Implementation of a self-management support approach (WISE) across a health system: a process evaluation explaining what did and did not work for organisations, clinicians and patients

Abstract

BackgroundImplementation of long-term condition management interventions rests on the notion of whole systems re-design, where incorporating wider elements of health care systems are integral to embedding effective and integrated solutions. However, most self-management support (SMS) evaluations still focus on particular elements or outcomes of a sub-system. A randomised controlled trial of a SMS intervention (WISE—Whole System Informing Self-management Engagement) implemented in primary care showed no effect on patient-level outcomes. This paper reports on a parallel process evaluation to ascertain influences affecting WISE implementation at patient, clinical and organisational levels. Normalisation Process Theory (NPT) provided a sensitising background and analytical framework.MethodsA multi-method approach using surveys and interviews with organisational stakeholders, practice staff and trial participants about impact of training and use of tools developed for WISE. Analysis was sensitised by NPT (coherence, cognitive participation, collective action and reflective monitoring). The aim was to identify what worked and what did not work for who and in what context.ResultsInterviews with organisation stakeholders emphasised top-down initiation of WISE by managers who supported innovation in self-management. Staff from 31 practices indicated engagement with training but patchy adoption of WISE tools; SMS was neither prioritised by practices nor fitted with a biomedically focussed ethos, so little effort was invested in WISE techniques. Interviews with 24 patients indicated no awareness of any changes following the training of practice staff; furthermore, they did not view primary care as an appropriate place for SMS.ConclusionThe results contribute to understanding why SMS is not routinely adopted and implemented in primary care. WISE was not embedded because of the perceived lack of relevance and fit to the ethos and existing work. Enacting SMS within primary care practice was not viewed as a legitimate activity or a professional priority. There was failure to, in principle, engage with and identify patients' support needs. Policy presumptions concerning SMS appear to be misplaced. Implementation of SMS within the health service does not currently account for patient circumstances. Primary care priorities and support for SMS could be enhanced if they link to patients' broader systems of implementation networks and resources.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-014-0129-5) contains supplementary material, which is available to authorized users.

Process evaluation of the Data-driven Quality Improvement in Primary Care (DQIP) trial: case study evaluation of adoption and maintenance of a complex intervention to reduce high-risk primary care prescribing

“…For example, Kennedy et al found that the Whole System Informing Self-management Engagement (WISE) intervention was not routinely adopted by practices because it was not perceived as relevant or legitimate activity or a priority for general practice, and it did not fit within existing work. These findings align with the findings of this study that lack of coherence and cognitive participation were important barriers to implementation, and therefore may be important targets for intervention 25. Likewise, Berendsen et al 26 found the BeweegKuur (combined lifestyle intervention) was not implemented according to protocol and had poor sustainability because patient's expectations of the intervention were not met and tailoring to general practice and patient contexts was required.…”

Evolving ‘self’‐management: exploring the role of social network typologies on individual long‐term condition management

“…Furthermore, participants did not report any changes in care from their general practice over the course of the study; thus, training of health‐care professionals as part of the WISE intervention was not considered to influence the networks. These results were mirrored in the main RCT results …”

Delivering person centred care in long term conditions

“…A recent evaluation of a failed attempt to do this in the UK shows that the way change is introduced is vital. 17 A top down approach, without clinical or management engagement and leadership, and failure to change attitudes from a biomedical and paternalistic approach, meant that support for self management was perceived as irrelevant and received little priority from staff or patients.…”