Self-Management Concept Analysis in Psychiatric Nursing

Introduction and Aims

In nursing, behavior management—that is, helping individuals alter their behavior in order to achieve a positive aim—draws on a variety of available strategies. One concept of behavior management that has been handed down over generations of nursing practice is self-management. This concept analysis paper examines self-management by describing its history, defining characteristics and attributes, antecedents and consequences, illustrative cases, empirical measurements, and recommendations arising from the analysis.

Aims

The aims of this analysis are: (1) to obtain a better understanding of the concept; (2) to obtain clarity regarding what the concept means and how it impacts an environment, a population, a sector, an industry, or a strategy; and (3) to establish definition in terms of empirical evidence that can be used to develop evidence-based practice, which is crucial for improving the quality of care in nursing overall (Northington, 2018).

Purpose

The purpose of this analysis is to define the concept of behavioral self-management as it applies to psychiatric nursing by: (a) evaluating the history of the concept—how it was identified, developed, tested, and revised; (b) defining its characteristics and attributes; (c) analyzing model, borderline, related, and contrary cases; (d) obtaining empirical measurements; and (e) discussing the research so as to provide recommendations for practice.

Definition and Theoretical Foundations

Behavioral self-management is an empowering tool that appeals to the patient's need to be more engaged with and actively participating in his or her own care process. Self-management occurs when patients are active participants in the care process, when they oversee the care strategy designed and developed between them and their care provider so that they can manage their own care, and when they implement the care design themselves in order to effectively manage their own behavior and bring it into conformity with the target goals of the behavior management process.

This definition helps add to the nursing body of knowledge because it combines specific terms that integrate a number of theories supporting behavioral self-management in the psychiatric nursing field. These theories include Maslow's (1943) theory of human motivation and the needs hierarchy he developed to explain the progression of motivation—having lower-level needs met first as the individual grows toward self-actualization.

Other theories embedded in this definition are the classical conditioning frameworks developed by Pavlov (1927) and Skinner (1953). These two theories helped pave the way for cognitive behavior theory, which was subsequently developed into one of the leading psychotherapeutic approaches today—cognitive behavioral therapy (CBT). CBT plays a role in behavioral self-management in that the target behavior is identified by the patient with the assistance of the psychiatric nurse, and the patient is then given the tools and empowered to self-manage his or her own behavior in order to reach that target.

Literature Review

Databases searched for this analysis included: PsycINFO; the U.S. National Library of Medicine's MEDLINE; the Cochrane Database of Systematic Reviews; the Cochrane Central Register of Controlled Trials; the American Psychological Association's PsycARTICLES; the Sociology Research Database SocINDEX; and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). The keyword used to conduct the searches was "behavior self-management."

History of the Concept

How It Was Identified

Creer was the first to use the term (Grady & Gough, 2014), applying it "to indicate that the patient was an active participant in their care" (Lubkin & Larsen, 2013, p. 552). For Creer, self-management referred to the practice of giving patients more say in decisions about how care should proceed and what the goals should be—much of which is currently incorporated into the practice of cognitive behavioral therapy.

How It Was Developed

The concept developed over time as care providers recognized the need to include patients in their own care process. Patients frequently demonstrate a need to feel more included, and the concept emerged as providers realized they needed to meet this need more effectively (Baird, Rehm, Hinds, Baggot, & Davies, 2016; Al Danaf et al., 2017). As the concept was applied in diverse ways across diverse settings and conditions, outcomes were, predictably, diverse (Lubkin & Larsen, 2013).

How It Was Tested

The impact of self-management has been tested across various fields using both qualitative and quantitative analysis. Methods have included multivariate statistical analysis (Verchota & Sawin, 2016), self-reporting (Schilling et al., 2009a, 2009b), randomized controlled experiments (Lorig et al., 1999), meta-analysis (Chodosh et al., 2005), and interviews and surveys (Lorig, Sobel, Ritter, Laurent, & Hobbs, 2001).

Notable examples include the following. Lorig et al. (1999) examined 952 patients in a randomized controlled trial. Their intervention was a Chronic Disease Self-Management Program conducted over seven weeks, with sessions explaining how to self-manage in order to achieve self-identified goals rather than goals prescribed by a caregiver. Measures consisted of health behavior, status, and utility. Results showed that participants had fewer functional limitations six months after the intervention, along with less fatigue and decreased anxiety about their health care.

Chodosh et al. (2005) attempted to measure the effect of self-management on patients suffering from hypertension. Their findings revealed that it was unclear what exactly constituted self-management, making it difficult to measure effectively whether self-management had any real impact on care—though blood pressure levels did drop among participants.

How It Was Revised

Over the years the concept was incorporated by various care providers across diverse disciplines, acquiring multiple and often vague meanings, and eventually losing a clear, consistent definition. In short, self-management came to apply to virtually any situation in which a patient took over the day-to-day operations of administering self-care for chronic conditions.

Defining Characteristics and Attributes

Characteristics

The defining characteristics of behavioral self-management are that the patient is in control of the process of assigning targeted goals and of overseeing implementation. The patient manages the process by assuming responsibility and accountability—that is, keeping accurate records of the care process's progression. A degree of collaboration exists between the patient and the provider, but the primary decision maker in terms of setting goals is the patient.

Attributes

The defining attributes of behavioral self-management are diverse and vary depending on the patient and the type of problem being addressed. They may include any of the following (Green, 2014):

Proactive lifestyle. This includes any behaviors the patient proactively engages in to support physical and mental health—diet, exercise, recreation, and the patient's demonstrated ability to research the illness or health issue and incorporate findings into a proactive lifestyle plan to facilitate full recovery.

Proactive problem-solving management. This includes any management practice designed to address a health problem, such as taking medication or monitoring mood and blood pressure.

Proactive collaboration. This attribute encompasses any support person or group the patient utilizes who takes a vested interest in providing support and assumes a degree of responsibility for the patient—checking on the patient, offering expert advice, and so on.

Proactive mental support. This includes behaviors the patient undertakes to develop a healthy mental status: demonstrating awareness, the ability to monitor oneself, the ability to recognize and resist risky situations, and the ability to plan and prepare.

Proactive planning. This attribute is defined by the ability to identify and pursue the goals of the intervention.

Dynamic management. This attribute follows review of the process and includes revision of approach when necessary.

Reactive management. This attribute facilitates the flexible management the patient displays in response to changing conditions.