The term ‘self management’ is used a lot in health care, but I’m not sure yet whether there is a satisfactory definition of it. Some of the definitions I found on the internet suggest it’s a relationship between the patient and the practitioner, with the focus on the patient ‘taking responsibility for doing what it takes to manage [the] illness effectively.’
Another publication I found, written by two New Zealanders, suggests self management is about ‘engaging in activities that protect and promote health, monitoring and managing symptoms and signs of illness, managing the impacts of illness on functioning, emotions and interpersonal relationships and adhering to treatment regimes in partnership with health professionals and community resources.’ As an aside, that particular document I’ve cited from contains some excellent recommendations for how to support people to make some of the changes needed in self management.
Some of the things I’ve identified from my ongoing work in pain management are that people have to be ready to make changes to live with their health condition rather than focusing on getting rid of it, that self management can include a range of different behaviours that sometimes at face value don’t seem to be ‘self’ management at all – for example, obtaining ongoing treatment from a health provider such as a massage therapist or chiropracter… and that self management doesn’t happen quickly because it involves a range of long-term habit changes.
Back to today’s paper, written by a group of researchers from the Butler University in Indianapolis. This paper examines, through focus groups, the responses of a group of people with chronic musculoskeletal pain, to nurse ‘care managers’ as compared with primary care physicians. Now in New Zealand I don’t think nurse care managers are routinely employed, but perhaps the GP practice nurse could be in a similar role.
In this study, participants from a combined chronic pain and depression management programme were involved in focus groups to discuss their experience of the two health providers. The self management programmes some of the participants were involved with included six sessions of education, goal setting, exercises, relaxation techniques and methods to overcome fear of reinjury and negative emotions. In chronic pain management terms, this is pretty standard self management but compared with an intensive cognitive behavioural approach for chronic pain, was probably a little on the light side. Other participants had routine care through a physician.
The methodology of focus groups has some good points and some not so good points – good points are that, as these authors point out, ‘collective energy’ from group members can help elicit rich and dense qualitative material for analysis. Not so good points can be that ‘groupthink’ can emerge, with that good old confirmatory bias that humans do so well meaning everyone in the group starts to say the same thing rather than disagreeing.
Anyway, back to the results. The authors of this study state that despite not specifically asking about the difference between nurse care managers and physicians, this was a strong theme that emerged.
Specific concerns participants had about physician-based management included lack of time, access and continuity of care from physicians, that doctors ‘didn’t understand the pain’ (participants indicated they thought ‘doctors don’t understand that you are having pain because they’ve never had it’), and that doctors didn’t have time or inclination to listen. Some participants thought doctors were particularly looking for ‘a quick fix’, saying things like ‘Don’t rush out of the room… They need to pay a little more attention and ask a few questions’.
In terms of treatment, participants thought doctors either under or over prescribed pain relief, with the majority in these focus groups saying they were overprescribed.
By comparison, nurse care managemenrs were most often referred to as ‘understanding’, ‘helpful’, ‘took a lot of interest’. Nurse care managers spent more time in conversation with participants with at least bi-weekly visits or phone calls. Nurses were reported to spend more time listening, and participants said they ‘kept me on track in my pain management’.
Hmmm. So the relationships were different – not surprisingly, when the nurses were provided with more time to spend with patients, and the specific role of the nurse care manager was to encourage and reinforce healthy behaviour!
I wonder whether specific outcomes such as reduced disability, improved engagement in life apart from being a ‘patient’, and general activity level and mood were improved – and whether this was sustained.
One of the problems I see with an approach where people with pain are encouraged to maintain contact with a health provider is that they will do just that – maintain contact with health care providers. While this is pleasant for some (who wouldn’t like an hour with someone who is specifically there to talk all about YOU?!), it also means that while this goes on, the person becomes a patient or a recipient again – and talks about his or her pain.
I wonder what it might be like if that person was out doing grocery shopping, spending time with family and friends, enjoying the sun, wind and rain, reading – anything but focusing on pain and receiving care. In the end, do programmes that encourage ongoing engagement in ‘care’ enable participants to go out from ‘care’ into the real world?
This particular paper vexed me also in that it described ‘outcomes’ in terms of patient satisfaction – yet satisfaction is only one aspect of outcome. Patients ‘enjoying’ input may not be in the best interests of the patient! Sometimes it’s important to challenge beliefs, to be a little hard-nosed, to encourage the person to take those scarey steps forward into independence. After all, I may enjoy staying in bed all day – but it’s not going to help me get to work!
Some good things came from this study, though, as it’s clear that patients are not always certain of what they want from their doctor – some want medication, others don’t. Listening skills and the appearance (at least) of having more time with patients is a theme across many studies looking at medical practitioner and patient interactions. The ongoing question is whether these skills make a difference to what the patient can and does do in the real world.
Matthias, M., Bair, M., Nyland, K., Huffman, M., Stubbs, D., Damush, T., & Kroenke, K. (2009). Self-Management Support and Communication from Nurse Care Managers Compared with Primary Care Physicians: A Focus Group Study of Patients with Chronic Musculoskeletal Pain Pain Management Nursing DOI: 10.1016/j.pmn.2008.12.003