Differing Perspectives on Conceptual Approaches to Self-management

Commentary

Differing Perspectives on Conceptual Approaches to Self-management

The identification and development of interventions to enhance individual’s and families’ ability to manage health-related challenges has been of enduring interest of nurse researchers. The concepts of individual self-management, family management, and family self-management have proven useful in understanding human response to illness and often are the target of nursing interventions. These complex concepts have been studied from varying perspectives and are key components of several conceptual frameworks, including two that were published in Nursing Outlook. Following the recent publication, “Individual and family self management: Background and perspectives on context, process, and outcomes” (Ryan & Sawin, 2009), Grey and Knafl contacted Ryan and Sawin to express concern about inaccuracies in the presentation of the framework they developed (Grey, Knafl & McCorkle, 2006). This contact led to conversations among the authors and resulted in this commentary. The intent of this commentary is to clarify the presentation of Grey, Knafl and McCorkle’s framework, compare key aspects of the two frameworks, and provide an overview of ways in which similar but different frameworks inform research.

Errata

Although the Grey, Knafl and McCorkle framework depicts the "Self and Family Management Framework" as having four outcomes including Health Status (control, morbidity, mortality), Individual Outcomes (quality of life and adherence), Family (function and lifestyle), and Environmental Context (access, utilization, and provider relationships), only one outcome category was mentioned in the Ryan and Sawin article. Outcome categories for health status complement or match risk and protective factors (not inclusion as stated in the Ryan and Sawin article). Ryan and Sawin noted that a limitation of the Grey, et al. framework was its exclusive focus on the “impact of the child on families and the need to manage the care of children” (p. 219). However, the article presents the framework as applicable to self and family management in the context of both adult and child chronic conditions, and one of its developers (McCorkle) has focused her program of research on adults.

Comparison of Two Frameworks

The goal of the Grey, Knafl, and McCorkle article was to identify themes that cut across chronic conditions and were germane to both individual and family response to chronic conditions. The article presented a synthesis of the literature on the factors influencing self and family management as well as potential outcomes from enhanced management. The purpose of the Ryan and Sawin framework was to identify gaps in the science of self-management and present a framework designed to provide a foundation for intervention development and identification of self-management behavior-specific outcome measures. Ryan and Sawin’s approach was not limited to chronic conditions.

Both frameworks identified risk and protective factors (identified as Context in Ryan and Sawin) and outcomes--several of which are similar. Grey, Knafl and McCorkle indicate that risk and protective factors influence self-management and family management, which, in turn, mediate outcomes. Ryan and Sawin define Context: Risk and Protective Factors as condition-specific factors that challenge or protect individuals and families engagement in self-management. In contrast to Grey, Knafl, and McCorkle’s four categories of outcomes delineated above, Ryan and Sawin delineate individual and family proximal outcomes (i.e., engagement in self-management behaviors) and distal outcomes (i.e. health status, quality of life/perceived well being, and direct and indirect costs).

Both frameworks include family; however, the concepts are somewhat different. In the Grey et al. framework, family structure and function are included as one category of risk/protective factors and family function is listed one possible outcome. Family management, on the other hand, is conceptualized as how the family incorporates ongoing family management into everyday family life. The Ryan and Sawin framework includes characteristics of the family as risk/protective factors and focuses on the family self-management processes of enhancing knowledge and beliefs, regulation skills and abilities and social facilitation. In addition, family quality of life is included as an outcome.

Both of these frameworks address individual self-management but differ with respect to family management and family self-management. The Grey, et al. framework does not specify management processes and notes the need for further research to identify and test effective self and family management behaviors. On the other hand, Ryan and Sawin identify specific self management processes. The decision to use one or the other framework should be based on the research aims being addressed. The chosen framework informs the selection of concepts to be studied, their proposed relationships, selection of measures, and development of interventions. -Both frameworks are comparatively new and empirical evaluation of the frameworks, concepts and relationships among the concepts will be addressed in future studies. For example, researchers using Grey, Knafl and McCorkle’s framework might study the relationship between an individual’s self management of their treatment regimen for type 2 diabetes and the family’s efforts to incorporate the individual’s self management into their daily routine. In contrast, researchers using Ryan and Sawin’s framework could test the impact of strengthening some or all of the self-management process components to enhance self-management behaviors. Likewise enhancement of processes could be tested for their mediation of self-management behaviors. Evaluation of risk and protective factors could be tested for moderation in both frameworks.

Applications

Both frameworks were developed to support NINR-funded centers on self-management. It is anticipated that over time each will lead to the strengthening of interdisciplinary and community partnerships and the advancement of the science of self-management In the Yale Center for Self and Family Management of Vulnerable Populations, the framework has provided the infrastructure for the development of multiple studies on the understanding, development, and testing of interventions interventions designed to improve self and family management of chronic conditions. The risk and protective factors are used as moderators in studies, whereas self-management activities are mediators for outcomes. It is clear that the next generation of self-management studies need to go beyond simple testing of interventions on outcomes to understanding what interventions work in what people under what conditions. For example, Grey and Whittemore are currently testing an internet-based intervention, TEENCOPE, (Whittemore, Grey, Lindemann, Ambrosino, & Jaser, In press) for teens with type 1 diabetes. They will not only evaluate the efficacy of the intervention, but the effects of various risk and protective factors (moderators) on outcomes and whether hypothesized mediators function as the framework would suggest.

The Individual and Family Self Management Theory (Ryan & Sawin, 2009) provided the foundation for several projects in the Self Management Science Center at The University of Wisconsin-Milwaukee. For example, Morgan used the Center framework as foundation for development and testing of an intervention. Her study focuses on self-management process while controlling for a condition-specific context factor (severity of the functional decline) to positively affect the proximal (caregiver self-management of unmet needs) and distal outcomes (reduced family member agitation, discomfort and stress as well as reduced caregiver stress and burden). The family self-management processes addressed in the intervention include caregiver’s abilities to recognize and understand unmet needs, particularly pain, problematic interactions, and overstimulation that can lead to disruptive and agitated behaviors (theoretical concepts of knowledge and beliefs).

Conclusions

Different frameworks across centers for the study of self-management contribute to the science of self-management and will lead to improvements in our ability to provide appropriate and effective care to persons and their families. Feedback from studies using these frameworks will likely lead to further development of the frameworks and development of the science of self-management.