Division of Population Medicine, Cardiff University, Cardiff, UK.
School of Social Sciences, Cardiff University, Cardiff, UK.
Med Educ. 2018 Mar;52(3):274-287. doi: 10.1111/medu.13492. Epub 2018 Jan 4.
Accompanying the growing expectation of patient self-management is the need to ensure health care professionals (HCPs) have the required attitudes and skills to provide effective self-management support (SMS). Results from existing training interventions for HCPs in SMS have been mixed and the evidence base is weaker for certain settings, including supporting people with progressive neurological conditions (PNCs). We set out to understand how training operates, and to identify barriers and facilitators to training designed to support shifts in attitudes amongst HCPs.
We undertook a realist literature synthesis focused on: (i) the influence of how HCPs, teams and organisations view and adopt self-management; and (ii) how SMS needs to be tailored for people with PNCs. A traditional database search strategy was used alongside citation tracking, grey literature searching and stakeholder recommendations. We supplemented PNC-specific literature with data from other long-term conditions. Key informant interviews and stakeholder advisory group meetings informed the synthesis process. Realist context-mechanism-outcome configurations were generated and mapped onto the stages described in Mezirow's Transformative Learning Theory.
Forty-four original articles were included (19 relating to PNCs), from which seven refined theories were developed. The theories identified important training elements (evidence provision, building skills and confidence, facilitating reflection and generating empathy). The significant influence of workplace factors as possible barriers or facilitators was highlighted. Embracing SMS often required challenging traditional professional role boundaries.
The integration of SMS into routine care is not an automatic outcome from training. A transformative learning process is often required to trigger the necessary mindset shift. Training should focus on how individual HCPs define and value SMS and how their work context (patient group and organisational constraints) influences this process. Proactively addressing potential contextual barriers may facilitate implementation. These findings could be applied to other types of training designed to shift attitudes amongst HCPs.
随着患者自我管理期望的增长，需要确保医疗保健专业人员（HCPs）具备提供有效自我管理支持（SMS）的所需态度和技能。现有的 SMS 培训干预措施对 HCPs 的效果参差不齐，某些情况下的证据基础较弱，包括支持患有进行性神经疾病（PNC）的患者。我们着手了解培训的运作方式，并确定支持 HCPs 态度转变的培训的障碍和促进因素。
我们进行了一项真实主义文献综合研究，重点关注：（i）HCPs、团队和组织如何看待和采用自我管理；以及（ii）如何为 PNC 患者量身定制 SMS。我们使用了传统的数据库搜索策略，同时进行了引文跟踪、灰色文献搜索和利益相关者推荐。我们从其他长期疾病的数据中补充了 PNC 特定的文献。关键信息员访谈和利益相关者咨询小组会议为综合过程提供了信息。生成了真实主义的背景-机制-结果配置，并将其映射到 Mezirow 的变革性学习理论中描述的阶段。
共纳入 44 篇原始文章（其中 19 篇与 PNC 相关），从中开发了 7 个精炼理论。这些理论确定了重要的培训要素（提供证据、培养技能和信心、促进反思和产生同理心）。强调了工作场所因素作为可能的障碍或促进因素的重要影响。接受 SMS 通常需要挑战传统的专业角色界限。
SMS 融入常规护理并不是培训的自动结果。通常需要一个变革性的学习过程来触发必要的思维模式转变。培训应侧重于 HCPs 如何定义和重视 SMS 以及他们的工作环境（患者群体和组织限制）如何影响这一过程。主动解决潜在的背景障碍可能会促进实施。这些发现可应用于旨在改变 HCPs 态度的其他类型的培训。
