling that communication was better in specialist palliative care compared to the general National Health Service (NHS).

Olivia (carer): ‘There is an awful lot to be learned from the NHS about liaising and communications they could learn an awful lot from the way that the palliative care is operating and running’.

The carer also became an advocate for the patient’s needs and relaying information about symptoms and concerns to the healthcare professionals which the patient may not have themselves. Andrew (patient): ‘ I mean she (partner) tells (hospice nurse) things that I don’t’ cos‘ I mean I sometimes bottle quite a few things up and don’t say nothing but (partner) notices these things and then she will tell (hospice nurse) about them’.

This was also seen during a research interview, where the patient was willing for the carer to ‘tell the story’ on their behalf.

Mary (carer): Sorry I’m doing all the talking.

Martin (patient): Well no you need to because I’m useless.

We identified that patients had unmet needs in communicating about their condition ‘ Yeah, erm, again it’s, people are very reticent to use the word cancer. So they balk at saying the word’ (Wendy, patient)  and symptom experience with family and friends other than their regular carer.

Wendy (patient): I don’t know where she’s (my sister) at in terms of knowing about my symptoms and about the treatment I’m having, well no I do tell her actually, it’s not that I don’t but she has very bad arthritis…so I don’t push that too much because I’m thinking she’s actually in as much pain as I might be.’

This lack of communication could come from a position of wishing to protect the feelings of family members:

Wendy (patient): ‘Oh it’s been very difficult with family. You don’t know how much you want to tell them and you don’t know how far down the line you are anyway. I think over the years, I’ve been protecting my family’ )

Sometimes there were other important conversations that had not been held with family members.

Martin (patient): ‘I suppose my point in bringing up was because they’re particularly good kids and they are particularly, although I wouldn’t like them to hear me say it but they are, very good’ .

The work of medicines management

Medicines management was a time consuming and complex task, even for carers who has a background working in healthcare.

Sandra (carer): ‘I’m having to ring back my fourth phone call today to see is it a week off or have they forgotten to give him it. The communication isn’t great and I kind of think you know I’m kind of used to the NHS I’m, I know to ring and that sort of thing but I do think, I think if someone isn’t, got a health background or that sort of background there’s a lot of left to guesswork’ .

Commonly, the responsibility of managing the medicines could be delegated to the carer due to the side effects of the medication on the patient’s memory. It was felt that the patient would not have been able to manage by themselves. Mary (carer): ‘ a lot of the medication has made him not so aware, maybe a little bit muddled at times and his memory’s not as good as it was….you know he does forget quite easily so I wouldn’t, I have to say I wouldn’t trust him with his medication at all.’.

Carers took responsibility for ensuring medications were taken on time. As previously reported, this carer viewed this a joint endeavour with the patient.

Patricia (carer): I wake (patient) at 9 o’clock and make sure that she has her Lansoprazole and that she has her 12 hourly Longtech tablet. I generally am doing everything and as I say, we put the injection in at lunchtime every day and at night I remind her, not that she doesn’t, she doesn’t really need reminding but at 9 o’clock, I say have you had your tablets?’ .

The carer (who did not have a healthcare background) had developed an understanding of complex concepts such as the different modes of metabolism of medication for pain.

Patricia (carer): ‘So she’s now on a different set of pain relief which, the morphine was better but not better for her. So the pain killing stuff that she’s on is processed through the liver rather than through the kidneys and the kidney function has stabilised.’ .

Impact of COVID-19

Interviewees were asked about whether COVID-19 had impacted upon their experience. It seemed that for this selected group of patients and carers the impact was minimal.

Patricia (carer): ‘Can I just add that Covid seems to have, people have been complaining that this has stopped and that’s stopped whereas with Wendy her appointments, they’ve always wanted face to face and we’ve done phone appointments when it’s been appropriate and the care has been absolutely marvelous’.

Availably of hospice staff sometimes filled the gap in other services.

Kathleen (carer): ‘Because of lockdown and the virus and everything obviously all that (GP support) changed and you did start to feel a bit isolated and alone ‘cos you don’t always want to have to get in the car and drive to (hospital) for something if it’s not absolutely necessary and so therefore having someone else to talk to who knew more about things because obviously we’re learning as we go along Harry and I, it was very helpful’.

Problems were attributed to the general NHS system rather than being COVID-19 specific.

Sandra (carer): ‘I think as far as forthcoming information, I don’t think Covid has any bearing on that to be honest. You know, it just, I think it’s just an age-old problem in the NHS is communication.’ .

The close alignment of this patient and carer data with our HCP-based conceptual model provides additional reinforcement of the importance of multidisciplinary working and continuity of care in shaping symptom management experience. Indeed, the ability to see preferred member of general practices staff was recently reported as a factor associated with satisfaction with ends of life care in England [ 3 ].

Palliative care takes a holistic view of the patient and carer, the concerns of both being intertwined and interdependent. The observation that carers and patients viewed themselves as a single unit and talked about ‘we’ when describing the experience of symptoms and service referral, aligns with the dimension of the carer ‘living in the patients world’ and living in ‘symbiosis’ recently described by Borelli et al [ 4 ] and in earlier qualitative work with advanced cancer patients [ 5 ]. Carer opinion can be a close but not always perfect proxy of patient voice, even in this small sample we observed some discordance between patient and carer perception of symptom burden. However, carers were vitally important for communication with healthcare providers, relaying concerns, managing medication and generally advocating for the patient when they were unable or willing to do so. In the UK in 2022, the number of people living alone was 8.3 million. Since 2020, the number of people over 65 years old living alone has also increased [ 6 ]. Household composition is not a general indicator of wider social support networks, but these data do suggest that there could be a considerable number of people with palliative care needs without live-in carer support. This raises the questions of whether the experience of those living without a supportive carer can be equitable and how services might better facilitate this.

Home-based palliative care is thought to reduce symptom burden for patients with cancer [ 7 ]. To enable this, it is therefore vital that carers are adequately supported. Carer burden is a multifaceted experience, however our interview schedule specifically asked about symptom management experience. In agreement with the term ‘role strain’ in the review by Choi and Seo [ 8 ] we saw carers involvement in symptom management and in mediating communication between the patient and healthcare providers. Additional aspects reported by Choi et Seo include physical symptoms of the carer, psychological distress, impaired social relationships, spiritual distress, financial crisis, disruption of daily life and uncertainty [ 8 ] and these will not have all been probed by our interview topic guide.

Although in our original study HCPs talked about medicines from their perspective, the role of the carer was not discussed. Medicines management was an important way that carers facilitated effective symptom management but is a complex task. One carer commented: ‘I have to say that would be a nightmare if I wasn’t a nurse by background’ . Our data on the difficulties with medicine management are not novel and closely mirror the report of Pollock et al., [ 9 ]. Our findings echo and support their conclusions that managing medicine at home during end-of-life care could be improved by reducing the work of medicines management and improving co-ordination and communication in health care and we echo their calls for further research in the area.

We identified that patients and carers viewed mediating communication as an important role for healthcare professionals. This could be enabling communication between patients and carers and other healthcare professionals, for example arranging follow-up care or explaining information received. There was also a need for better communication between patients and their family members. As reviewed and synthesised by Murray et al., (2014) the importance of effective communication in palliative care has been long recognised [ 10 ]. In our study, an opportunity for HCPs to facilitate better communication about symptom experience between patients and their wider family was identified. Our previous survey of English hospices found that healthcare professionals, particularly nurses and allied health professionals felt that they needed more training in basic and advanced communication skills [ 11 ]. Having relevant experience and if the appropriate training was provided, staff may be well placed to support patients with developing an approach to these potentially difficult conversations. Participants were offered a choice of joint or individual interviews, but most chose to be interviewed as a dyad. It is possible that being interviewed as a pair may have altered the information disclosed. Although the aim was to discuss factors that impacted upon effective symptom management, discussions at times deviated to a more general appraisal of a participant’s experiences and all data collected may not be relevant to the research question.

When data was collected that lead to the development of the HCP-based model of effective symptom management (May to November 2019) a global pandemic was unforeseen. At the time of the patient and carer interview described here (October to December 2020), COVID-19 restrictions were in place in the UK. The patients and carers we interviewed were already receiving specialist palliative care support as outpatients. For these individuals it appeared that the impact of COVID-19 pandemic had had minimal impact on their care. The availability and reassurance of telephone support from hospice staff seemed in part to ameliorate the reduced support available from other services such as GPs. This contrasts sharply with the negative impact of COVID-19 on the experience of patients and carers in the more immediate end of life phase [ 12 ], receiving oncology care [ 13 ] or with cancer more generally [ 14 ]. Selection bias is likely as patients and carers with the capacity and willingness to participate in our research study possibly reflect those where the illness is in a more stable phase and immediate needs were being met. Indeed, participants talked about difficulties before referral to specialist palliative care and with other services but were overwhelmingly positive about the support currently being provided by the hospice.

Limitations

Due to the constraints of conducting a research study during the COVID-19 lockdown, more purposive sampling was not possible, this led to a lack of diversity in our sample. All participants identified themselves as of white British or white Scottish ethnicity which potentially means issues related to diverse ethnicities were not captured. All the patients who participated (and the non-participating patient whose carer was interviewed) lived with another person and had carer/family support. The experience of those managing their symptoms in isolation was therefore not captured. All participants were currently accessing support from a single hospice, the experience of those not yet receiving specialist support or receiving support from a different organisation may differ. The sample were diverse in age and included males and females, but all carers were female. Demographic information was not collected on socioeconomic background. COVID-19 restrictions necessitated the use of telephone interviews which may have lost subtle communications cues such as body language or conversely may have facilitated candid description. The transcripts do suggest that participants felt comfortable to tell their experience and they mostly spoke freely with limited prompting. One participant mentioned that he found it very difficult to leave the house, and therefore a telephone interview might have facilitated his inclusion. In some interviews more data was derived from the opinion of the carer than the patient, with the pair agreeing that the carer took responsibility for many tasks involved in managing the condition. We cannot be certain that carer interpretation accurately matches patient experience for all symptoms [ 15 ].

We set out to answer the question; does a healthcare professional data derived model represent the experience of patients and carers of people with advanced cancer? Overall, the answer was yes, as our healthcare professional based conceptual model of effective symptom management aligned well with the experience of patients with advanced cancer and their carers. Domains that did not align were those specifically related to professionals; experience (of staff), training (of staff), guidelines and evidence, psychological support (for staff) and the provision of formal psychological support (for patients), a resource patients and carers might be unaware of. Additional domains of carer burden, communication, medicine management and the impact of COVID-19 were identified. We make four recommendations arising from this research.

Routine appraisal and acknowledgement of carer burden, medicine management tasks and previous experience in healthcare roles.

Increased access to communication skills training for staff caring for palliative care patients and their families.

Review of patient communication needs with support provided where needed.

Further research into the symptom management experience of those living alone and exploration of how these people can be better supported.

Availability of data and materials

Original recordings generated and analysed during the current study are not publicly available due to protection of confidentiality. Anonymised transcripts with identifiable information removed may be available from the corresponding author on reasonable request.

Abbreviations

Coronavirus disease 2019

Healthcare professional

National Health Service

United Kingdom

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Acknowledgements

We are grateful to the patients and carers who in giving valuable time to share their experiences, made this research possible. We thank research nurses Kath Black and Angela Wray for their support with recruitment.

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: this work was supported by Yorkshire Cancer Research programme grant L412, RESOLVE: “Improving health status and symptom experience for people living with advanced cancer”. The sponsor had no role in study design or the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.

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Emma J. Chapman, Carole A. Paley & Lucy E. Ziegler

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Contributions

Original idea, EC and SP; Data collection, EC; Data Analysis, EC and CP; Data interpretation, All, Methodological oversight, SP and LZ; writing the manuscript, All. All authors contributed to the development of the updated conceptual model and approved the final submission.

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Correspondence to Emma J. Chapman .

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Chapman, E.J., Paley, C.A., Pini, S. et al. Updating a conceptual model of effective symptom management in palliative care to include patient and carer perspective: a qualitative study. BMC Palliat Care 23 , 208 (2024). https://doi.org/10.1186/s12904-024-01544-x

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Received : 08 March 2024

Accepted : 08 August 2024

Published : 19 August 2024

DOI : https://doi.org/10.1186/s12904-024-01544-x

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