Research Article: Patient factors that influence clinicians’ decision making in self-management support: A clinical vignette study

Date Published: February 6, 2017

Publisher: Public Library of Science

Author(s): Irene D. Bos-Touwen, Jaap C. A. Trappenburg, Ineke van der Wulp, Marieke J. Schuurmans, Niek J. de Wit, Monika R. Asnani.


Self-management support is an integral part of current chronic care guidelines. The success of self-management interventions varies between individual patients, suggesting a need for tailored self-management support. Understanding the role of patient factors in the current decision making of health professionals can support future tailoring of self-management interventions. The aim of this study is to identify the relative importance of patient factors in health professionals’ decision making regarding self-management support.

A factorial survey was presented to primary care physicians and nurses. The survey consisted of clinical vignettes (case descriptions), in which 11 patient factors were systematically varied. Each care provider received a set of 12 vignettes. For each vignette, they decided whether they would give this patient self-management support and whether they expected this support to be successful. The associations between respondent decisions and patient factors were explored using ordered logit regression.

The survey was completed by 60 general practitioners and 80 nurses. Self-management support was unlikely to be provided in a third of the vignettes. The most important patient factor in the decision to provide self-management support as well as in the expectation that self-management support would be successful was motivation, followed by patient-provider relationship and illness perception. Other factors, such as depression or anxiety, education level, self-efficacy and social support, had a small impact on decisions. Disease, disease severity, knowledge of disease, and age were relatively unimportant factors.

This is the first study to explore the relative importance of patient factors in decision making and the expectations regarding the provision of self-management support to chronic disease patients. By far, the most important factor considered was patient’s motivation; unmotivated patients were less likely to receive self-management support. Future tailored interventions should incorporate strategies to enhance motivation in unmotivated patients. Furthermore, care providers should be better equipped to promote motivational change in their patients.

Partial Text

In the Netherlands, a third of the older population has one or more chronic diseases [1]. Adequate self-management behaviour may be advantageous for individuals living with chronic disease [2]. In the guidelines for many chronic diseases, self-management support is included to help the patient “manage the symptoms, treatment, physical and psychosocial consequences and lifestyle changes inherent to living with a chronic condition” [3]. Chronic care is increasingly embedded in primary care. In addition, in the past decade, care provision has shifted from the general practitioner (GP) to the practice nurse (PN), especially for type 2 diabetes, chronic obstructive pulmonary disease (COPD) and cardiovascular disease [4].

Of the 230 health care providers approached, 161 agreed to participate (response rate of 70.0%). Of the 1932 vignettes that were presented, 1762 were completed (91.2%), and 21 (13%) of 161 respondents had incomplete data. Respondents with missing values and those without missing values did not differ in terms of profession, practice type, gender, age, work experience or in their perceptions (role, aim and importance) of self-management.

This study found that in both types of care providers, motivation was the most important factor in deciding to provide self-management support and in expecting self-management support to be successful. For GPs, illness perception was the next most important factor, and for PNs, the patient-provider relationship was the next most important. All other factors played either a minor or no role in providers’ decision to provide self-management support. Furthermore, this study showed that it was unlikely that self-management support would be provided in every patient, meaning that not every patient was considered suitable for self-management and that certain patients would not receive self-management support.

This study shows that patient factors play a role in the decision to provide self-management support, as in 30% of the presented cases, self-management support was unlikely to be provided. By far, the most important factor was motivation in both the likelihood of providing self-management as well as in expecting that self-management support would be successful for a patient. Unmotivated patients were less likely to receive self-management support. Future tailored interventions should incorporate strategies that enhance motivation in unmotivated patients. Furthermore, care providers need more insight into what causes a patient to be unmotivated, what other factors play a role and how to increase motivation. Increasing providers’ motivational interviewing skills could be a strategy to improve their ability to stimulate motivational change. Few differences between GPs and PNs were observed, although GPs placed more importance on illness perception and PNs on the patient-provider relationship. Scientific efforts are needed to evaluate whether this is caused by differences in roles or (vocational) training. All other factors played a minor or even no role in self-management support. The three patient factors that were the most important are all factors that can be influenced by care providers by increasing their awareness, communication skills and probably consultation time.




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