The UK's population has been increasing steadily and was estimated to be 67 million in 2021 (Statista, 2023). In the past 10 years, the number of individuals aged 65 years and over has increased from 9.2 to 11 million and is predicted to rise further (Office for National Statistics, 2021; 2023). Ageing, alongside lower socio-economic status, increases the prevalence of long-term condition. An estimated 1 in 3 people live with a long-term condition and this situation threatens to overwhelm the current healthcare system (Manderson and Wahlberg, 2020; Public Health England, 2020; Statista, 2023).
The NHS Long Term Plan (2019) is committed to developing and investing in community services and highlighting the importance of healthcare professionals' role in promoting patient self-care and management. The requirement for highly qualified district nursing staff to meet this commitment is further emphasised in the NHS Long Term Workforce Plan (NHS, 2023a), to meet the increasing complexity of the population's needs. The staffing crisis, alongside unsafe and unsustainable demands on services, requires a focus on alternative strategies to promote self-management of long-term conditions and to avoid overwhelming the system (Queen's Nursing Institute (QNI), 2019; 2023, Devine, 2021; NHS, 2023a). This article explores the promotion and empowerment of self-care and self-management strategies for individuals with long-term conditions from a district nursing perspective.
Background
According to the National Institute for Health and Care Excellence (NICE), a long-term condition is one that lasts for over one year and significantly impacts a person's life (NICE, 2016a). Long-term conditions may include arthritis, dementia, stroke, heart disease, cancer or, more recently, long-COVID, with hypertension, diabetes and mental health conditions being the most prevalent (NICE, 2016a; 2022; Chilton and Bain, 2017; NHS, 2021).
Moreover, patients with socioeconomic deprivation have a 60% higher prevalence of long-term conditions or increased severity and are more likely to have multiple long-term conditions, compared to those less deprived (Woodward et al, 2023). The cost of living crisis may increase socioeconomic inequalities, further impacting the health of the population (Robinson, 2023). These statistics highlight the correlation between ageing populations, deprivation and prevalence of long-term conditions, contributing to the complex and demanding district nursing caseloads (QNI, 2022).
The impetus for self-management
COVID-19 posed a significant risk to population health, which increased substantially for patients with long-term conditions and those who are immunocompromised (Ng et al, 2023). This caused radical changes to people's lives, including isolation to prevent transmission, resulting in an increase in self-management behaviours (Utli and Vural-Dogru, 2021). Self-care relates to completing a medical task, whereas self-management is described as the daily medical, emotional and behavioural management of those with long-term conditions (Ng et al, 2023; Turnbull, 2023). Self-management improves self efficacy and treatment concordance, resulting in regulated long-term conditions, improved quality of life and reduced healthcare service contacts (Cottom, 2020).
The risks of COVID-19 caused barriers to service accessibility, which motivated the development of new processes, policies and safety measures, changing the way healthcare was delivered (Smith et al, 2023). To reduce pressure and increase hospital capacity, high-risk patients were discharged into the community, increasing complexity and demands on the already depleted district nursing services (Penfold, 2020).
To alleviate increased pressure, non-emergency services adapted care delivery, restricting face-to-face interactions, utilising remote methods and promoting self-care through digital technology (Smith et al, 2023). The population began delivering self-care tasks such as lateral flow self-testing for COVID-19, hygiene practices and using personal protective equipment (Smith et al, 2023). Bernacki et al (2021) documented that the decline in face-to-face input resulted in patients taking responsibility for their health, engaging in self-monitoring while identifying and resolving issues themselves. Green et al (2020) reported a decline in distric nurse visits, positively impacting caseloads to facilitate focus on the most complex and appropriate patients for the service. Families also began supporting and caring for elderly relatives as a form of protection from COVID-19, alleviating pressure on the NHS (Green et al, 2020; Phillips et al, 2020).
Therefore, COVID-19 transformed the views of the population to become fully engaged in self-care and management, a progression the NHS had been striving for to ensure its survival (Smith et al, 2023). The importance of self-care was first highlighted in the Wanless report (2002) on the long-term future of the NHS, where relationships between healthcare and the public envisioned the creation of a fully engaged society by 2022.
The report focused on empowering and promoting self-care to gain information, skills and equipment so that people could take an active role in their treatment and maintenance of conditions (Wanless, 2002). Because of the ageing population, it was predicted that public engagement in self-care could generate significant cost benefits for the NHS, dependent on the uptake—a strategy that could ultimately save the system (Wanless, 2002). Self-management features in the comprehensive model of personalised care (Table 1) to encourage people to manage their physical and mental wellbeing (NHS, 2018; 2019; 2023a).
This model features self-management as one of its six evidence-based components and promotes interventions such as peer support, health coaching and education to increase people's skills, knowledge, and confidence (NHS, 2018). Poor self-management uptake is linked to increased cost, disease progression, mortality and multimorbidity. An estimated 436 000 emergency admissions could be avoided, if the least able patients were supported to manage their conditions. (NHS, 2018; Wood, 2018).
District Nurses care for the most vulnerable and least able populations and should be high on the community's agenda. Green et al (2020) suggests capitalising on the positives that COVID-19 has provided for district nursing, such as family involvement and technological advancements to support caseload management. Notwithstanding this, it is unclear if self-management behaviours accelerated by COVID-19 have continued after the pandemic as more research is needed. The QNI (2022) identifies unsustainable pressure on district nursing caseloads which, unlike other services, has no maximum capacity. It is vital that district nurses utilise leadership skills to enable and empower patients, families, carers and peers to promote self-management to relieve system pressure (Green et al, 2020; Nursing and Midwifery Council (NMC), 2022).
Supporting patients to self-manage
Self-management requires holistic assessment and, by encouraging shared decision-making, it shifts the responsibility to the patient and promotes sustainability (Turnbull, 2023). NICE (2016b) recommends individualised care planning for patients with multiple long-term conditions, establishing values, goals and priorities with the aim of maintaining independence. Significant risks associated with self-management should be thoroughly considered and monitored; if patients lack the capacity to self-manage, it could place them at significant risks (Turnbull, 2023). Excellent communication skills are required to establish risks, encourage shared decision-making and to build a rapport capable of engaging patients in behaviour change and self-management practices, thus improving clinical outcomes (Petersson et al, 2022).
NHS places patient knowledge high on the personalised care agenda and offers self-management education programmes for long-term conditions (NHS, 2023b). Education is not always enough; the frequent disconnect between knowledge and behaviour often accompanies assumptions that education supports healthier choices, which is not always true and can hinder ‘behaviour change strategies’ (NHS, 2018; Carrier, 2023). Patients with long-term conditions can struggle to accept their condition, contributing to a resistance in self-management, requiring positive healthcare relationships to facilitate engagement (Budge et al, 2021). A lack of patient involvement in care planning and multidisciplinary team (MDT) communication may drive assumptions that patients have insufficient knowledge to self-manage long-term conditions (Brand and Timmons, 2021). Integrated holistic approaches during assessment and among the MDT are crucial to establish and share a patient's ability to self-manage (NHS, 2018; Brand and Timmons, 2021). This constructs a thorough picture of the patient's self-management activities, ensuring care is coordinated and the patients feeling that they are heard (NHS, 2018; Brand and Timmons, 2021).
Self-management strategies
To further facilitate engagement, behavioural strategies to manage long-term conditions can be used to influence adherence to treatment, self-efficacy and engagement in goal setting and care planning (Lawless et al, 2021). The Public Health England (PHE, 2018) initiative ‘making every contact count’ links behaviour changes to reduced prevalence of long-term conditions and improved wellbeing of those already living with long-term conditions. It focuses on opportunities to engage and motivate patients to initiate behaviour change across all NHS services (PHE, 2016). District nurses, who are skilled communicators, are well-placed to initiate this through motivational interviewing and their therapeutic relationships with patients (Day et al, 2017). Motivational interviewing is used to promote self-management and involves evoking patients' concerns and values to develop person-centric goals (Day et al, 2017). Carrier echoes this and believes that engaging a person's motivation links to their core values and effectively achieves sustained behaviour change (Carrier, 2023). Motivational interviewing does require timely communication that focuses on positivity and avoiding conflict because all patients may not recognise the need for change and might resist (Walsh, 2019). Staffing reductions, increased workload, and poor skill mix may mean that implementing motivational interviewing as a strategy is not always feasible (QNI, 2022). However, nursing leaders should enable and advocate pre- and post-registration nurses to gain this transferable skill to improve self-management of long-term conditions, imporve population health and alleviate demands on the service (Day et al, 2017).
Time constraints can cause detrimental effects on the elderly population, who often rely on healthcare interactions as their only socialisation, thus requiring support from voluntary or social services (Wakefield et al, 2022; Turnbull, 2023). Without meaningful interactions, loneliness can exacerbate long-term conditions and contribute to the need for more services, creating additional strain (Wakefield et al, 2022). Distric nurses can use social prescribing by referral to a link worker, assisting patients to join voluntary or community groups and improving connections for their physical or social needs (Wakefield et al, 2022). Social presccribing features in the NHS policy and has proven useful in creating a sense of belonging by connecting patients to their community and their peers and by improving health and wellbeing through participation and shared experiences, thus reducing the overall cost (NHS, 2018; 2019; Wakefield et al, 2022).
District nurses have the expertise to implement and promote social prescribing during holistic assessment, which can benefit a large proportion of the caseload that is socially isolated with complex long-term conditions (Howarth et al, 2020; Mendes, 2021). On the other hand, social prescribing is not always appropriate for severely unwell and complex patients and relies on volunteers and local authority funding, resulting in limited budgets and capacity (Drinkwater et al, 2019). A reliance on funding among private and voluntary resources can cause geographical disparities, contributing to health inequalities rather than preventing them as intended (McFarland and MacDonald, 2019; Okpako et al, 2023).
Patients from socio-economically deprived backgrounds do not always participate in self-management strategies, causing barriers for district nurses who are promoting the strategy, futher contributing to health inequalities (The Kings Fund, 2021; Okpako et al, 2023). Partnerships, education and continued professional development specific to health inequalities are essential to identifying inequalities and becoming a patient advocate for equal opportunities (McFarland and MacDonald, 2019).
Technology and self-management
Technology is an NHS priority in improving access to health information, delivering peer support and empowering patients to use digital tools to manage long-term conditions (NHS, 2019; 2023b). Monitoring devices, virtual appointments and the NHS app are among the many innovative tools created to support self-management and independence, thus reducing hospital admissions (NHS, 2019; 2023c). Self-management technologies, including smart glucometers, insulin pens, dialysis machines and voice reminders can support individuals with diabetes, chronic kidney disease and dementia to lead independent lives (Moody et al, 2022).
Through the use of ‘telehealth’ technology, health professionals can remotely monitor patients to improve safety while reducing visits (Gajarawala and Pelkowski, 2021). During COVID-19, district nursing teams used ‘attend anywhere’ to carry out video or audio assessments, which decreased their visits, avoided hospital admissions and reduced cost (Grindle, 2021). Technology benefits patients and district nursing teams as they can deliver accessible and often immediate support for patients to manage their long-term conditions at home (Moody et al, 2022). Conversely, the QNI found that virtual wards, telehealth and remote consultations post COVID-19 were the least used forms of technology by district nurses (QNI, 2023). Poor engagement was cited secondary to technical issues, followed by reduced efficiency and district nurses perceiving technology as impersonal and a barrier to patient contact (QNI, 2023). This poor response undermines technological progress and suggests a need for engaging district nurses in technology developments (QNI, 2023). It is therefore essential that district nursing leaders encourage staff to maximise resources and productivity, to enhance quality of care (NMC, 2022).
Moody et al (2022) suggested that self-management technology was also underutilised by patients, resulting in poor management of long-term conditions, reduced quality of life and complications. This can cause financial strain beacause of wasted equipment and increased treatment costs (Moody et al, 2022). Iglesias Urrutia et al (2022) reported that some patients did not utilise monitoring devices, preferring professionals to carry out tasks for them and favouring face-to-face consultations. Equally, the unreliability of self-monitoring because of gender, age, health literacy and education may produce inaccurate results, effecting the patient's experience and ability to use technology to manage their long-term conditions (Reychav et al, 2019). Moody et al (2022) found that despite technology benefiting elderly patients to self-manage, lack of digital education, poor dexterity and low cognition, alongside the lack of motivation to seek alternatives, prevented its uptake. Therefore, it is significant for healthcare professionals and patients to have the correct support needed for the implementation of technology (Fotteler et al, 2023).
During holistic assessments, district nurses can consider family or carer involvement to initiate and facilitate the use of technology, as this may be a significant motivator for the patient (Moody et al, 2022). Developing therapeutic relationships to instil professional trust is important for elderly patients and their families, which can be critical to them accepting the technology (Day et al, 2017; Moody et al, 2022). Enhancing district nurses' knowledge of technology will enable them to personalise information, specific to patient needs, and prevent them feeling overwhelmed, thereby helping to achieve digital goals (NHS, 2019; Moody et al, 2022).
The increase in technologically delivered healthcare and self-management creates disparities for other groups who cannot access digital services, perpetuating health inequalities (The Kings Fund, 2023). The Kings Fund (2021) reported that 1 in 10 people could not access the internet and digital exclusion contributed to poorer care by impacting individuals with disabilities, those from ethnic minorities and lower socio-economic backgrounds, traveller communities, or the homeless. Additionally, patients with lower socio-economic status were less likely to engage in health technologies, even if made available to them. The NHS policy must recognise this barrier and adjust its approach accordingly (The Kings Fund, 2021). The NHS digital inclusion framework highlights digital exclusion and the support available from voluntary organisations for free devices, data and discounted internet (NHS, 2023c). The NHS has established investment in its adult social care technology fund 2023-24, to enable access to remote monitoring for patients with long-term conditions in their own homes (2023a). However, patients may not be aware of the support available, therefore district nurses must have cultural competence and an awareness of health determinants to advocate for patients by signposting and improving their access to care (NMC, 2022).
Conclusions
The requirement for self-management is evident from the increased prevalence of long-term conditions, the ageing population and social deprivation. The current NHS burden is unsustainable and depends upon patients, carers and families taking responsibility for their future health. Assumed responsibility during COVID-19 has proven that this is possible and district nurses can use a variety of skills and strategies to continue this momentum. However, individuals ultimately influence choices and patients and healthcare professionals face many challenges when accessing the appropriate skills, knowledge and strategies needed to promote self-care and empower self-management. Investments are needed to implement self-management educational strategies for district nurses, patients and carers. Shared decision-making and individualised care is essential in strategic development to mitigate risks and ensure suitability of methods to promote sustainability of future practices.
Key points
- Self-management strategies are essential to ease the strain of an ageing population and the burden of chronic long-term conditions.
- District nurses play a key role in promoting self-management for long-term conditions, but high workloads may limit their efficacy.
- The digitalisation of healthcare provides new approaches aimed at supporting self-management.
- Socio-economic deprivation and health literacy gaps can lead to disparities in self-management and the success of digital innovations.
- District nurses must advocate for patients to ensure equal access to resources and support.
CPD reflective questions
- Critically reflect on your personal learning needs in relation to self-care and self-management.
- Explore what barriers have prevented you from promoting self-management for patients with long-term conditions.
- Identify appropriate learning opportunities and resources to support self-management from an individual and team perspective.