Discussion: Alternative Research Design

Implementing an interprofessional model of self-management support across a community workforce: A mixed-methods evaluation study Stefan Tino Kulnik a,b, Heide Pöstgesa,b, Lucinda Brimicombea,b, John Hammonda, and Fiona Jonesa,b

aFaculty of Health, Social Care and Education, Kingston University and St. George’s, University of London, London, UK; bBridges Self-Management Limited, London, UK

ABSTRACT The importance of implementing self-management support (SMS) is now widely accepted, but questions remain as to how. In 2015, we facilitated the implementation of an interprofessional model of SMS (Bridges Self-Management) for people with complex multiple long-term conditions through community rehabilitation and social care services in one Southeast England locality. Over 90 professionals and support workers from this workforce received interprofessional training to integrate SMS into their care and rehabilitation interactions. This gave an opportunity to explore how SMS can be implemented in practice. We conducted a mixed-methods study with unequal weighting (qualitative emphasis), con- current timing, and embedded design. Staff provided written feedback and case reflections, participated in group discussions, and completed a survey of self-management beliefs and attitudes. We recruited a convenience sample of 10 service users and conducted qualitative interviews and standardised ques- tionnaires. Findings showed that staff appreciated and benefited from the interprofessional learning environment. Staff reported changes in their interactions with service users and colleagues and had gained knowledge and confidence to support individuals to self-manage. Data also highlighted the need to facilitate SMS practice at the level of service organisation. Service user data illustrated the impact of interactions with staff, and how SMS had increased service users’ confidence and encouraged different skills to manage life with their conditions. This project has shown how multi-agency commu- nity teams can benefit from interprofessional training to enhance SMS for people living with long-term conditions, build a shared understanding of SMS, and integrate effective SMS strategies into everyday practices.

ARTICLE HISTORY Received 23 January 2016 Revised 19 August 2016 Accepted 5 October 2016

KEYWORDS Community rehabilitation; interprofessional education; long-term conditions; mixed-methods; self- management support; social care

Introduction

Self-management support (SMS) is now considered a neces- sary component of health and social care provision, in order to adapt systems to increasing numbers of people who are living with one or more long-term conditions (Eaton, Roberts, & Turner, 2015). The concept of SMS is based on the under- standing that a person living with a long-term condition is at the centre of managing life with the condition, not healthcare services (Boger et al., 2015; Demain et al., 2015; Lorig & Holman, 2003). The principles of SMS focus on the ways in which individuals can work in partnership with health and social care professionals, predicting potential challenges and managing their health. This runs contrary to a traditional focus on episodic service provision in response to acute illness or crisis. Interventions to promote SMS can deliver promising clinical outcomes and more appropriate health and social care use (Coulter et al., 2015; de Silva, 2011; Hibbard & Greene, 2013). While the case for SMS has been made, questions remain as to the best ways of implementing effective SMS on a large scale.

In 2015, we facilitated the implementation of an interprofes- sional model of SMS (Bridges Self-Management) for people with different long-term conditions who are clients of community

rehabilitation and social care services in one locality in the South East of England. The organisation of these services broadly reflects current service provision in the United Kingdom (Allen & Glasby, 2009). Briefly, this workforce includes teams that provide rehabi- litation and social support to individuals with predominantly physical health concerns, in order to enable integration and parti- cipation in the local community. The workforce typically com- prises health professionals (nurses, occupational therapists, speech and language therapists, physiotherapists, and social workers) and support workers. The nature of the work consists of individual one-to-one support in the community and background case work. This workforce shares a client base of people with varying long- term conditions who may present with different individual impairments and activity limitations. For example, individuals may be referred for temporary community support after discharge from hospital; or for re-evaluation of community support systems and a period of community rehabilitation following deterioration in their long-term conditions.

For this project, we drew on two main perspectives. Firstly, we took an interprofessional approach to workforce education and practice, which has constituted a strong influence in the development and implementation of Bridges Self-Management since inception. Interprofessional education (IPE) is defined as

CONTACT Stefan Tino Kulnik s.t.kulnik@sgul.kingston.ac.uk Faculty of Health, Social Care and Education, Kingston University and St. George’s, University of London, Cranmer Terrace, London, SW17 0RE, UK.

JOURNAL OF INTERPROFESSIONAL CARE 2017, VOL. 31, NO. 1, 75–84 http://dx.doi.org/10.1080/13561820.2016.1246432

© 2017 Taylor & Francis

http://orcid.org/0000-0001-5419-6713
an intervention whereby two or more professions learn from and about each other to improve collaboration and the quality of care (Oandasan & Reeves, 2005a). This approach suited the diverse workforce and the complexities of delivering SMS in this project. IPE has been found to improve professional competence, colla- boration, and patient-centred outcomes in pre- and post-licen- sure training of healthcare teams in various areas of practice (Hallin, Henriksson, Dalen, & Kiessling, 2011; Reeves et al., 2016; Reeves, Perrier, Goldman, Freeth, & Zwarenstein, 2013). However, there is currently little evidence relating to IPE in the field of self-management. While the objective of the present project was to impart knowledge and skills of SMS, this was framed and operationalised in training according to principles of IPE. In concrete terms, there was a focus on learning about and understanding others’ roles, and on communication across roles and team boundaries (Suter et al., 2009). We aimed to create a non-threatening learning environment which encouraged infor- mation exchange and discussion of individuals’ own role, per- ceptions of others’ role, and personal and professional biases and interests, to create shared meaning and a common purpose (Oandasan & Reeves, 2005a, 2005b). In addition, we placed emphasis on the need for critical reflection to be integrated into training. In IPE, reflection is used as a strategy to advance knowledge in the often confusing and ‘messy’ reality of real-life practice (Clark, 2009; Eaton, 2016). SMS training incorporated reflection by providing course attendees with a space and time for ‘reflection-on-action’ (Kinsella, 2010; Schön, 1992), includ- ing a written case reflection and group discussions.

We also drew on normalisation process theory (NPT) (Murray et al., 2010) to underpin the implementation and change manage- ment aspects of the project. Within the NPT framework, imple- mentation is defined as a cyclical, complex and emergent social process, in which participants collectively produce and embed new practices into their everyday work (May & Finch, 2009). NPT operationalises implementation in four mechanisms or compo- nents: coherence (meaning and sense making of the intervention by participants); cognitive participation (commitment and engage- ment by participants); collective action (the work participants do to

make the intervention function); and reflexive monitoring (parti- cipants reflect on or appraise the intervention; May & Finch, 2009). Figure 1 outlines where opportunities for NPT components were focussed along our project timeline.

Current health and social care policy in England directs that different organisations and professions are expected to align their approach to supporting self-management, but these groups often have very different starting points in their understandings and operationalisation of SMS, and experience different challenges to implementation (Mudge, Kayes, & McPherson, 2016; Norris & Kilbride, 2014; van Hooft, Dwarswaard, Jedeloo, Bal, & van Staa, 2015; Young et al., 2015). While these studies highlight the differ- ent professional perspectives, it is more challenging to evaluate how teams overcome these issues and work more effectively to support person-centred outcomes (Reeves et al., 2013). Therefore, an evaluation of SMS implementation can be useful and provides the rationale for incorporating an evaluation study in our project. Here, we report the findings from our evaluation study to describe howa workforcecancometogether,createasharedunderstanding and common purpose for SMS, and defineand deal with particular challenges in the local context. We use these data to illustrate the implementation process, discover participants’ views and reflec- tions, and interpret the observed trends and themes. The aim was to evaluate the project and provide insights into how SMS can be implemented in this community setting. The research question was: what are the processes, successes, and challenges of imple- menting SMS in this particular context?

Methods

Research design

We chose a mixed methods design, which is frequently used in the evaluation of health services research (O’Cathain, Murphy, & Nicholl, 2007). We considered that the research question would best be addressed through an emphasis on qualitative data from course attendees’ reflections according to an ‘epistemology of practice’ (Kinsella, 2010; Schön, 1992).

Timeline

Month 1

Month 2

Month 3

Month 4

Month 5

Month 6

Month 7

Month 8

Month 9

Month 10

Month 11

Month 12

NPT

mechanisms

Coherence

Cognitive

participation

Collective

action

Reflexive

monitoring

SMS training delivery

Project

management

Contextualisation to local

services and client groups

Training

sessions

Project steering

group meeting 1

Introduction of

project in team

meetings

Project steering

group meeting 2

Project steering

group meeting 3

Observation of

practitioners

Service user focus group

Qualitative interviews with

service users

Production of bespoke self –

management booklet

Part 1

Part 2

Part 3

Data collection for evaluation study

Practitioner data Service user data

Pre-training

questionnaires

(SMS beliefs and

attitudes)

Written feedback

and case reflections

Group discussions

Written feedback

Post-training

questionnaires

(SMS beliefs and

attitudes)

2 research visits

per participant,

8 weeks apart:

standardised

questionnaires,

qualitative

interview

Figure 1. Overview of project timeline and structure. NPT, normalisation process theory; SMS, self-management support.

76 S. T. KULNIK ET AL.

This allowed a focus on in-depth understanding of organisa- tional context (Robert & Fulop, 2014), the normalisation process (Murray et al., 2010) and reflection on practice (Clark, 2009). We used quantitative data to supplement the description of the study setting and participants through standardised instruments.

Accordingly, our study used an embedded mixed-methods design, i.e. one type of data provided a supportive, secondary role to the other data type (Creswell, 2014). The weighting was unequal with an emphasis on qualitative data. The timing was concurrent, i.e. qualitative and quantitative data were collected, analysed and interpreted at the same time. Mixing of qualitative and quantitative data was embedded at the design level (Fetters, Curry, & Creswell, 2013).

Setting

The setting was a community rehabilitation and social care workforce in one South East England locality. The group comprised four distinct services, which operated within dif- ferent organisational parameters but with overlapping and aligned service aims. Service details are given in Table 1.

Participants

Ninety-two members of staff attended training in SMS. This was a diverse group of social workers, enablement officers, physiotherapists, occupational therapists, speech and language therapists, therapy assistants, care workers, support workers, and voluntary sector workers. For the purpose of this article, we refer to this workforce as ‘practitioners’. A project steering group including service leads was set up, which provided managerial support and facilitated spread and adoption of the project. Depending on the service, training was either arranged as a scheduled activity for the entire team, or practi- tioners were invited to attend on the basis of interest.

After workforce training, we recruited a convenience sam- ple of 10 service users living with long-term conditions. Service users were eligible if they were newly referred, and if

the practitioner/s working with the person intended to imple- ment SMS strategies. Service users were excluded if they lacked decisional capacity to give informed consent to the study, or if they were unable to participate due to commu- nication difficulty. Recruitment took place during summer 2015. Eligible service users were invited to the study through the participating teams. Out of 13 service users who expressed interest, ten consented to take part.

Intervention

The intervention was Bridges Self-Management, originally developed in stroke rehabilitation (Jones et al., 2016, 2012). Based on self-efficacy and behaviour change principles, this intervention supports practitioners to integrate SMS through their interactions with service users, team and organisation processes, and through utilisation of unique self-management tools for people with long-term conditions. It is a complex intervention, in which practitioners promote self-manage- ment principles, placing particular emphasis on the language used in conversation with clients. Practically, the implementa- tion of Bridges is supported by utilising co-production meth- ods (de Silva, 2011; Newbronner, Chamberlain, Borthwick, Baxter, & Sanderson, 2013).

Training sessions were held in interprofessional groups of up to 20 practitioners and incorporated interactive activities and group discussions, which challenged practitioners to reflect on knowledge held about self-management and how support was delivered both at an individual level and within and across teams. Practitioners were also encouraged to utilise experiences from their own caseload, successes and chal- lenges, to construct ways of integrating SMS. To mitigate potential issues of power, trainers adopted the role of facil- itators rather than ‘expert teachers’. Strategies were utilised to facilitate sharing individual and interprofessional perspectives, and to challenge assumptions and common practices in rela- tion to SMS. Training was structured in three parts, each delivered in a three-hour session. Parts one and two delivered theory and practical aspects of SMS, and part three provided

Table 1. Characteristics of participating services.

Type Aim Staffing structure Service provision Funding Service user groups

Community rehabilitation service

Rehabilitation therapy for people living in the community and unable to access outpatient services

Physiotherapists, occupational therapists, speech and language therapists, therapy assistants

Flexible, dependent on clinical need, with no restrictions on time period or number of visits; on average one initial visit and four follow-up visits

NHS Adults who require rehabilitation or therapy management

Enablement service Care support and rehabilitation therapy to people living in the community to achieve independence

Enablement officers, rehabilitation support workers, physiotherapists, occupational therapists

Time-limited, up to six weeks, with up to four daily visits

NHS and local authority

Adults who require support to achieve or re-gain independence, for example after a period of hospitalisation or illness

Adult social care service

Assessment of needs, support planning, safeguarding, advice and information, signposting

Social workers, occupational therapists, support planners

Variable service provision, mostly one single face-to-face meeting, followed by background casework

Local authority

Adults who qualify for social services input

Community development service

Prevention and early intervention to support vulnerable and isolated people living in the community

Development workers, support facilitators, volunteers

Flexible, individual meetings from short-term input up to three months of one-to-one support, including signposting, advocacy, case-work, practical support

Local authority and voluntary sector organisation

Vulnerable and isolated adults

NHS, National Health Service.

JOURNAL OF INTERPROFESSIONAL CARE 77

an opportunity for practitioners to give feedback, reflect, and share ideas after trialling SMS strategies in practice.

Data collection

The following methods were used to collect qualitative data from practitioners: feedback forms, which practitioners com- pleted during training sessions two and three; written case reflections, which practitioners prepared after trialling SMS in practice; and six group discussions held in training sessions three. Group discussions were moderated by two facilitators (HP and LB). Hand-written notes by one researcher were taken at discussion groups. Course attendees were first guided to discuss experiences of applying SMS in pairs, and then share with the whole group, while key learning points were noted on a flip chart by one of the facilitators. Service users participated in audio-recorded semi-structured in-depth interviews. These were conducted by FJ and SK in the second of two research visits and aimed at eliciting participants’ experiences and reflections on the SMS received through the participating service. The topic guide for group discussions and the service user interview schedule are given in Table 2. Qualitative data collection aimed at exploring how practi- tioners worked with each other and with service users to implement SMS into their practice, capturing successes but also documenting challenges and barriers and how practi- tioners dealt with these.

Quantitative data collection comprised a survey of SMS beliefs and attitudes (Jones & Bailey, 2013), which practitioners completed before and after training. Service users completed the following standardised interviewer-administered question- naires in the first of two research visits: EQ-5D-5L (van Reenen & Janssen, 2015), Nottingham Extended Activities of Daily

Living (NEADL) questionnaire (Nouri & Lincoln, 1987), General Self-Efficacy scale (GSE; Schwarzer & Jerusalem, 1995), and Client Socio-demographic and Service-Receipt Inventory (CSSRI; Chisholm et al., 2000). These instruments capture constructs that are relevant to the self-management intervention and describe participants in a standardised way, allowing comparison with groups of participants in other contexts.

Data analysis

All qualitative and quantitative data were anonymised. Practitioner data were analysed for the group as a whole (as opposed to analysis according to service or professional background). Qualitative data were transcribed using Microsoft Word 2013 software and analysed manually. Thematic analysis was selected as an appropriate approach in preliminary health service research (Green & Thorogood, 2013). Quantitative data were used to describe the participants (practitioners and service users) and processed using Microsoft Excel 2013 software.

Qualitative data analysis was conducted by SK in the first instance. SK read and re-read data sources and summarised prevalent themes, following a structured process of coding and constant comparison, and taking note of extreme or negative accounts. Coded passages that aligned with dominant themes were copied and pasted into another text document according to emerging themes. Key themes were then reviewed against the raw data by FJ, HP, and LB and finalised following discussion. Findings were presented to the members of the project steering group, whose feedback provided an additional layer of peer review. Rigour was further enhanced by maintaining an audit trail of data sources, data analysis steps and key analysis deci- sions; and through a reflexive approach of the study team

Table 2. Topic guide for practitioner group discussions and interview schedule for service user interviews.

Topic guide for practitioner group discussions

Topic Questions Feedback about your experiences of supporting self-management using Bridges principles

What do you remember from training parts 1 and 2? What—if anything—have you done differently since then? Did you get a chance to use the self-management tool [client-held booklet] with someone? What’s one example of a self-management challenge you came across? What did you do? What’s one example of a self-management success you had, however small? What happened?

Strength, weaknesses, opportunities, threats (SWOT) analysis of your practice or service

How are you currently supporting self-management? How could it be more effective? Strengths—What elements of your current practice/service are supporting self-management? Weaknesses—What elements of your current practice/service could be better at supporting self-management? Opportunities—What elements about your practice/service could you change? Threats—What elements about your practice/service could cause barriers to these changes?

Personal action plan What is the one thing you will do differently in your practice going forward?

Interview schedule for service user interviews

Opening question Prompts I would like to ask you about the [relevant service/team]. I understand that you were referred to them about eight weeks ago. Can you tell me a little about how that went?

Do you remember who you met from the [service] and what you did with them How did the sessions start—can you give me an example of what you would do first Generally who would decide what you did in your sessions and what you worked on Were you asked your views about what your priorities were What goals did you have What did you learn from working with the service How much do you feel the sessions followed a format set by the practitioner or by you How did you feel when the services stopped

Is there anything you remember particularly well about the [relevant service/team]?

Was there anything you thought was particularly good Was there anything that you wished had happened differently

Some people feel quite confident to continue to manage under their own steam once sessions stop—how did you feel?

Is there anything you continued to do after session stopped Did you achieve the things you were aiming for, or are you continuing to work towards them If you ran into a problem/difficult situation in the future, how would you deal with that

78 S. T. KULNIK ET AL.

members (FJ, HP, LB, SK), who made transparent their parallel roles of training providers and project evaluators and reflected on potential influences in open discussions.

Ethical considerations

Ethical approval was obtained from the UK National Research Ethics Service (Committee South East Coast—Surrey, refer- ence 15/LO/0621). Organisational and managerial research approvals were obtained for each participating team. All ser- vice users gave written informed consent.

Findings

Participant overview

Fifty-five practitioners completed all three training sessions, and 28 completed two out of three sessions. Eighty-two prac- titioners attended part one, 84 practitioners attended part two, and 65 practitioners attended part three. There was a wide range of work experience and level of seniority amongst practitioners. There was some fluctuation in this group over the duration of the project, due to individuals moving in and out of teams (rotational posts, temporary employment) and absences due to annual leave and sickness. At the beginning of the project, just under two thirds of practitioners were certain that they would still be working in their current team at the end of the training and implementation cycle. This accounts for the differing cohorts and completion rates for the survey of SMS beliefs and attitudes, with only 34 practitioners com- pleting the survey both before and after training.

In total, 10 service users participated and completed the stan- dardised interviewer-administered questionnaires in the first of two research visits. Qualitative in-depth interviews with service users were conducted in the second research visit, approximately eight weeks later. Two service user participants were unavailable for interview. One withdrew because they found the first visit too tiring, and one participant could not be reached.

Service user participants were an overall diverse group (seven women, three men, age range 20–79) living with differ- ent and multiple long-term conditions (multiple sclerosis, myalgic encephalopathy, stroke, cancer, arthritis, diabetes, hypertension, asthma, chronic obstructive pulmonary disease, sickle cell anaemia, epilepsy, chronic pain). The quantitative questionnaire results illustrate the complex needs of this group. In EQ-5D-5L descriptors (mobility, self-care, usual activities, pain/discomfort and anxiety/depression) service users reported moderate, severe or extreme problems for 43 (86%) out of overall 50 domain descriptors. The median (range) EQ-5D- VAS rating was 30 (5, 55), compared to a UK population mean of 82.8 across all age groups (Janssen & Szende, 2014). The median (range) NEADL score was 20 (0, 36), compared to a maximum score of 66 indicating full independence in activ- ities of daily living. Participants’ GSE scores were spread across the possible range (10–40), with a median (range) of 22 (10, 38). Over six weeks, each participant had an average of four consultations with general practitioners, six contacts with com- munity health professionals (not including any of the teams participating in this study), five outpatient clinic appointments,

three hospital admission days, and there was one Emergency Department attendance. In the same time period, each partici- pant received an average of ten weekly hours of publicly funded care support, two weekly hours of care support through volun- tary agencies, and an estimated 30 weekly hours of care support from friends or family.

How self-management support was implemented

Qualitative data sources from practitioners comprised 121 writ- ten feedback forms, 29 written case reflections, and six group discussions. We analysed these data with a focus on practi- tioners’ views and reflections. Quantitative results from the survey of SMS beliefs and attitudes add to these qualitative data, as per our concurrent embedded study design.

Four themes were prevalent across practitioner data, which we describe under the following headings: individual practitioner learning, reflections on collaborative working, perceived barriers to SMS, and need to facilitate SMS at organisational level. We supplement practitioner data with service user accounts from eight qualitative interviews. Service user accounts are presented under the heading ‘service users’ experience of SMS’.

Individual practitioner learning Practitioners’ feedback illustrated their reflective learning pro- cesses at an individual level. Talking about their experiences after trialling SMS, practitioners commented on the deliberate appli- cation of different practical SMS strategies discussed in the training sessions, for example the use of problem solving, small steps to achieve targets, encouraging service users to reflect, use of open-ended questions and active listening to discover clients’ hopes and plans for the future. Some practitioners acknowledged their own limited confidence and the need to work at applying these strategies, as one practitioner noted, “I need to practice this more” (case reflection 27, physiotherapist). Others felt the train- ing programme validated their current practice:

Actually I use a client-centred, client-expert perspective in my work. I think the process has empowered me to use/recognise this approach. (case reflection 24, speech and language therapist)

Several reflections illustrated how training and application of SMS highlighted and reinforced fundamentals of SMS for practitioners, such as the overall purpose of SMS, the practi- tioner’s role in SMS, and the use of language:

I have learned that when you start working in the self-manage- ment model, you are thinking or looking at how the person can take control of what is going on with them, even if it’s a small step or achieving a small goal. (case reflection 12, enablement officer)

[The training] made me reflect on language I had been using that was counter-productive to providing patients with a sense of control. (feedback form 57, occupational therapist)

Individual learning was further illustrated by practitioners’ personal action plans to strengthen individual SMS practice going forward, for example to use the strengths of clients as starting point rather than focusing on what ‘we’ (i.e. the practitioner/service) can do and to take a step back and let people figure out what works well for them. The survey of SMS beliefs and attitudes before and after training also shows

JOURNAL OF INTERPROFESSIONAL CARE 79

how over the duration of the project practitioners as a group shifted towards a mind-set that is more aligned with SMS principles (Table 3).

Several practitioners commented that the interaction with others during training had been enjoyable; and that meeting and learning with and from others across the boundaries of professional roles led to enrichment as well as critical reflection on own roles and practices: “[I] found enjoyment and assistance in the interactive elements of the training” (feedback form 94); “[The training was] extremely informative and thought provok- ing sharing professional experiences” (feedback form 13).

Reflections on collaborative working These referred to interactions with service users as well as other practitioners. Talking about their relationships with clients, several practitioners reflected on how SMS training had fostered a more collaborative working style, and a more liberated approach to goal setting and treatment planning. They described tangible changes in language and the nature of their interactions, which illustrated collaboration in action. For example, several practitioners reported reducing verbal prompts and guidance, letting the client find out for them- selves what works and being flexible to follow the client’s lead. One practitioner reported purposely doing less for the person but encouraging them to do things for themselves, and

another practitioner reflected, “I could be more positive, [ask- ing clients] ‘what can you do now’” (group discussion 3).

Collaboration in action was also evident in the stance practitioners took towards their clients’ goals, plans and hopes for the future. For example, several practitioners reflected on changing from ‘what I think they need’ to asking and listening to what clients say they need, giving the service user a chance to say what is important to them. A number of practitioners shared insights into accepting the choices people make, for example acknowledging a client’s own goal and plan, despite it being perceived as unwise by the practitioner; the insight that a client might give up on a goal, ‘but this is ok if it is their decision’; and an example of a successful transfer of control by giving the client a say in the decision about occupational therapy.

In this context, practitioners talked about the importance of interprofessional collaboration and good communication across professional and team boundaries to facilitate SMS. For example, an occupational therapist talked about the intention to work more closely with enablement officers when setting goals, to draw on insights from their interactions with clients and achieve a more coherent SMS approach. Another practitioner thought that time constraints may present a barrier, but noted, “hopefully by meeting with team and making issue of [SMS] part of our processes we can overcome this” (feedback form 57).

Perceived barriers to self-management support Prior to trialling SMS in practice, the following anticipated barriers were listed most frequently by practitioners: time constraints and inconsistency in staff (i.e. barriers relating to the service provider); and clients’ lack of engagement with the approach (i.e. barrier relating to service users). After imple- menting SMS, time constraints were less prominent in practi- tioners’ feedback, and the majority agreed that there was generally time within their role to introduce clients and their family/carers to self-management strategies. Several practitioners did, however, report that inconsistency in staff- ing made it difficult to build the rapport and trust with clients they felt was needed for successful SMS.

Lack of clients’ engagement was to some extent confirmed as a potential barrier. Where lack of engagement had been encountered, in some cases this was attributed to clients’ cognitive and communication difficulty (e.g. due to advanced dementia, long-term alcohol dependency):

The approach is perhaps not for everyone. It varies very much, depending on the client’s level of cognition and the stage they are at in their journey. (case reflection 25, speech and language therapist)

In other cases it was attributed to high levels of depen- dency and complex health and social care needs; or to indi- viduals’ attitudes of entitlement and expectation that ‘the system‘ was there to ‘deliver goods and services’, which was seen as counter-productive to the SMS approach:

Breaking the barrier of patient expectation with some difficult patients, who I may recognise to have the ability to self-manage but are reluctant to stop having professional input. (feedback form 52, physiotherapist)

Table 3. Survey of self-management support (SMS) beliefs and attitudes, before and after training completion.* Shown are survey items (sentiments) that elicit respondents’ beliefs and attitudes towards core constructs of SMS. Response options are strongly agree, agree, disagree, and strongly disagree. Analysis shows the percentage of respondents who answered in concordance with SMS principles.

Questionnaire item (in brackets the response in concordance with SMS)

Percentage of respondents in concordance with SMS

Before training (n = 60)

After training* (n = 54)

When ideas/goals suggested by clients are unrealistic, it holds back progress (disagree)

43% 67%

It is important to educate the client about setting achievable goals (disagree)

5% 44%

The practitioner should usually lead the rehabilitation/enablement process (disagree)

50% 54%

A self-management programme mostly includes education for the client and their family (disagree)

16% 38%

Where possible, goals or targets of rehabilitation/enablement should always be written in the client’s own words (agree)

79% 88%

A client’s confidence has more influence on the outcome of rehabilitation/enablement than the skills of the practitioner (agree)

84% 88%

Rehabilitation/enablement plans should be guided by the practitioner (disagree)

29% 51%

Self-management should always be introduced just before discharge from services (disagree)

33% 62%

Self-management is all about getting people to do more for themselves (disagree)

14% 19%

If clients have cognitive problems they would be unable to learn to self-manage (disagree)

74% 78%

*Due to fluctuation in the practitioner sample, only 34 respondents completed the survey both before and after training.

80 S. T. KULNIK ET AL.

As a consequence, some practitioners reflected on feeling the need to get to know clients in order to ‘possibly cherry- pick the right person’ for a dedicated SMS approach. In contrast, other practitioners reported successes when trialling the approach without such pre-selection and also, for exam- ple, with clients who exhibited challenging behaviour patterns or complex psychological states. Sharing and discussing these reflections on successful experiences in the interprofessional learning environment supported the credibility of the inter- vention from within the group, and facilitated meaning and sense-making for other practitioners, who commented: “[I got to know] useful new options/ways of empowering clients” (feedback form 72); “I will take this on board both profes- sionally and personally” (feedback form 74).

Need to facilitate self-management support at the organisational level Practitioner reflections highlighted that, in addition to the integration of SMS principles as individuals, the approach needs to be facilitated and fostered at organisational level. One practitioner, for example, commented that although the SMS intervention was thought to be:

Very positive as to how to promote the service user to make changes themselves, due to service needs it is going to be difficult for this to be effective in the team I am based in. (case reflection 23, social worker)

The most commonly mentioned difficulty was frequent change-over in practitioners working with one client. This was most prominent for the enablement service, which oper- ates a high-intensity seven-day service with up to four daily calls, necessitating multiple visits to one client by different members of staff. Other organisational aspects were men- tioned, for example making services more flexible, re-thinking rigid goal setting practices and optimising interprofessional communication to facilitate a shared SMS approach. These points were also acknowledged by senior and managerial team members, who reported intentions to review service processes to facilitate SMS.

Overall, the need to facilitate SMS at organisational level was consistently represented throughout data sources and across project stages. Despite acknowledging tangible changes in individual practice this highlights uncertainty and frustra- tion perceived by some practitioners that their team structures and processes would be challenged to support this new way of working. Reflective discussions emphasised that SMS was more effective if the same self-management messages were being used across teams, but how to manage this consistent approach operationally would be a challenge. There were however, examples of successful continuation of SMS by practitioners who covered for colleagues, and acknowledge- ment of the importance of good communication within and across teams to achieve consistency in SMS.

Service users’ experiences of self-management support Service user interviews revealed the complex and precar- ious nature of living with a long-term condition, and the wide-ranging needs of those accessing community ser- vices. Most service user accounts told an illustrative

story of the impact of interactions with practitioners in this study. In many cases the support they had received had increased confidence and encouraged different skills to manage their condition. Overall most participants felt positive about the SMS intervention. There were two par- ticipants who highlighted some of the negative aspects of services they had received, comments mostly related to time and budgetary constraints and not directly to the question about SMS. But, they raise an important distinc- tion between how services and the efforts of practitioners are interpreted by service users. Whilst some service users may appreciate being given freedom and flexibility to define solutions to issues of living with their condition, others may take a critical view of ‘self-management’. One service user, for example, interpreted the self-management rhetoric as a strategy to justify cuts in health and social care support:

In the last three or 4 years, I feel that they are just looking for reasons to find you ineligible for services, you know . . . So, it feels a bit more like . . . you prove that you’re as disabled as you say you are, sort of thing, rather than someone saying, I can see you’ve got all these problems, it must be pretty difficult, how can we help. (Participant M2)

There were a number of examples given by service users which illustrated how support to self-manage had been received and the positive impact it had made. Some service users talked about how working with practitioners had increased their self-confidence:

[The practitioner] found ways of helping me to be confident in myself, and letting me know, you can do that . . . Like a coach, it’s like having a coach . . . So yeah, it was fantastic having someone coming in the home and supporting to help me to get back to being able to function better and that, rather than other people doing things for me, you know. (Participant F3)

Other service users gave accounts that demonstrated appreciation of and satisfaction with practitioners’ SMS intervention:

[The practitioner] always kept in mind what I wanted to achieve and asked me about that. It was more [the practitioner] provided me the tools to do what I wanted to be able to do . . . But it made sense to finish when we did in some ways, because I have a list of exercises that I can carry on with. (Participant F6)

These illustrative quotes indicate some of the ways in which SMS was constructed by service users. The language they use also reflects some of the methods used by practi- tioners, such as enhancing self-efficacy (self-confidence), pro- blem-solving around person-centred goals, and putting the person at the centre of their long-term management.

Discussion

This study described how practitioners from different profes- sional groups and agencies came together to learn ways of implementing contextualised SMS for people with long-term conditions living in one South East England locality. Researchers in the field of self-management and rehabilitation increasingly recognise the added value of operationalising SMS through interprofessional training, such as in the work

JOURNAL OF INTERPROFESSIONAL CARE 81

by Gucciardi, Espin, Morganti, and Dorado (2016), Kawi, Schuerman, Alpert, and Young (2015), Semrau et al. (2015), and McColl et al. (2009). However, few of these studies provide in-depth insights into processes of interprofessional learning and implementation of SMS practices. In our evalua- tion study we used a number of ways to measure and explore the impact of the project and used NPT (Murray et al., 2010) as a framework to help us understand how practitioners made sense of this way of working, how it was distinct from their previous practice and how collectively they reflected on SMS in practice in this interprofessional context. Our data touch on many of the key themes of interprofessional learning and practice, showing positive findings for most of the commonly defined educational outcomes of IPE, i.e. reaction to the IPE approach, modification of attitudes/perceptions, acquisition of knowledge/skills, behavioural change, change in organisa- tional practice, and benefits to clients (Freeth, Hammick, Koppel, Reeves, & Barr, 2002; Oandasan & Reeves, 2005b).

Skills, attitudes, and beliefs of the workforce are critical for successful implementation of SMS (Ahmad, Ellins, Krelle, & Lawrie, 2014; de Longh, Fagan, Fenner, & Kidd, 2015; de Silva, 2011; Newbronner et al., 2013). A dedicated interpro- fessional focus of the SMS intervention and the training programme suited the structure and organisation of the work- force in our project, and particularly helped staff understand the shared purpose and their own role within this collabora- tive context. Although our survey of SMS beliefs and attitudes was limited due to the fluctuation in the group between the first and second survey time points, these data nevertheless reflect some group shift in attitudes and beliefs towards a mind-set more aligned with SMS principles. Importantly, we delivered training sessions in a non-threatening environment of mutual respect and appreciation, using facilitators rather than ‘expert teachers’. This helped the normalisation mechan- ism of ‘reflexive monitoring’, by allowing for open and also self-critical discussion amongst a mixed audience of practi- tioners from varying professional and support roles and dif- fering levels of seniority. Frequently described challenges to effective interprofessional teamworking are differing patterns of professional socialisation, lack of knowledge and apprecia- tion of others’ roles, and issues of hierarchy and power (Baxter & Brumfit, 2008; Brown et al., 2011; Gucciardi et al., 2016; Hall, 2009). Our findings reflect some of these chal- lenges and highlight overlap with findings from other self- management research, for example variations in how self- management is understood (Van Hooft et al., 2015; Young et al., 2015) and tensions around control and partnership working (Mudge et al., 2016; Norris & Kilbride, 2014). In addition, our study provides evidence of how these challenges can be addressed. Our findings show that practitioners chan- ged their understanding and practical application of SMS, as they reflected on more conscientious collaboration with and deliberate hand-over of control to service users. Our findings also demonstrate intentions of closer collaboration and com- munication with colleagues within and across teams. This resonates with work by Sims, Hewitt, and Harris (2015), who describe how interprofessional teamworking affects out- comes and patient experience through mechanisms of shared purpose, critical reflection, innovation, and leadership.

Our data also provide some evidence of benefit to clients. As opposed to many previous condition-specific and/or group-based self-management programmes, the intervention in this project delivered generic individualised SMS to people with heterogeneous medical background, utilising the existing workforce and infrastructure of community rehabilitation and intermediate care services. These services work on the basis of client home visits, which gives a convenient route to deliver- ing provider-based integrated SMS to groups that are tradi- tionally ‘hard-to-reach’, such as people with complex health and social care needs or restricted mobility. The small con- venience sample of service users in our study represented such a group. Our data give many tangible examples of small changes to individual practitioners’ practice having a positive impact on the self-management of service users, and service user accounts provided corroborating evidence of that. That SMS strategies were successfully implemented with service users who experienced considerable levels of disability coun- ters the frequently held view that self-management approaches are not suitable for groups with complex and significant disability—a view that may perpetuate a prescrip- tive ‘doing to’ the person approach in this type of rehabilita- tion setting, which is counter-productive to self-management.

Successful SMS requires change across a whole system and the success of this project was contingent on a number of key areas, all of which align with the current evidence (Ahmad et al., 2014; de Longh et al., 2015). We made considerable efforts to adopt an interprofessional approach to facilitate shared meaning and col- laboration. While these aspect were well received by the workforce in this study, practitioners cited practical organisational barriers that hindered SMS, for example frequent staff turnover and com- munication across boundaries. These challenges echo findings from other studies of interprofessional teamwork in multi-agency settings. For example, Robinson and Cottrell (2005) highlighted how participants perceived the responsibility to overcome some of these issues should be initiated or enabled through changes in service organisation. This is not uncommon in research that attempts to evaluate the impact of IPE on practice (Reeves et al., 2013), and strategies to empower practitioners to initiate changes at organisational level through interprofessional discussions need to be explored.

Nevertheless, our findings highlight the importance of enga- ging senior managers through site visits and involvement in our project steering group. This helped to ‘sell’ the idea of the work- force working differently in an interprofessional manner, and how this could lead to greater efficiencies as well as improve service user experience. This was further supported by a political drive for integration of health and social care and implementation of SMS in the locality, which contributed to creating a ‘receptive context’ (Robert & Fulop, 2014). Moreover, our data show that there remained scope for adapting organisational and team processes in order to facilitate individual SMS practice. A clear message from our data therefore is that this way of working requires ongoing sustainability work and commitment at organisational level to ensure long-lasting implementation and effect—a finding which is supported by other research in self-management (Ahmad et al., 2014; De Longh et al., 2015; Eaton et al., 2015; Newbronner et al., 2013) and interprofessional teamworking (Brown et al., 2011; Robinson & Cottrell, 2005). The conditions need to be created to

82 S. T. KULNIK ET AL.

foster the type of ongoinginterprofessional development that leads to social learning in the workplace and contributes to continuous service improvement (Wilcock, Janes, & Chambers, 2009).

There are some limitations to this study. We acknowledge that this was a small, single-institutional project, and that our data are perceptions-based and relate to short-term outcomes of IPE and SMS only. Based on a number of recently updated systematic reviews of the interprofessional literature (Reeves et al., 2016, 2013), there has been a call to develop the interprofessional field further by conducting larger multi-centre studies, utilising empiri- cal observational methods and demonstrating longer-term out- comes and economic impact of IPE through longitudinal study designs (Reeves, 2016). While we recognise that these approaches will bring considerable advances to the scholarship and evidence base of interprofessional learning and practice, it was not possible to address these aspects in our study, which was a publicly commissioned SMS implementation project with an integrated, but opportunistic evaluation study and therefore constrained by project resources. A further limitation to our study design was fluctuation within the group of practitioners and the challenges associated with organising training for large numbers of staff. Lack of group stability, in particular in post-licensure training, and logistical problems are known barriers to implementing IPE (Oandasan & Reeves, 2005a, 2005b). This identifies considerations for sustainability and the planning of future implementation projects in this sector. We developed good lines of communica- tion with team leads who helped to expedite and streamline processes, but these challenges need to be considered when inter- preting our findings.

Concluding comments

This study provides an insight into the processes of implementing SMS for people living with long-term conditions through a diverse community workforce of rehabilitation and social care practi- tioners. Our data illustrate how theory and application of inter- professional learning and practice can add value to operationalising a self-management approach in community reha- bilitation and social care. We conclude that it is possible to embed a self-management model like Bridges Self-Management in this setting and to impact on interactions between service users and staff, leading to increased service user confidence and encouraging different skills to manage long-term conditions. An important enabling factor is organisational commitment to addressing pro- cesses and structures that facilitate interprofessional teamworking.

Declaration of interest

FJ is founding director and CEO of Bridges Self-Management Limited, a social enterprise conducting research and training in self-management support in health and social care. HP, LB, and SK are employees of Bridges Self-Management Limited. JH reports no conflict of interest. The authors alone are responsible for the content and writing of this article.

ORCID

Stefan Tino Kulnik http://orcid.org/0000-0001-5419-6713

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Abstract
Introduction
Methods
Research design
Setting
Participants
Intervention
Data collection
Data analysis
Ethical considerations
Findings
Participant overview
How self-management support was implemented
Individual practitioner learning
Reflections on collaborative working
Perceived barriers to self-management support
Need to facilitate self-management support at the organisational level
Service users’ experiences of self-management support
Discussion
Concluding comments
Declaration of interest
References