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Implications for practice and research
The findings indicate the need to educate and change the mindset of patients/service users to realise that:
There are nurses who are highly skilled educated practitioners specifically trained to take on key roles in chronic disease management (CDM).
CDM has been developed for application within the primary rather than the acute care setting.
Future research should ascertain the views of service providers and health professionals regarding nurse's contribution to CDM.
In direct response to the rapid rise in the incidence and prevalence of chronic illness models of chronic disease management have evolved. These CDM models have required validation within a nursing context and the focus of this validation has been to consider the origins, processes and outcomes associated with effective models of CDM. This study reports on the qualitative findings of the PEARLE study (Prevention, Enabling self care and care in Long-term conditions Evaluation). A key strategy in CDM is the introduction of chronic care models of service delivery, particularity in the primary care setting. These models seek to empower patients/service users and establish proactive multidisciplinary healthcare teams who effectively undertake CDM. Nurses occupy key roles within these teams. However, patient/service user's perspectives on the nurses’ role and their contribution to CDM are relatively unexplored.
This UK-based research used a mixed method approach employed in PEARLE and underpinned by whole systems theory. The focus of this paper is on the qualitative findings derived from service users and patients in addition to drawing upon data from health professionals to further contextualise findings. A purposive sample of seven case-study sites was selected from a systematic search of UK practice websites and a national consensus conference on nursing contribution to models of CDM. These seven sites included a diverse number of chronic care models, populations and geographical spread. Semistructured interviews (using an interview guide) were conducted with adults, young people and family carers (n=84) and health professionals (n=51). Six children/younger people participated in focus groups at their school. Data analysis guided by systems theory, involved open coding and thematic analysis.
The themes derived from service users/patients included: nurses were not often appreciated for their expertise in their respective CDM field; a preference for the traditional method of care provided by doctors in acute care is what is familiar and therefore trusted.
This study provides an illuminating account of service users/patients perceptions of nurse's contribution to CDM. The use of qualitative methods is most appropriate to establish the emerging themes associated with the application of these models. The diverse and relatively large sample involved in this qualitative study adds to the robustness of the findings. The authors are to be commended for disentangling the qualitative elements from the larger body of work. However, the description of the design of the study is at times confusing and little detail is given on how the different qualitative data sets were integrated or how themes were identified. Additional information on the mixed methods approach utilised in the main study, for example, sequential or concurrent and more detail on the multiple case-study design employed, referring to the work of Yin1 or Stake2 would have added more clarity. The authors do not explicitly refer to the application of any particular framework to maintain rigour; however, it is evident that cognizance was taken of key criteria identified by Lincoln and Guba.3
Interviews were conducted by experienced researchers who spent time in the interview process (90 min) and data saturation was achieved. Although a team of researchers analysed the data, the description of the strategies used to facilitate data management and to ensure consistency of approach are clear and appropriate. The peer debriefing and member checking processes are explicitly described.
The verbatim accounts enhance the credibility of the data and sufficient detail is provided to enable the reader evaluate and judge the applicability of the findings to other contexts.
This study adds important data on patients/service users’ perspectives on the evolving and extended role of the nurse in CDM.
Competing interests None.