Implementing, embedding and integrating self-management support tools for people with long-term conditions in primary care nursing: A qualitative study

BACKGROUND: An implementation gap exists between policy aspirations for provision and the delivery of self-management support in primary care. An evidence based training and support package using a whole systems approach implemented as part of a randomised controlled trial was delivered to general practice staff. The trial found no effect of the intervention on patient outcomes. This paper explores why self-management support failed to become part of normal practice. We focussed on implementation of tools which capture two key aspects of self-management support - education (guidebooks for patients) and forming collaborative partnerships (a shared decision-making tool). OBJECTIVES: To evaluate the implementation and embedding of self-management support in a United Kingdom primary care setting. DESIGN: Qualitative semi-structured interviews with primary care professionals. SETTINGS: 12 General Practices in the Northwest of England located within a deprived inner city area. PARTICIPANTS: Practices were approached 3-6 months after undergoing training in a self-management support approach. A pragmatic sample of 37 members of staff - General Practitioners, nurses, and practice support staff from 12 practices agreed to take part. The analysis is based on interviews with 11 practice nurses and one assistant practitioner; all were female with between 2 and 21 years' experience of working in general practice. METHODS: A qualitative design involving face-to-face, semi-structured interviews audio-recorded and transcribed. Normalisation Process Theory framework allowed a systematic evaluation of the factors influencing the work required to implement the tools. FINDINGS: The guidebooks were embedded in daily practice but the shared decision-making tools were not. Guidebooks were considered to enhance patient-centredness and were minimally disruptive. Practice nurses were reluctant to engage with behaviour change discussions. Self-management support was not formulated as a practice priority and there was minimal support for this activity within the practice: it was not auditable; was insufficiently differentiated from existing content and processes of work to value in its own right, and considered too disruptive and time-consuming. CONCLUSION: Supporting self-management through the encouragement of lifestyle change was problematic to realise with limited evidence of the development of the needed collaborative partnerships between patients and practitioners required by the ethos of self-management support.