Faculty  of  Medicine  and  Health  Science        

 

 

Self-­‐management  within  a  healthcare  perspective:  What  is  in  the  name?!  

A  concept  analysis  

 

Freya  DE  ZUTTER  

 

Master  thesis  submitted  to      

obtaining  the  degree  of  

Master  of  Science  in  Occupational  Therapy  

 

Promoter:  prof.  dr.  Dominique  Van  de  Velde  

Co-­‐promoter:  prof.  dr.  Patricia  De  Vriendt  

Academic  year:  2016-­‐2017  

MASTER  OF  SCIENCE  IN  OCCUPATIONAL  THERAPY      

Interuniversity  co-­‐operation  with:  

 

UGent,  KU  Leuven,  UHasselt,  UAntwerpen,    

Vives,  HoGent,  Arteveldehogeschool,  AP  Hogeschool  Antwerpen,    

HoWest,  Odisee,  PXL,  Thomas  More  

 

 

   

 

 

 

 

 

 

 

 

Faculty  of  Medicine  and  Health  Science    

 

 

Self-­‐management  within  a  healthcare  perspective:  What  is  in  the  name?!  

A  concept  analysis  

 

Freya  DE  ZUTTER  

 

Master  thesis  submitted  to      

obtaining  the  degree  of  

Master  of  Science  in  Occupational  Therapy  

 

Promoter:  prof.  dr.  Dominique  Van  de  Velde  

Co-­‐promoter:  prof.  dr.  Patricia  De  Vriendt  

Academic  year:  2016-­‐2017  

MASTER  OF  SCIENCE  IN  OCCUPATIONAL  THERAPY    

Interuniversity  master  in  co-­‐operation  with:  

 

UGent,  KU  Leuven,  UHasselt,  UAntwerpen,    

Vives,  HoGent,  Arteveldehogeschool,  AP  Hogeschool  Antwerpen,    

HoWest,  Odisee,  PXL,  Thomas  More  

 

Abstract

Aim This qualitative study sought to explore and provide contextual understanding to

the concept of self-management within healthcare in general.

Background Self-management is not a new concept within healthcare and is often the

subject of effectiveness studies on chronic conditions. Furthermore, self-management is

a part of the suggestive definition to substitute the current WHO-definition of health.

Data sources PubMed, Scopus, and Web of Science

Method The Walker and Avant’s method (2014) was used to create a concept analysis

of self-management. It consists of eight steps: select concept, determine purpose,

identify uses, determine defining attributes, identify model case, identify additional

cases, identify antecedents and consequences, and define empirical referents.

Results Ten attributes, eight antecedents and twelve consequences have arisen from this

concept analysis. Based on these defined properties an operational definition is

compiled.

Discussion A lot of inconsistency in the literature about self-management made it

difficult to include certain elements. Certain elements could be assigned to more than

one step, which is not always possible according to the rules of the utilized method.

Further investigation of the separate elements of the concept is needed to make the

concept more measurable.

Conclusion The results of this study recognized the complexity of the concept, but also

showed the need for further investigation to make the concept more measurable.

Lucidity about the concept will enhance understanding, and will facilitate

implementation into practice.

Keywords Self-management, healthcare, chronic conditions, concept analysis, Walker

and Avant’s method

Number of words master thesis (excluding abstract, table of contents, appendices and

bibliography): 12.064

Samenvatting

Doelstelling Deze kwalitatieve studie tracht contextueel begrip te verwerven wat betreft

zelfmanagement binnen de gezondheidszorg.

Achtergrond Zelfmanagement is geen nieuw concept binnen de gezondheidszorg en is

regelmatig het onderwerp van effectiviteitsstudies omtrent chronische condities.

Bovendien is het concept zelfmanagement een onderdeel van de suggestieve definitie

om de huidige Wereldgezondheidsorganisatie-definitie van gezondheid te vervangen.

Databronnen PubMed, Scopus, and Web of Science

Methode De methode van Walker en Avant (2014) werd gebruikt om de conceptanalyse

van zelfmanagement uit te voeren. Deze methode bestaat uit acht stappen: selecteer

concept, bepaal doel, identificeer gebruik, bepaal attributen, identificeer model casus,

identificeer bijkomende casussen, identificeer antecedenten en gevolgen, en definieer

empirische referenten.

Resultaten Zelfmanagement binnen de gezondheidszorg kan gedefinieerd worden aan

de hand van tien attributen, acht antecedenten en twaalf gevolgen. Op basis van deze

gedefinieerde eigenschappen is een operationele definitie samengesteld.

Discussie De veelvuldige inconsistentie wat betreft zelfmanagement bemoeilijkte het

opnemen van bepaalde elementen in de conceptanalyse. Bepaalde elementen konden

aan meer dan één stap worden toegewezen, wat niet altijd mogelijk wordt geacht

volgens de regels van de gebruikte methode. Verder onderzoek naar de afzonderlijke

elementen van het concept is nodig om het concept meetbaarder te maken.

Conclusie De resultaten van deze studie tonen herkenning voor de complexiteit van het

concept, maar benadrukken eveneens de noodzaak van verder onderzoek om het

concept meetbaar te maken. Verheldering van het concept vergroot het begrip en

faciliteert de implementatie ervan in de praktijk.

Kernwoorden Zelfmanagement, gezondheidszorg, chronische condities,

conceptanalyse, methode van Walker en Avant

Aantal woorden masterproef (exclusief samenvatting, inhoudstafel, bijlagen en

bibliografie): 12.064

Table of contents

1. INTRODUCTION ................................................................................................................ 1

2. METHOD .............................................................................................................................. 7 2.1. EIGHT STEPS OF WALKER & AVANT ............................................................................... 7

3. RESULTS ............................................................................................................................ 13 3.1. STEP 1: SELECT A CONCEPT ........................................................................................... 13 3.2. STEP 2: THE AIM OF THE ANALYSIS ............................................................................... 13 3.3. STEP 3: IDENTIFYING USES OF THE CONCEPT ................................................................ 13 3.4. STEP 4: DEFINING ATTRIBUTES ..................................................................................... 14 3.5. MODEL CASE ................................................................................................................. 24 3.6. ADDITIONAL CASES ....................................................................................................... 25 3.7. ANTECEDENTS AND CONSEQUENCES ............................................................................... 32 3.8. EMPIRICAL REFERENTS ................................................................................................... 34 3.9. SELF-MANAGEMENT: WHAT IS IN THE NAME?! ................................................................ 34

4. DISCUSSION ..................................................................................................................... 37

5. CONCLUSION ................................................................................................................... 44

6. BIBLIOGRAPHY .............................................................................................................. 45

7. APPENDIX ......................................................................................................................... 54 7.1. APPENDIX 1- CONCEPT LIST BASED ON WALKER & AVANT (2014) ............................... 1 7.2. APPENDIX 2 - TOELATING CONSULTATIE EN GEBRUIK VAN INHOUD .............................. 1

List of tables TABLE 1: OVERVIEW OF THE ATTRIBUTES ................................................................................... 14 TABLE 2: OVERVIEW OF THE AVAILABLE DEFINED ATTRIBUTES IN THIS MODEL CASE .............. 24 TABLE 3: OVERVIEW OF THE AVAILABLE DEFINED ATTRIBUTES IN THIS BORDERLINE CASE ..... 26 TABLE 4: OVERVIEW OF THE MISSED DEFINED ATTRIBUTES IN THIS BORDERLINE CASE ............ 26 TABLE 5: OVERVIEW OF THE AVAILABLE DEFINED ATTRIBUTES IN THIS CONTRARY CASE ........ 27 TABLE 6: OVERVIEW OF THE AVAILABLE DEFINED ATTRIBUTES IN THIS INVENTED CASE .......... 31

List of Figures FIGURE 1: EIGHT STEPS OF WALKER & AVANT (2014) ................................................................. 7 FIGURE 2: METHAPHOR USED FOR DESCRIBING THE INVENTED CASE ......................................... 30 FIGURE 3: TRIPTYCH OF SELF-MANAGEMENT CONSISTING OF ANTECEDENTS, ATTRIBUTES AND

CONSEQUENCES ................................................................................................................... 36 FIGURE 4: CLARIFICATION OF THE DEFINED ATTRIBUTES SUMMARIZED IN A SELF-MANAGEMENT

MODEL ................................................................................................................................. 36

Foreword This thesis is the final work to obtain a master degree. For me, this final work was

challenging, because of the theoretical character. It investigates the age-old definition of

health, doubting such a definition creates some resistance.

This master’s thesis contributes to a larger project, called Joint International Project

(JIP), which arose from an ENOTHE-congress. This project enables lecturers, bachelor-

and master students from different countries to string along with the same subject.

Currently the shared subject is about self-management within the international curricula.

Because of a pleasant cooperation, I want to thank all of the students and lectures that

participated in the JIP.

Choosing for this topic delivered me a lot of great opportunities. To prepare for this

research I was allowed to attend the COTEC-ENOTHE joint congress (Galway, June

2016) and the Joint International Project (Nijmegen, October 2016). Joining these

meetings got me inspired and motivated to continue attending some conferences in the

future. Sara Janquart, thank you for being an amazing conference partner. I also need to

thank you for discussing self-management with me, the motivational speeches, collegial

support, and being an awesome friend.

An exceptional thank you to my promoter dr. Van de Velde and my co-promoter dr. De

Vriendt for giving me the chance to co-operate in the Joint International Project,

attending the COTEC-ENOTHE joint congress, helping to demarcate my subject,

giving constructive feedback, and sharing their expertise. I am pleased that both of you

assisted me in this process.

Dear family, dear friends, dear boyfriend, you also deserve some acknowledgement for

the motivational speeches and the patience and for accepting that I would spend a little

less time with you. Special thanks to my boyfriend, for getting indoctrinated by my self-

management theories and especially for motivating me in the exciting challenge of

combining my first work experience with a part of the master’s program.

Last but not least, I am grateful to my brother for creating the visualizations of the

model and metaphor. He converted my sketches into decent digital versions. Without

you, everything was a little more amateurish, thank you for your Photoshop-skills!

Thank you all for believing in me!

Freya De Zutter, august 2017

1

1. Introduction The aim of this study is to analyse the concept of self-management by screening the

current state of the healthcare science literature, in order to create an operational

definition. The content of the healthcare literature has varied throughout the years and

self-management is a concept that has been used more frequently since healthcare

delivery is changing from a biological towards a more bio-psycho-social model. This

change of vocabulary is in line with the changing paradigm and scientific reasoning

about defining health. Throughout the years, health has been a much-debated concept.

The traditional point of view on ‘health’ is perhaps no longer in line with the

contemporary discourse (Van de Velde, Eijkelkamp, Peersman, & De Vriendt, 2016).

Only in 1948 the World Health Organization (WHO), which arose as a reaction to the

atrocities of World War II, came out with a definition of the concept ‘health’.

“Health is a state of complete physical, mental and social well-being and not merely the

absence of disease or infirmity.” – (World Health Organization [WHO], 1948).

This definition, despite the global changes in healthcare, has not been changed. As a

result, many critics do not consider this circumscription as adequate, because a number

of critical points give rise to controversy. Firstly, the above definition states that one can

only be healthy if he is in a ‘complete’ state of physical, mental and social wellbeing.

Starting from that assumption, people with a long-term condition are persistently

unhealthy. This ‘complete’ state cannot be measured and therefore is not operational

(Huber et al., 2011; Huber, Vliet, & Boers, 2016). Unfortunately experiencing a

complete state of wellbeing is a utopia. Already in 1979, Garner states that “since this

definition 99% of world’s population must be in need of care and attention” (Garner,

1979, p.14). That ‘complete state’ has been seen as abstract and oversimplifying, what

seems to be an ultimate purpose more than a guideline.

Moreover, it underestimates the human capacity of individuals to cope with physical,

mental and social challenges, and to live with chronic conditions. Striving for such a

utopia implicitly encourages medicalization of our society, which sustains medical

technology and drug industries. Thus, abnormalities are detected at levels that do not

2

cause diseases and drugs that are produced for conditions that are not defined as health

problems. In consequence, an inquiry about the value of the WHO-definition of health

for clients might be useful nowadays (Huber et al., 2011; Huber et al., 2016; Larson,

1999).

Two decades later after Garner, Larson reviewed the literature (1999) and pointed at

multiple criticisms that he had collected over the years. To start with, there is no

consensus on the meaning of wellbeing. Nowhere the meaning of social wellbeing is

described, whether it refers to the environment of society or to the functional status of

the individual. He refers to Pannenborg (1979) who states that both death and disease

must be included in the definition of health. Because of the cultural differences between

health descriptions, the WHO-definition is too expansive. Furthermore, this definition

does not provide gradations in being healthy, whereby there is no explanation of which

states of health are better. Larson (1999) also uses an example of Barenthin (1975) to

show the incompleteness of the definition. The example says that in a fourteen-day

period the average adult experiences about four symptoms, so in that case we are all

sick.

Again, two decades later, the debate is still ongoing. Huber et al. (2011) described that

the nature of disease is shifted from acute to chronic, and argues that the definition of

1948 is not applicable anymore. She proclaims that there is no need for a static

definition, as the current one, but that there is an urgent demand for a dynamic

definition.

As a result of the shortcoming described above, the current definition contains a very

idealistic content and is difficult to complement in the current health system (Huber et

al., 2011). The ongoing definition does not fit in the bio-psycho-social model either

(Van de Velde et al., 2016). In the Netherlands, the need for a reformulation of the

WHO-definition of health is widely supported (Huber et al., 2016). Therefore Huber

and colleagues (2011) moot to focus on health as:

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“the ability to adapt and to self-manage in the face of social, physical and emotional

challenges”. – (Huber et al., 2011).

This suggestion is a result of a two-day international invitational conference that took

place in 2009 in the Netherlands. The WHO is not considering any change of the

definition as long as certain aspects of the concept cannot be measured (Huber et al.,

2011).

This paper aims to further examine a specific part of the suggested definition, namely

self-management. Some signals make us believe that self-management is increasingly

present in our healthcare system. Only by the sheer number of published articles about

self-management interventions for chronic diseases. For example, Jonkman,

Schuurmans, Groenwold, Hoes, & Trappenburg (2016) and Kos et al. (2016) recently

published a randomized controlled trial and a systematic review combined with a meta-

analysis. Despite the numerous publications, there’s still a need for uniformity with

regard to the concept. Jonkman et al. (2016) and Pearce et al. (2016) declare that a lack

of taxonomy and a further subdivision of self-management interrupt the understanding.

Due to the expanding prevalence of chronic conditions, multimorbidity, as well as the

financial pressure on cost-effectiveness of the healthcare services, there is a worldwide

interest in innovation of services. Worldwide, 63% of mortality can be explained by

chronic disease, whereby chronic disease can be seen as the most important cause of

mortality and morbidity (WHO, 2010). The expectation exists that the prevalence of

chronic conditions will further increase in the future. Attributable to the aging of the

population, and to the increasing presence of some diseases (like hypertension, diabetes,

cancer and osteoporosis (Fortin, Hudon, Haggerty, Akker, & Almirall, 2010; Van der

Heyden et al., 2001).

Latest figures from 2008 in Belgium show that 27,6% of the total population had at

least one long-term illness, disorder or disabling condition, which is more than one

quarter. These results were published in the Health Systems in Transition (HiT), which

4

is a country-based report that provides a detailed description of a health system

(Gerkens & Merkur, 2010).

It is complicated to register the precise costs of multimorbidity, but the European Union

Policy Forum communicates that 70-80% of the total healthcare spendings were for the

sake of the chronically ill individuals. For the European Union it amounts to 700 billion

euros. These costs include direct and indirect costs, like productivity loss for employers,

unemployment benefits, increasing risk of poverty etcetera (Paulus, Van den Heede, &

Mertens, 2012). Figures of the UK Department of Health (2005) show that 70-80% of

the chronic diseases can be maintained with self-care.

Lorig & Holman (2003, p.1) support the following statement: “One cannot not

manage”. Besides this, they state that, even if an individual does not actively manage

his disease, it is also a reflection of a personal management style. According to Rintala,

Jaatinen, Paavilainen, & Åstedt-Kurki (2013), individuals always self-manage in their

unique social context. So, the question is not whether individuals manage their chronic

conditions, but rather how they manage it (Bodenheimer, Lorig, Holman, & Grumbach,

2002).

The mandatory reduction of expenditure draws the attention to more effective models of

care and cost-benefit studies. Establishing interventions about self-management appears

to bring some benefits. Such interventions should provide informed and activated

clients. This would give rise to better health outcomes, better quality of life and

thoughtful choices of healthcare services (Packer, 2013; Panagioti et al., 2014). As

stated by Panagiotti et al. (2014) interventions about self-management can reduce

hospitalization and total healthcare utilization.

Unfortunately, there is a lot of ambiguity in defining self-management. In the

randomized controlled trials, as described above, different definitions of the concept

have been used. The results of research can therefore not be compared. However, it is

argued that if an operational definition could be found, measurement purposes, research

and evaluating interventions can be pursued. Measurement might be helpful when

5

constructing health frames that systematise different operational needs (Huber et al.,

2011).

This paper is based on literature from multiple disciplines and is not target-specific,

which can count on an enormous accountability by different disciplines and settings.

However, an occupational perspective is noticeable. There are some points that justify

compelling links between self-management and occupational therapy. Like,

occupational therapists are used to treat individuals with chronic conditions, wherefore

nowadays self-management interventions are being set up (American Occupational

Therapy Association [AOTA], 2014; Centers for Disease Control and Prevention, 2014;

National Institutes of Health [NIH], 2010).

Packer (2013) also claims that an occupational vision on self-management is needed to

rework the concept. Many interventions aim at reducing risk factors etc. (medical

management), but less at acquiring meaningful participation and occupational

engagement (role- and emotional management) (Van Hecke et al., 2017; O’Toole,

Connolly, & Smith, 2012). Nevertheless, a few interventions focus on role- and

emotional management, which have been developed and tested by occupational

therapists. A client-centred approach, which is also based on occupation, delivers new

insights on services and interventions that are necessary for individuals with chronic

conditions (Packer, 2013).

The most fundamental incentive of this research is to eliminate the existing ambiguity

about the concept ‘self-management’, by delineating the concept itself. Thus, it

becomes feasible to define an operational definition of self-management within

healthcare in general.

Throughout this thesis, ‘client’ instead of ‘patient’ is used to appoint the service user.

The term ‘client’ endorses a more empowered view of interaction with their healthcare

services, whereas ‘patient’ refer to an individual who is seeking and/or receiving

healthcare. The meaning of ‘client’ is more suitable with the underlying ideas of self-

6

management. Therefore, ‘client’ is applied. Existing terms like ‘patient education’ were

not adjusted (Christmas & Sweeney, 2016).

7

2. Method A concept analysis, based on the guidelines from Walker & Avant (2014), was

performed to further investigate the concept of self-management. Eight steps were

followed: (1) select a concept; (2) determine the aims or purposes of analysis; (3)

identify all uses of the concept; (4) determine the defining attributes; (5) identify the

model case; (6) identify additional cases; (7) identify antecedents and consequences;

and (8) define empirical referents. These eight steps will be discussed chronically, but in

fact, they are iterative (Walker & Avant, 2014). A concept list is set up to simplify the

readability (Appendix 1). This list includes the explanation of the used terms, according

to Walker & Avant (2014). In this method paragraph, these eight steps will be further

described.

2.1. Eight steps of Walker & Avant

Figure 1: Eight steps of Walker & Avant (2014)

2.1.1. Select a concept

This first step was actually performed before this master-project and derived from a

Joint International Project (JIP) that is called ‘health promotion and self-management’

between partners from HAN University of Applied Sciences (Netherlands), Metropolia

University of Applied Science (Finland), Health University of Applied Sciences

Step  8  Determine  empirical  referents  

Step  7  Identify  antecedents  and  consequences  

Step  6  Identify  additional  cases  

Step  5  Identify  model  case  

Step  4  DeUine  attributes  

Step  3  Identify  uses  of  concept  

Step  2  Determine  aims/purposes  of  analysis  

Step  1  Select  a  concept  

8

(Austria), Ghent University (Belgium), School of Nursing Portuguese Red Cross

Oliveira de Azeméis (Portugal), Artevelde University College Ghent (Belgium),

University College Absalon (Zealand), FH Joanneum University of Applied Science

(Austria), National Sports Academy (Bulgaria), Brunel University London (United

Kingdom), FH Campus Wien University of Applied Science (Austria), Zurich

University of Applied Science (Switzerland), and School of Health Technology Lisbon

(Portugal). Below the logos of the partner institutions are presented (Costa, De Vriendt,

Satink, & Senn, 2016).

The preliminary investigation and expert discussions within this JIP revealed the lack of

clarity about the concept of self-management. Discussions leaded to the need of a

concept analysis. This JIP is a multidisciplinary and international project in which

students, researchers, and lecturers are involved. Some participants from the JIP can be

called experts in self-management, which allows the statement that an expert discussion

preceded the decision to conduct this concept analysis.

According to Walker & Avant (2014), a concept contains the following: “Concepts

contain within themselves the attributes or characteristics that make them unique from

other concepts. Thus, we speak of concepts as containing defining characteristics or

attributes that permit us to decide which phenomena match the concept and which do

not. Concepts are mental constructions.” (p.163).

2.1.2. Determine the aims and purposes of analysis

Well-developed key concepts are an essential prerequisite to build scientific research.

Concepts, such as self-management, are abstract and have an ambiguity of meaning.

Concepts concerning healthcare disciplines are frequently associated with

understanding health and illness experiences. Not taken into account the discipline,

9

concepts are inextricably linked with knowledge development (Walker & Avant, 2014).

As stated by Cronin, Ryan, & Coughlan (2010) “The ultimate goal is to be able to

define abstract concepts so clearly that their true value in respect of any situation or

object could be determined” (p.63). Therefore, the aim of this analysis is previously

determined in the introduction and the title of this study also reveals the aim. “Self-

management within a healthcare perspective: What is in the name?!”, reflects the

purpose to delineate the concept of self-management, causing an elimination of

ambiguity. In other words, this study sought to explore and provide contextual

understanding to the concept of self-management within healthcare.

2.1.3. Identify all uses of the concept

When looking for the Oxford Dictionaries-definition of self-management a relatively

broad definition is found: “Management of or by oneself, taking of responsibility for

one’s own behaviour and well-being” (Oxford Dictionaries, n.d.). Self-management

occurs in multiple professional domains, including different meanings. This concept can

refer to a method, a skill, a strategy, a process and an outcome.

In order to find out the most common uses of the concept, the available healthcare

literature was searched, but also the literature of other professional domains and the

experience of employees within those particular domains were consulted (Walker &

Avant, 2014). Omisakin & Ncama (2011) point out, next to healthcare, the different

fields in which self-management is used: “In the field of computer science, self-

management refers to the process by which pre-programmed computer systems will

(one day) manage their own operation without human intervention” (p. 1734). In terms

of workplace decision-making, self-management can refer to employees agreeing

themselves on choices instead of the supervisor telling workers what to do. Moreover,

self-management appears in fields like business, education, and psychology (Omisakin

& Ncama, 2010). The concept is also known in sports management, human resources,

economics, and organizational management.

Consequently, there are extensive possibilities and contexts in which self-management

can be understood. Therefore, a specific context as to be chosen, and in this thesis the

only focus will be on self-management within healthcare in general. Articles were

10

defined as eligible for inclusion in the concept analysis if they were: (1) healthcare

related (2) written in English or Dutch (3) without any time restriction (4) full text

available. Likewise, effectiveness studies focused on specific target groups or diagnoses

were also included. Articles concerning ‘self-management education’ and ‘self-

management support’ were utilized too, only for the delineation of the concept ‘self-

management’, not for ‘self-management support’ or ‘self-management education’ itself,

because that would interfere the concept analysis.

Articles were selected by the use of databases like PubMed, Scopus, and Web of

Science, using terms like ‘self-management’, ‘management of chronic disease’, and

‘self-management AND healthcare’. Using the snowball method, related concepts were

also acquired. Therefore terms like ‘self-care’, ‘self-efficacy’ and other related concepts

were also applied.

The snowball method was used to complete the data collection process, of which the

process endured from September 2016 until June 2017. The snowball method owes its

name on its remarkable process. When a snowball rolls down a hill, it is accumulating

snow. A comparable phenomenon occurs when the number of sampling size expands

with time (Sedgwick, 2013). This could be named as a non-random sampling method,

whereas a random sampling method was not adequate for this study. Making a list of all

the existing self-management articles would have been irrelevant for the concerning

research question (Sedgwick, 2013). A manual search in reference lists is performed in

order to look for articles, due to the snowball method.

2.1.4. Determine the defining attributes

Step 4 seems to be a very crucial part of the analysis, which is about determining the

defining attributes. This step is seen as the heart of the concept analysis, whereby

gathering of the most frequently associated characteristics constitutes the purpose of the

fourth step (Walker & Avant, 2014). A systematic and purposeful approach was applied

to discover the most defining attributes: (1) reading selected articles; (2) recognizing

characteristics that designate self-management; (3) placing the characteristics of

frequent occurrence into a coding scheme (grouping the characteristics and classifying

under an overall term, which will later form the attribute); (4) making a selection of the

11

frequently used characteristics to describe self-management; (5) discussions with

colleagues who are also familiar with the concept of self-management; (6) by finding

antecedents and consequences, and constructing model case and additional cases, the

attributes can be reordered or changed a last time; (7) a final revision can be done by

comparing frequently used definitions of self-management to the list of defined

attributes.

2.1.5. Identify a model case

To continue the analysis, a model case needs to be identified, which takes place in the

fifth step. The model case represents an example of the use of self-management,

wherein all of the defining attributes, found in the preceding step, are present (Walker &

Avant, 2014). Diagnosis-specific literature is used to gain insight into disease-related

symptoms and self-management literature is consulted to find general difficulties in the

self-managing process, both with the intention to create a veracious model case. Stories

from practice and a portion of creativity helped to establish this model case. In case all

attributes were detected, the case could be considered as a model case.

2.1.6. Identify additional cases

In addition, there is also a need to identify borderline, contrary, and invented cases,

which contribute to include characteristics of interest and exclude the valueless ones.

These additional cases ameliorate the judgements about including and excluding certain

attributes. Depending on the concept, not all cases are necessary to form an image of the

concept (Walker & Avant, 2014).

A similar approach to the model case is utilized to identify additional cases. Diagnosis-

specific literature and self-management literature is also used in the borderline case to

compose a veracious borderline case. The borderline case differs from the model case,

because it does not include all the attributes and/or differ in one of them, such as length

of time or intensity of occurrence (Walker & Avant, 2014). For constructing the

contrary case, an example case of Bodenheimer et al. (2002) was used to find

inspiration regarding weak self-management. This case needs to be a clear example of

what is not reflecting self-management. Moreover, it is opposite to the concept. The

12

invented case does not need to be an idea of own experience, but can be surrealistic

(Walker & Avant, 2014). A metaphor is used to fill in the invented case.

2.1.7. Identify antecedents and consequences

Antecedents describe events or incidents that occur before the occurrence of the

concept, whereas consequences describe events or incidents that occur after the

occurrence of the concept. Theorists can identify underlying assumptions by

discovering antecedents. On the other hand, consequences can determine often-

neglected ideas that may be useful. Searching the literature, incidents or events required

to achieve self-management, are identified as antecedents. Consequences are found in

healthcare literature as the outcomes of self-management, these words are

interchangeable (Walker & Avant, 2014).

2.1.8. Define empirical referents

Ultimately the empirical referents will be determined, which is the final step. According

to the words of Walker and Avant (2014), these are “classes of categories of actual

phenomena that by their existence or presence demonstrate the occurrence of the

concept itself” (p.174). Empirical referents are extremely workable in instrument

development, especially contributing to the content and construct validity in developing

a new instrument. Defining empirical referents requires a profound analysis of the

defined attributes. These empirical referents aim at recognizing ore measuring the

defining attributes, not the entire concept itself (Walker & Avant, 2014). After

following these steps, an operational definition will be obtained at the end of the

concept analysis (Walker & Avant, 2014).

13

3. Results For the clarity of this study, the results are also organized according to Walker and

Avant’s method following eight steps. The main result however starts from step 4:

defining the attributes. As a short introduction the results of steps 1-3 are summarized

briefly here. As indicated above, a concept list can be found in Appendix 1, explaining

the key terms of Walker and Avant’s method. It is advisable to keep the concept list

within reach when reading the results section.

3.1. Step 1: Select a concept The concept being analysed is self-management. The selection of the concept occured in

response to the discussions of the JIP.

3.2. Step 2: The aim of the analysis As described in the method section, the aim of this concept analysis is to investigate the

current state of healthcare science literature in order to develop an accurate conception

of self-management.

3.3. Step 3: Identifying uses of the concept In spite of the fact that self-management occurs in many professions, this work focuses

on self-management specifically within the healthcare context in general. There is no

further specification or demarcation regarding target groups, countries, and different

views on self-management.

The concerned inclusion criteria, described in the method section, facilitated the

decision whether an article may or should not be included in the study. Screening the

titles and abstracts of the accessible articles, as a first criterion, and utilizing the

inclusion- and exclusion criteria, as a second criterion, yielded a select number of

articles. 35 articles were used to describe the attributes of self-management. These

articles can be subdivided into three groups: self-management in general (n=9), self-

management linked to chronic conditions and diseases (n=13) and self-management

diagnosis-specific (n=13). The analysis of these 35 articles is grounded on different

points of views (stakeholders, therapists, clients) and is based on research from different

countries. The average population consists of white middle class. Chronically, from

14

high to low: United States of America (n=14), Canada (n=9), United Kingdom (n=6),

Australia (n=3), the Netherlands (n=2), Sweden (n=2), Iran (n=1), and South Africa

(n=1).

3.4. Step 4: Defining attributes In the following section the different attributes of self-management are listed and are the

result of a thorough and in depth analysis of the literature in search for dspecifications

and clarifications of the concept. For reasons of clarity, these attributes are described

here as stand-alone items, but need to be considered in conjunction with all other

attributes. A total of ten attributes were found and further examined separately (table 1).

The further description of these separate attributes can be found below under the

subtitles per attribute. Table 1: Overview of the attributes

Attribute 1 Responsible client Attribute 2 Informed client Attribute 3 Active client Attribute 4 Autonomous client Attribute 5 Individualized Attribute 6 Partnership client-healthcare provider Attribute 7 Social support Attribute 8 Client’s self-management skills

§ Problem-solving § Decision-making § Utilizing resources § Forming a client-healthcare provider partnership § Taking action § Self-tailoring § Disease-specific self-management skills

Attribute 9 Three domains § Medical management

o Self-monitoring

o Symptom management

§ Role management

§ Emotional management Attribute 10 Lifetime task

15

3.4.1. Attribute 1: Responsible client

Lorig and Holman (2003) state that the client is the only actor within his or her care

process that can be responsible for his or her day-to-day care. The personal

responsibility of the client is also acknowledged by Edworthy (2000), Ellis et al. (2017)

and Lorig et al. (1999). Ellis et al. (2017) named this individual responsibility as ‘self-

governance’ and as a characteristic of a remoralized social citizen. Nevertheless,

Bodenheimer, MacGregor, and Sharifi (2005), delineates self-management as a shared

responsibility for making and carrying out health-related decisions, but the key message

here is that the client must take responsibility for his care-process.

3.4.2. Attribute 2: Informed client

Packer (2011) underlines that knowledge needs to be underset by information,

confidence and support to achieve self-management. Notwithstanding, several authors

are convinced of the importance of the attribute ‘knowledge’ to execute good self-

management (Barlow, Wright, Sheasby, Turner, & Hainsworth, 2002; Clark et al.,

1991; Clement, 1995; Edworthy, 2000; Ellis et al, 2017; Lorig, Sobel, Ritter, Laurent, &

Hobbs, 2001; Lorig et al., 1999; Packer, 2013).

This specific attribute includes obtaining and developing knowledge about the

condition, disease and treatment, namely being informed as a client (Barlow, Turner, &

Wright, 2000; Barlow et al., 2002; Bodenheimer et al., 2005; Clark et al., 1991;

Edworthy, 2000; Lawn, McMillan, Pulvirenti, 2011; Norris, Engelgau, & Narayan,

2001; Pulvirenti, 2011; Richardson et al., 2014; Schulman-Green et al., 2012). It also

includes the understanding of your own life circumstances (Barlow et al., 2002). Being

knowledgeable can be attained through accessing the right resources, community and

support services (Audulv, Packer, Hutchinson, Roger, & Kephart, 2016; Barlow et al.,

2002; Clark, 1991; Lawn et al., 2011; Lorig et al., 1999; Miller, Lasiter, Ellis, &

Buelow, 2015; Panagioti et al., 2014).

3.4.3. Attribute 3: Active client

Even though a client must be responsible and informed, in order to be a good self-

manager, it is also expected that he actively participates in his care process (Audulv,

16

2013; Clement, 1995; Packer, 2013). Within self-management, a client cannot be

passive, because he is in full responsibility (Bodenheimer et al., 2005; Lorig & Holman,

2003). Moreover, self-management indicates increased active patient engagement

wherefore an active attitude regarding their treatment planning and management of

health issues is required (Bodenheimer et al., 2005; Boger et al., 2015; Ellis et al., 2017;

Kitt et al., 2012; Panagioti et al., 2014; Taylor, & Bury, 2007).

Ellis et al. (2017) consider that ‘being pro-active’ can be seen as a characteristic of a

remoralized social citizen, what goes another step further than ‘being active’, given the

preventive nature of the prefix ‘pro’. In addition, Packer (2013) explains that self-

management is gained through conscious and planned engagement.

3.4.4. Attribute 4: Autonomous client

When a client can manage himself, we can expect him to act autonomously. It means a

client can manage his own health issues without direct professional input, what does not

mean that professional help needs to be avoided at all. Rather, the client is designated

on himself first (Omisakin, & Ncama, 2011). Ellis et al. (2017) declare that being

autonomous is a moral obligation of the client towards the society, because autonomous

clients do not use the welfare state inappropriately (Ellis et al., 2017). This proposition

implies the individual responsibility of the client, which was previously mentioned as

one of the attributes. Omisakin and Ncama (2011) describe ‘self-help’ as a way to cope

with adversity. Which refers to ability to care for themselves towards their own health

and wellbeing (Ellis et al., 2017).

3.4.5. Attribute 5: Individualized

Self-management cannot be completed by default, depending on the individual’s ability

self-management will get shape (Barlow et al., 2002; Schulman-Green et al., 2012; van

de Wiel & Weijmar Schultz, 2004; Wilkinson, & Whitehead, 2009). It is an

individualized and personal concern, whereas it is client-driven (Audulv, 2013; Barlow

et al., 2002; Bodenheimer et al., 2005; Clark et al., 1991; Ellis et al., 2017; Miller et al.,

2015; Norris et al., 2001; Packer, 2013; Richardson et al., 2014; Thille, Ward, &

Russell, 2014). The concept ‘self-management’ is based on client perceived problems

and personally perceptions of the client about their condition (Lorig, & Holman, 2003;

17

Thille et al., 2014). Without the individual engagement of the client, self-management

cannot be pursued, which implies the client’s central role (Lawn et al., 2011). This

individual engagement aims to promote health in activities (van Schie et al., 2016).

Furthermore, when a client is a self-managing individual, he necessitates intrinsic

motivation (Barlow et al., 2002; Richard & Shea, 2011; van de Wiel, & Weijmar

Schultz, 2004). Lawn et al. (2011) conclude that the client’s needs, values and priorities

ought to be placed at the heart of healthcare.

3.4.6. Attribute 6: Partnership client-healthcare provider

Bodenheimer et al. (2002) state that there has been a shift from traditional care to

collaborative care. Traditional care refers to professionals seen as experts who tell

clients what to do, and in this case, clients are passive. In collaborative care, there is a

shared expertise. The partnership between the client and the healthcare provider

declares that professionals are experts about the disease and clients are experts about

their lives. This sentence briefly describes where this attribute is all about (Bodenheimer

et al., 2002). An advantage of this way of thinking is that the client receives feedback

from the healthcare provider, which allows him to continue his care process (Alderson,

Starr, Gow, & Moreland, 1999).

When a client is a self-managing individual, this implies collaboration and guidance of

physicians and other healthcare providers (Barlow et al., 2002; Bodenheimer et al.,

2005; Clark et al., 1991; Lawn et al., 2011; Lorig et al., 2001; Richard, & Shea, 2011;

Schulman-Green et al., 2012: Thille et al., 2014). This means that a client-provider

partnership has to be built up, in which the client and the provider occupy an equal

position and co-operatively work together (Bodenheimer et al., 2005; Edworthy, 2000;

Lorig, & Holman, 2002; Miller et al., 2015; Packer, 2013; Panagioti et al., 2014). This

also means that the client needs to know when to report changes to his healthcare

provider. Communication strategies (e.g. being assertive) are required to allow

appropriate interaction between the provider and the client (Barlow et al., 2000; Barlow

et al., 2002; Bayliss, Ellis, & Steiner, 2007; Clark et al., 1991). Positive reinforcement

in response of the client his care question is essential (Edworthy, 2000).

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3.4.7. Attribute 7: Social support

A surrounding environment is important, despite of the requirement for a self-managing

client to act autonomously and to be responsible for his own care process. Such a

surrounding environment is enabled through family support, the relationship with peers

family and significant others (Barlow et al., 2002; Clark et al., 1991; Richard & Shea,

2011, Schulman-Green, 2012). These significant others refer to the entire self-

management support systems, which can consist of his family, friends, voluntary

groups, but also health professionals (Audulv, 2013). Miller et al. (2015) describe this

as the healthcare and social community environment. The role of the health

professionals is discussed in the previous attribute (partnership client-healthcare

provider). In order to strengthen the necessary relationships the client must

communicate with his family and with his environment in general (Audulv, 2013;

Barlow et al., 2000; Miller et al., 2015).

Noteworthy, Ellis et al. (2017) regret that self-managing finds its origin in the

individualistic behavioural change approaches. Herewith the importance of social

support is disregarded. Ellis et al. (2017) want to emphasize the importance of

combining individual responsibility and social support. Alongside of self-reliance,

family and community reliance is necessary to fulfil a self-managing attitude (Omisakin

& Ncama, 2011). The need of social support is recognized by Alderson et al. (1999),

Barlow et al. (2002), Raymond, Levasseur, Chouinard, Mathieu, & Gagnon (2016).

Audulv (2013) clearly summarizes this attribute with the following citation:

“Individuals always self-manage in their unique social context” (p.2).

3.4.8. Attribute 8: Client’s self-management skills

Some skills are returning in multiple articles when it comes to self-management,

regardless of the type of the condition.

a. Problem-solving

The problem-solving ability of an individual is regularly discussed when self-

management skills are explored (Barlow et al., 2002; Bodenheimer et al., 2002; Lorig &

Holman, 2003; Omisakin & Ncama, 2011; Packer, 2011; Packer, 2013). It consists of

problem definition, generation of possible solutions, solution implementation, and

evaluation of results. This skill does not have the intention to dictate some solutions for

19

specific problem, rather learning skills to deploy them. Following Lorig and Holman

(2003) the concept itself is problem-based, more specifically based on client perceived

problems.

b. Decision-making

Decision-making is the second recognized skill of self-management (Barlow et al.,

2002; Lorig & Holman, 2003). This skill is related to the attribute ‘informed client’,

because it is needed to make informed choices (Alderson et al., 1999; Ellis et al., 2017).

On the other hand, this skill can be linked to partnership client-healthcare provider,

because self-management contains collaborative decision-making (Bodenheimer et al.,

2005; Lawn et al., 2011).

c. Utilizing resources

Having access to the right resources makes reference to the attribute ‘informed client’.

Utilizing resources is aimed at learning how to find and use the right resources (Lawn et

al., 2011). Resources could include websites, libraries, community agencies et cetera

(Thille, Ward, & Russell, 2014).

d. Forming a client-healthcare provider partnership

This part of self-management was already offered as a separate attribute. Several

authors described the importance of this partnership as an independent attribute of self-

management. Notwithstanding, a few authors consider this partnership to be one of the

self-management skills (Corbin & Strauss, 1988; Lorig & Holman, 2003).

e. Taking action

The fifth self-management skill is action-planning, which is based on making a short-

term action plan and implementing it. The need to recognize ‘taking action’ as a self-

management skill, is supported by more than one researcher (Barlow et al., 2002; Lorig

& Holman, 2003; Miller et al., 2015; Packer, 2011; Thille et al., 2014). Action-planning

is also related with goal-setting, because individuals need to set up goals before

implementing. Achieving these goals is a yes or no-question (Alderson et al., 1999;

Barlow et al., 2000; Barlow et al., 2002; Norris et al., 2001; Thille et al., 2014).

f. Self-tailoring

Lorig and Holman (2003) describe five core self-management skills, but added another

sixth skill, namely self-tailoring. Self-tailoring compromises the core skills based on

20

personal evaluation of personal needs, instead of an evaluation performed by healthcare

providers (Miller et al., 2015).

g. Disease-specific self-management skills

This subtitle refers to all attributes that can be understood as a disease-specific self-

management skill. These attributes are in some way related to self-management, but

they are not needed to explain self-management in general within a healthcare

perspective. For example, smoking cessation (which is a part of medical management)

can be understood as a self-management skill specifically for individuals with chronic

obstructive pulmonary disease and asthma (Clark et al., 1991).

3.4.9. Attribute 9: Three domains

In this concept analysis, the most recent subdivision of the three domains is utilized:

medical management, role management and emotional management. According to

Lorig and Holman (2003), Corbin & Strauss (1988) subdivided three sets of tasks:

medical management, role management, and emotional management. A lot of

researchers also refer to these three domains, constructed by Corbin and Strauss,

without using the same terms (Bodenheimer et al., 2002; Lorig & Holman, 2003;

Packer, 2013; Raymond et al., 2016).

Paton (1990) reviewed the book of Corbin and Strauss, titled ‘Unending Work and

Care’. She summarized the required kinds of work to manage chronic illness as: illness-

related work, biographical work, and everyday work. This subdivision is equal to the

above-mentioned domains (medical, role, and emotional management). Audulv (2013)

also refers to this subdivision of work, but also mentions commonly used synonyms.

According to Audulv (2013) the illness-related work reflects managing symptoms or

crisis prevention, what is often named illness management. Additionally, he equalizes

managing work or household tasks with everyday life work or role management. At last,

he uses biographical work to reflect managing emotions or identity.

Lorig and Holman (2003) state that Corbin and Strauss (1988) used the terms medical

management and behavioural management as interchangeable. This use of synonyms

can cause confusion, because according to Lorig and Holman (2003) ‘maintaining,

changing, and creating new meaningful behaviours’ is a part of role management.

21

a. Medical management

The first domain includes both very complex and technical tasks (e.g. dialysis at home),

as well as quite simple tasks (e.g. taking medicine) (Audulv, 2013). Certain researchers

stipulate that lifestyle changes must be undertaken to perform medical management

(Omisakin & Ncama, 2011; Barlow et al., 2002). Herewith, they suggest reducing

lifestyle risk factors and promoting health (prevention and early intervention) through

maintaining a therapeutic exercise regimen, adhering to a diet, using an inhaler, taking

medicine and smoking cessation (Clark et al., 1991; Lawn et al., 2011; Lorig &

Holman, 2003; Norris et al., 2001). Organizing, planning a medication administration

schedule and remaining compliant with this schedule are also a part of medical

management (Barlow et al., 2002; Dunbar, Jacobson, & Deaton, 1998; Packer, 2013).

Alongside, self-monitoring and symptom management are required to explain the

medical management (Bodenheimer et al., 2002; Clement, 1995; Packer, 2013; Richard

& Shea, 2011; van Schie et al., 2016).

§ Self-monitoring

Richard and Shea (2011) describe self-monitoring as “monitoring of specific

physiologic parameters or symptoms of a health condition” (p. 258). Certain researchers

underline explicitly the importance of monitoring changes in the health condition

(Bayliss et al., 2007; Dunbar et al., 1998; Norris et al., 2001; Omisakin & Ncama, 2011;

Richardson et al., 2014; Schulman-Green et al., 2012; van Schie et al., 2016). The

concept analysis of self-monitoring, written by Wilde and Garvin (2007), shows that

two components give rise to seek contact with health professionals or for the clients to

take action themselves. First, the individual needs to be aware of bodily symptoms,

sensations, daily activities, and cognitive processes. Second, it implies measurements,

readings, and recordings. This includes, glucometers for diabetes, but also checklists

and diaries. Some authors refer to self-monitoring as recording subjective and objective

measurements. In addition to, it also happens that recorded symptoms were compared

with measurements (Wilde & Garvin, 2007). Edworthy (2000) gives emphasis the

monitoring of the level and the intensity of symptoms (e.g. pain) in combination with

collecting objective data (e.g. blood pressure), while Clark et al. (1991) underscore the

usefulness of physical indicators. Lawn et al. (2011) expanded the list and consider, in

22

addition to the physical functioning, the impact of emotional, occupational and social

functioning as well. The major focus is on measuring, which is not the case with

symptom-management (Wilde & Garvin, 2007). Contrary to the findings of Wilde &

Garvin (2007), that is to say that self-monitoring and symptom management are equal

terms, Barlow et al. (2002) disclose self-monitoring as an element of symptom

management.

§ Symptom management

Symptom management can be seen as “subjective experiences reflecting changes in bio-

psycho-social functioning, sensations, or cognition of an individual” (Dodd et al., 2001,

p.669). In contrast with self-monitoring, symptom management is independent of

measurements. Another striking difference contains that symptom management can be

managed by the healthcare providers (Richard & Shea, 2011). The aim of self-

monitoring is similar to the aim of symptom management, namely controlling the

disease by recognizing and responding to symptoms (Audulv, 2013; Ghahari, & Packer,

2012; Lawn et al., 2011; Panagioti et al., 2014; Raymond et al., 2016; Richard & Shea,

2011) and preventing further illness or accidents (Lorig et al., 2001; Panagioti et al.,

2014).

b. Role management

When a self-managing client assumes the tasks of role management, he is deemed to

maintain, change or create new meaningful behaviours or life roles. This with the

purpose to manage the disease and its associated effects. This kind of management also

includes reviewing the roles of an individual, and afterwards accomplishing the

essential adaptations or changes (Bodenheimer et al., 2002; Bodenheimer et al., 2005;

Edworthy, 2000; Ghahari & Packer, 2012; Lawn et al., 2011; Lorig & Holman, 2003;

Lorig et al., 2001; Miller et al., 2015; Packer, 2011; Raymond et al., 2016). Some

authors define the content of the three domains, but do not use the denomination, like

medical, role and emotional management (Lorig et al., 2001; Richardson et al., 2014;

Thille et al., 2014). The fact that role management indicates behavioural changes, is

confirmed by the individualistic behavioural approaches on which self-management is

based (Ellis et al., 2017).

23

Audulv’s longitudinal qualitative study (2013) suggested that role management also

involves coordination and planning, if everyday activities are no longer self-evident

because of pain, fatigue and reduced mobility, caused by chronic conditions. As stated

by Packer (2013) role management needs to be performed in order to maintain

meaningful participation and occupational engagement.

c. Emotional management

Emotional management represents the ability to deal with emotions (Audulv, 2013),

specifically associated with the chronic disease (Miller et al., 2015). As a consequence

of chronic conditions (Clark et al., 1991; Ghahari & Packer, 2012; Girdler, Boldy,

Dhaliwal, Crowley, & Packer, 2010; Panagioti et al., 2014), individuals need to manage

emotions like uncertainty, anger, depression, stress etcetera (Audulv, 2013; Barlow et

al., 2002; Lawn et al., 2011; Lorig et al., 2001; Richardson et al., 2014). Emotional

management contains the predominantly inner process of reviewing one’s life goals and

identities. How individuals with chronic conditions manage their emotions, can

influence the way they perform their role and medical management (Audulv, 2013). As

specified by Packer (2013), in addition to role management, also emotional

management needs to be performed in order to maintain meaningful participation and

occupational engagement.

3.4.10. Attribute 10: Lifetime task

Lorig and Holman (2003) stipulate that self-management is a lifetime task, especially

for those clients with chronic conditions. These individuals are responsible for their

day-to-day care (Clark et al., 1991; Lorig et al., 1999). This day-to-day care refers to

decisions related to their health (Bodenheimer et al., 2005). According to Audulv

(2013), the most care for chronic conditions is performed in the home situation and

provided by the chronically ill ones. Ghahari & Packer (2012) focus on the management

of symptoms, the emotional consequences and the impact of their chronic conditions,

while exemplifying that self-management is an everyday life task. A few authors are

confirming this (Clement, 1995; Miller et al., 2015; Schulman-Green et al., 2012).

Knowing this, self-management can be understood as a lifetime task.

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3.5. Model case David is 34 years old and is suffering from a specific heart disease since four years.

Thereby, he needed to quit his professional sports career. After an intensive follow-up

during hospitalization (including an open-heart surgery), David was allowed to go back

home. He had difficulties finding his way in a total different lifestyle. He has always

been very busy doing sports, but now he needed to slow down. The fact that he was

diagnosed with a heart disease caused him anxiety, because for that reason he must

reduce his sport activities for the benefit of his own health. Furthermore, he is very

compliant to his medication schedule, and had always had a healthy lifestyle. When he

was dismissed from the hospital, he signed up for a patient education program about

heart diseases. Because of the intensive guidance, offered during hospitalization, he has

been able to build an excellent relationship of confidence with his specialist. Since he

survived the open-heart surgery, his faith in science and medicine was strengthened. His

family, and his wife in particular, are very supportive since he was diagnosed. In his

sports club he made friends, who continue to support him even when he reduced his

sports activities. This very independent young man is used to solve problems when they

occur, makes informed decisions et cetera. The last four years he was struggling with

his inability to cope with his feelings of impotence, now he is no longer allowed to sport

as much as he did four years ago. On the recommendation of his best friend, he decided

to become a board member of his own sports club. By taking that decision, he found joy

again. He reviewed his life roles and found another new meaningful life role, namely

being a board member. Hereby, the feelings of impotence were easier to cope and to

exchange for feelings of joy and pride.

Table 2: Overview of the available defined attributes in this model case

Defining attributes Examples of attributes in the model case

Responsible client

Registration patient education, he is willing to reduce

his sport activities.

Informed client

Active client

Autonomous client

Individualized Self-management is based on client perceived

problems and personally perceptions of the client

about their condition. For David, accepting his

25

diagnose is kind of a mourning experience. The way of

dealing with his diagnose fully depends on David.

Partnership client-healthcare provider Excellent relationship of confidence with his

specialist.

Social support Family and wife in particular, friends.

Client’s self-management skills

§ Problem-solving

§ Decision-making

§ Utilizing resources

§ Forming a client-healthcare provider

partnership

§ Taking action

§ Self-tailoring

§ Disease-specific self-management

skills

He solves problems when they occur, makes informed

decisions et cetera, disease specific skills (reducing

sport activities, maintaining healthy eating habits).

Three domains

§ Medical management

o Self-monitoring

o Symptom management

§ Role management

§ Emotional management

Taking medication, life style changes, eating healthy

and so on (medical management), reviewing life roles

(role management), and dealing with emotions

associated with chronic conditions (emotional

management).

Lifetime task Each day he needs to decide whether he eats healthy or

not, exercise or not, take medications or not, go for a

run or not.

3.6. Additional cases

3.6.1. Borderline case

Thomas is 47 years old and is diagnosed with Chronic Obstructive Pulmonary Disease

(COPD) five years ago. As soon as the diagnose was made, he chose resolutely for a

healthier lifestyle. He quit smoking and got interest in healthy cooking. His old mobile

phone was exchanged for a smartphone, on which he has installed many health- and

fitness apps in the meantime. Friends and family, who are very supportive, know

Thomas is a person who is eager to learn, very aware of his condition and has an

autonomous personality. He is remarkably alert for symptoms that indicate a negative

episode of his chronic disease. The fact that he is self-confident also has some

disavantages. It takes a long time before he consult his physician. Thomas himself does

26

not have a good connection with his personal doctor. His brother tells that Thomas,

since their father's death, has a negative attitude towards caregivers.

Table 3: Overview of the available defined attributes in this borderline case

Defining attributes Examples of the available attributes in the

borderline case

Resposible client

He is very aware of his condition, the fact that he

changed his lifestyle.

Informed client as a result of being eager to learn

Active client installation of health- and fitness apps

Autonomous client Thomas is designated on himself.

Individualized Intrinsic motivation

Social support Friends and family are very supportive

Three domains Medical management: smoking cessation, diet, and

lifestyle changes.

Table 4: Overview of the missed defined attributes in this borderline case

Defining attributes Examples of the missing attributes in the

borderline case

Partnership client-healthcare provider

A good relationship between client and healthcare

provider is lacking.

Client’s self-management skills

Despite knowing which agencies he can provide

him with assistence (Thomas is informed), the

attribute ‘utilizing resources’ is missing.

Three domains Focus on medical management, no attention to role

management and emotional management.

Lifetime task Not described

This case is too much focused on having a striking self-efficacy mechanism and being

very appointed on its own, which is good to achieve self-management, but because of

this other attributes are shifted to the background.

27

3.6.2. Contrary case

Clara is 68 years old and has been referred for treatment due to rheumatism in both

hands. This client refuses to believe in the advantages of treatment, whereby she starts

her treatment with some resistance. She has little insight into her condition and has no

intrinsic motivation to ameliorate. The doctor referred this client to an occupational

therapist to learn some joint-saving techniques. The treating therapist shows which

movements should be avoided, and which alternatives can be offered. In the presence of

the therapist, the client – sometimes reluctantly- performs joint-saving techniques. Once

Clara is home again, without the therapist’s supervision, joint-saving techniques are not

applied, medication is not taken and pain and feelings of impotence increase. During

her first therapy session, she told her occupational therapist: “It came naturally, and it

will leave the same way.” Furthermore she is isolating herself from the outside world.

The contradictions of the attributes we recognize in this case:

Table 5: Overview of the available defined attributes in this contrary case

Defining attributes Examples of oppositions to the defined attributes

Responsible client No efforts to take responsibility

Informed client Restrictedly knowledgeable

28

Active client Client is not actively involved in care process

Autonomous client Client does not act autonomous, because she is

dependent on the therapist. Without supervision, she

does not take into account restrictions and medication

requirements.

Individualized Not individualized, no intrinsic motivation

Partnership client-healthcare provider Imbalance in relationship between therapist and client

Social support Isolation from the outside world

Client’s self-management skills

§ Problem-solving

§ Decision-making

§ Utilizing resources

§ Forming a client-healthcare provider

partnership

§ Taking action

§ Self-tailoring

§ Disease-specific self-management

skills

No specific self-management skill can be recognized

Three domains

§ Medical management

o Self-monitoring

o Symptom management

§ Role management

§ Emotional management

Without supervision, she does not take into account

restrictions and medication requirements.

Lifetime task The client does not experience managing her

conditions as a lifetime task. As soon as she got fired

in the hospital, she stopped her care process.

29

3.6.3. Invented case

During bachelor education, I talked with a woman who was suffering psychiatric issues.

After years of therapy, she found a way to tell how she experienced the therapy. She

saw herself bicycle through the streets, everyday, with her therapist sitting on her

luggage carrier. With this metaphor, she wanted to prove that she had the steering wheel

and made choices on her own. The therapist, who was sitting on the luggage carrier, had

a coaching function and could occasionally give advice. Because the therapist already

had ridden many bumpy roads together with other clients, he knew where to find the

biggest obstacles on the road. Based on this story, I set up a metaphor to describe self-

management. All the defining attributes of self-management are included in this

metaphor.

30

Figure 2: Methaphor used for describing the invented case

31

Underneath you can find a summarization of the attributes displayed in figure 2.

Table 6: Overview of the available defined attributes in this invented case

Defining attributes Used metaphor Short explanation

Responsible client

Steering wheel

The client has the

control over the bicycle,

when he decides to turn

right, that happens too.

Informed client

Active client

Autonomous client

Individualized Bicycle

This bicycle is

individualized for the

client ‘Luca’, which

refers to the

individualized character

of self-management.

Partnership client-healthcare provider Luggage carrier

Because the therapist

drives with de client

everyday, they were

able to form a

partnership.

Social support Encouraging supporters

Encouraging

supporters: This role

can be filled in by

health professionals and

significant others

(family, friends,

voluntary groups etc.)

Client’s self-management skills

§ Problem-solving

§ Decision-making

§ Utilizing resources

§ Forming client-healthcare

provider partnership

§ Taking action

§ Self-tailoring

§ Disease-specific self-management

skills

Bicycle bag

This bag includes all

the necessary skills to

be a self-managing

individual.

Three domains

§ Medical management Three roads

It represents the three

domains (medical

32

o Self-monitoring

o Symptom management

§ Role management

§ Emotional management

management, role

management and

emotional

management).

Lifetime task Stopwatch

It represents the

duration of self-

management, namely it

is a lifetime task.

3.7. Antecedents and consequences

3.7.1. Antecedents

Lorig and Holman (2003) consider self-efficacy to be an antecedent of self-

management. They pronounce that self-efficacy is: “one the possible mechanisms by

which self-management achieves the previously mentioned outcomes” (Lorig &

Holman, 2003, p. 1). Richard and Shea (2011) and Miller et al. (2015) also aknowledge

self-efficacy to be an antecedent. Self-efficacy reflects the development of confidence

to manage the aspects of the three domains (Barlow et al., 2002; Ellis et al., 2017;

Packer, 2013). Bodenheimer et al. (2002) describe self-efficacy as “the confidence that

one can carry out a behaviour necessary to reach a desired goal” (p. 2471). It is about

dealing with chronic conditions and its consequences (Newbould, Taylor, & Bury,

2006; Packer, 2013) and having the confidence that specific behaviour can be

accomplished (Bodenheimer et al., 2005; Edworthy, 2000; Lorig et al., 1999). Self-

reliance is used as a synonym for self-efficacy (Omisakin & Ncama, 2011).

Perceived health status, which is not specified further, also complies with the conditions

of an antecedent of self-management (Richard & Shea, 2011). Mackey, Doody, Werner,

& Fullen (2016) imply that there is an association between health literacy and self-

management skills. Low health literacy would be an implication to poorer self-

management behaviours. Kitt et al. (2012) underlines health literacy to be an antecedent

of self-management. Health literacy is associated with the antecedent ‘disease

knowlegde’, revealed by Miller et al. (2015). Furthermore, social support, health beliefs,

motivation, and coping are also referred to as an antecedent (Miller et al., 2015). These

last consequences were not further defined.

33

3.7.2. Consequences

Having a self-managing attitude towards your own care process results in a variety of

outcomes, including improved health outcomes, reduced mortality, improved functional

ability, improved quality of life, reduced healthcare costs, improved personal

experience, improved social participation, improved functional outcomes,

improvements of health behaviors, improved self-efficacy, treatment adherence, and

reduced healthcare resource utilization (Audulv et al., 2016; Lorig et al., 2001; Miller et

al., 2015; Richard & Shea, 2011). Notwithstanding, self-efficacy is defined as an

antecedent in the above section it could also be considered a consequence. In that mind-

set, specific self-management techniques are taught to increase self-efficacy (Edworthy,

2000).

This multitude of consequences deserves further explanation. Firstly, the consequence

‘improved health outcomes’ (Richard & Shea, 2011) relates to improved ‘perceived

health (psychosocial well-being, perceived stress, and optimal health)’ (Audulv et al.,

2016) and ‘improved health status’ (Lorig et al., 2001). The consequence ‘improved

health outcomes’ is also similar to the consequence ‘disease status/severity (symptom

frequency and severity, number of exacerbations, and physiologic parameters)’ (Miller

et al., 2015). This consequence seems to be a diagnosis-specific consequence of self-

management and therefore, it is probably also related to the consequence ‘disease-

related outcomes’ (Audulv et al., 2016). Warsi, Wang, LaValley, Avorn, & Solomon

(2004) support undertow the assumption that improved healthcare outcomes are

disease-related. The outcomes are less clear in chronic obstructive pulmonary disease or

heart failure, than in individuals with asthma or diabetes (Warsi et al., 2004). These

disease-related outcomes include disease progressions, control of pain, fatigue

symptoms, cognitive symptoms, and depression) (Audulv et al., 2016).

Secondly, Audulv et al. (2016) summarized the occurrence of outcomes described in

self-management literature. Based on this study, the following consequences could be

added to the list: social participation (including activity level, keeping up social

relationships, participation), personal experience (acceptance, positive self-image,

control over negative feelings), functional outcomes (physical, emotional, and social

34

functioning), and quality of life. He also underlines that negative outcomes are

supposed to related to less self-management performance.

Thirdly, based on a before-after cohort study, similar consequences were proposed:

improved health status (health distress, social activity limitation, illness intrusiveness,

fatigue, pain, shortness of breath, depression), improvements in health behaviours

(aerobic exercise, range-of-motion exercise, cognitive symptom management,

communication with physician), improved self-efficacy, and healthcare utilization

(physician visits, emergency department visits, days in hospital) (Lorig et al., 2001). It

is remarkable that Lorig et al. (2001) can find a significant relation between a self-

management program and days in hospital (duration), but not to hospitalizations

(frequency).

3.8. Empirical referents Mostly, the empirical referents correspond with the defining attributes. In other cases,

the concept is highly abstract, which influenced the attributes to be abstract too. In that

case, empirical referents are requisite. On the one hand, in none of the used articles the

empirical referents of self-management were literally named. On the other hand, a few

researchers indirectly wrote about measurements of the attributes of self-management.

For example, self-efficacy can be proposed as an empirical referent, measured by self-

reported questionnaires. “How certain are you that you can reduce your pain a small

amount without taking extra medication?” (p.4), is an example of measuring self-

efficacy. This self-efficacy question can be answered by scaling from 0 to 10. Lorig and

Holman also debated the relation between improvements in healthful behaviors and

improvements in health status (Lorig & Holman, 2003). A qualitative study

demonstrated that participants felt that the impact of the program was the result of an

increased control of their illness, which reinforces the importance of self-efficacy

(Lenker, Lorig, & Gallagher, 1984).

3.9. Self-management: What is in the name?! Sequentially to the eight steps of Walker and Avant (2014), an operational definition is

constructed.

35

“Self-management is the individual (and intrinsically controlled) ability of someone

(who is active, responsible, informed and autonomous) to manage his chronic

condition(s), in conjunction with the social support and in partnership with the

healthcare provider(s), whereby self-management skills (decision-making, problem-

solving…) are necessary to fulfil this lifetime task, consisting of three domains (medical,

role, and emotional management).”

A model is created to outline the above operational definition, which is constructed by

the defining attributes, antecedents, and consequences.

36

Figure 3: Triptych of self-management consisting of antecedents, attributes and consequences

Figure 4: Clarification of the defined attributes summarized in a self-management model

37

4. Discussion As mentioned in the introduction self-management is not a new concept. Nowadays a

lot of research is done about self-management, but it is predominantly based on

different self-management-definitions. This negatively impacts the results, because it is

almost impossible to make a comparison of the results. As soon as the concept is

measurable, a revision of the WHO-definition of health can be considered, because

being measurable is one of the requirements of the WHO to make any reconsideration

(Huber et al., 2016). To get closer to a solution for these problems, this study aimed at

clarifying the meaning of the concept of self-management. By completing this concept

analysis, self-management became a less vague and ambigious concept. Although a lot

of ambiguities are eliminated, certain results need some verification.

First and foremost, the defined attributes need any further discussion. The first attribute

that deserves some clarification is ‘three domains’, because not all of the domains

receive equal attention. Mostly, the attention goes to medical management, rather than

to emotional and role management (Lorig & Holman, 2003; Packer, 2013). Therefore,

Packer (2013) pursued to focus on self-management with a more occupational vision.

Richardson et al. (2014) consider the trend of self-management as empowering clients

to be active and motivated in managing their chronic condition, to be a transition from

medical to behavioural management. This shows the slowly increasing interest in the

other domains. Focusing on these three domains, would fit in the bio-psycho-social

model rather, than in the biomedical paradigm. However, Van de Velde et al. (2016)

underline that the paradigm shift towards a bio-psycho-social model is not reality yet.

Because of the demographic and epidemiological transition, concepts such as self-

management became more widely discussed.

In this research, symptom management and self-monitoring are considered a part of

medical management. Also in this inquiry both symptom management and self-

monitoring are equal elements of self-management, despite Barlow et al. (2002) having

another opinion. Symptom management gives more responsibility to the healthcare

provider, whereas self-monitoring is based on the responsibility of the client.

38

Considering the attribute about partnership a combination of healthcare providers and

the client is necessary to achieve self-management, both terms are equivalent.

A second attribute that requires some clarification is ‘partnership client-healthcare

provider’. Following Lorig and Holman (2003), this element is not a separate attribute

but a part of the attribute ‘client’s self-management skills’. In all the other cases, this

element could be assigned as a separate attribute, namely ‘partnership client-healthcare

provider’. Because of the great interest in this partnership, also a separate attribute was

dedicated.

A third remark concerns self-efficacy, which is one meaningful mechanism of self-

management (Lorig & Holman, 2003). This is also visible through the fact that self-

efficacy is often discussed in this concept analysis. Depending on the author, self-

efficacy is regarded as an attribute, antecedent or consequence. Supplementary Walker

and Avant’s method (2014) suggest that an antecedent or a consequence cannot also be

an attribute at the same time. Based on this concept analysis, self-efficacy can be

considered as a separate concept, which is of course interactive with self-management.

Social support is the fourth point of discussion. Depending on the author this element

can be seen as an attribute or an antecedent. On the one hand, when it is assumed that

social support is an attribute, it encourages the assumption that individuals without or

with a weak social network cannot achieve self-management. Knowing self-

management works through the underlying mechanism of self-efficacy (which contains

social persuasion – following support), underlines the fact that social support can be

regarded as a defined attribute. On the other hand, certain authors speak of social

support as an antecedent. However, social support is an important influencing factor in

the concept of self-management. Because of these different views, both possibilities

were cited in this concept analysis.

Fifthly, concerning the consequences no significant relation between a self-management

program and hospitalizations (frequency) could be found in the before-after cohort

study of Lorig and colleagues (2001), while a significant relation with ‘days in hospital

39

(duration)’ could be established. From my opinion it is quite dangerous to link reduced

healthcare utilization with better self-management, because one of the attributes

‘informed client’ contains ‘accessing the right resources, community and support

services’. More correctly would be if researchers could link good self-management to

‘reduced unnecessary healthcare utilization’, because the attribute ‘informed client’

incites to well-considered and adequate hospitalizations. Further investigation will be

needed to show if a revision of the attribute ‘informed client’ or a review of the

consequence ‘reduced healthcare utilization’ is necessary. The way Miller et al. (2015)

described the consequence ‘healthcare resource use’ can be a broader suggestion,

because it is out of the question to look for declined numbers of healthcare utilization. If

future research shows that self-managing individuals are related to a higher amount of

hospitalisations, then that is a fact. We cannot assume that self-management is linked to

fewer hospitalizations without strong evidence.

Another sixth concern is the consequence ‘improved health outcomes’ (Richard & Shea,

2011) relates to improved ‘perceived health (psychosocial well-being, perceived stress,

and optimal health)’ (Audulv et al., 2016) and ‘improved health status’ (Lorig et al.,

2001). The consequence ‘improved health outcomes’ is also similar to the consequence

‘disease status/severity (symptom frequency and severity, number of exacerbations, and

physiologic parameters)’ (Miller et al., 2015). This consequence seems to be a

diagnosis-specific consequence of self-management and therefore, it is probably also

related to the consequence ‘disease-related outcomes’ (Audulv et al., 2016).

The seventh remark deals again about the consequence. Richard & Shea (2011):

“Researchers noted that the process of visualizing a health-related goal, establishing a

therapeutic regimen, and following and adapting the regimen has intrinsic value for

clients regardless of the effectiveness of the self-management treatment”. Lorig &

Holman (2003): “We assumed that changes in behaviours would be associated with

changes in health status. Much to our surprise, we found that the associations between

improvements in healthful behaviours and improvements in health status were weak to

non-existent. In a qualitative study (Lenker, Lorig, & Gallagher, 1984) conducted to

find an explanation for the improvements in health status, participants suggested that

40

they felt that the impact of the program was due to their feeling more in control of their

illness.”

And eight, empirical referents help to measure if the defined attributes of self-

management are present, while consequences help to investigate effectiveness studies of

self-management. You can ask yourself: “How can we measure the defined attributes of

self-management?” (empirical referents) and “How can we measured the effectiveness

of self-management?” (consequences). Disease status/severity can be seen as one of the

consequences of self-management. It refers to symptom frequency and severity, and

number of exacerbations, which are difficult to standardise and not only dependent of

good self-management. An examination of causality would bring more clarity. By

questioning the subdivision by Walker and Avant’s method, it is hoped to clarify further

research needs to elucidate certain matters before setting up an instrument for self-

management.

Due to the amount of sources referring to self-management linked to chronic condition,

it seems inconceivable to link healthy individuals with self-management. However,

Lorig and Holman (2003, p.1) state, “one cannot not manage”. Thereby implying that

everyone uses a management style, also those who does not suffer a chronic condition.

Furthermore, Richard and Shea (2011) enter into more detail. According to these

authors, self-management can be linked to chronic conditions, whereas self-care can be

linked to either acute and either chronic conditions.

The eight steps of Walker and Avant (2014) were used to formulate an answer to the

research question. This method is one of the available approaches to analyse a concept.

Other concept analyses (e.g. Wilson’s method, Walker and Avant’s method, the hybrid

model of concept analysis, Rodgers’ evolutionary method) were also available, but

found less accessible (Cronin, Ryan, & Coughlan, 2010). A concept analysis may be a

dynamic methodology, and is sensitive to cultural, contextual and societal changes. This

time-dependent methodology can produce different results over a few years.

Nevertheless, this kind of inquiry has its own advantages. The results of following those

eight steps encourage communication. Utilizing defined attributes for theory

41

development and research, will enhance understanding among colleagues and will

enable researchers to construct measurement instruments about the concerning concept

(Walker & Avant, 2014).

One disadvantage of the used non-random sampling method is selection bias, which

means that the included articles were systematically different from the excluded articles.

This could lead to an unrepresentative image of the overall self-management articles

(Sedgwick, 2013). But on the other hand, it facilitates a more targeted way of literature.

The fact that there is been chosen to include all health disciplines, makes this research

more accessible and applicable to multiple disciplines. The accessibility and

applicability are either increased through including articles from different countries,

different views (stakeholders, therapists, clients) and different target groups.

Limitations and recommendations

One of the possible criticisms of the use of self-management includes the fact that self-

management is not geared to the complex care cases. These critics are also right,

because a small proportion of the population with chronic conditions is named as

complex cases of comorbidity and high-risk cases. They cannot appeal on self-

management. Notwithstanding, 70-80% of this population can save itself mainly with

self-care. This means a large majority of this population can be reached with the use of

self-management (interventions). Likewise, it is not true that the complex care cases and

high-risk cases are not benefited with self-management at all. The fact is rather that the

proportion of self-management is simply smaller in those groups (UK Department of

Health, 2005).

Bodenheimer et al. (2002) highlight the difficulty of changing healthcare styles. It takes

a lot of time to implement a new way of thinking within healthcare. This change refers

to the shift from traditional care (passive client, provider is responsible) to collaborative

care (active client, provider and client are responsible). Health economists should verify

if our healthcare organization and financing system are ready for such a trend. Cost-

42

benefit analyses with strong evidence are a necessity. Provided that the concept of self-

management is approached in the same way.

When the suggestive definition (see introduction: “the ability to adapt and to self-

manage in the face of social, physical and emotional challenges” – Huber et al., 2011) is

used, self-management will also bring about consequences at policy level. The

conceptual framework of self-management will then contribute to the fact that someone

will be labelled as ill or healthy. Regarding repayments and sickness insurance, this is

very important.

Because of the increasing amount of individuals with multimorbidity (WHO, 2010),

non-diagnosis-specific research is more appropriate. Nevertheless, much more

diagnosis-specific literature is available. Moreover, multimorbidity also means that the

mutual influence between multiple diseases or disorders should be considered. For that

reason, research about self-management in general should be placed first, before

diagnosis-specific literature. Additionally, this will also improve reliability. Besides,

due to the chronicity of the conditions, growing use of extramural care will be

necessary. A further elaboration of the future organization of primary care is therefore

essential.

The most decisive elements of self-management are meanwhile clear, but mutual

relationships must be elucidated. This relates mainly to the antecedents, consequences

and the specific mechanisms of self-management. In the context of measurability of

self-management, the empirical referents are required. The development of a valid and

reliable measurement instrument of self-management enable researchers to compare

results of effectiveness studies. Nowadays, it is much more difficult to compare

research results, because no golden standard of self-management is available.

The results of this concept analysis offer possibilities for practice, research, and

education. As previously mentioned, the development of a conceptual framework

enhances the understanding between practitioners and researchers. Moreover, it

contributes to the development process of making a valid and reliable measurement

43

instrument of self-management. This concept analysis also has an added value at the

educational level. Pols et al. (2009) support that statement. Because of the rising

medical costs, alternatives to keep the healthcare organized are sought. These

remarkable changes greatly influence the education of healthcare providers. Therefor,

not only clients need to be educated, but also healthcare providers need training in self-

management skills. It means that self-management competencies are required to be a

part of the curricula.

44

5. Conclusion The discussion about the WHO-definition of health has been going on for years. The

delineation of self-management may be a step forward for the reformulation of the

WHO-definition of health. Outwardly, self-management is a container concept, about

which a lot of ambiguity exists. This concept analysis was an attempt to eliminate the

lack of agreement and make the concept more measurable. The results of this concept

analysis have favourable implications for practice, research, and education. On the basis

of the eight steps of Walker and Avant (2014) the following definition of self-

management was set up: “Self-management is the individual (and intrinsically

controlled) ability of someone (who is active, responsible, informed and autonomous) to

manage his chronic condition(s), in conjunction with the social support and in

partnership with the healthcare provider(s), whereby self-management skills (decision-

making, problem-solving…) are necessary to fulfil this lifetime task, consisting of three

domains (medical, role, and emotional management).” This operational definition was

based on the defined attributes: responsible client, informed client, active client,

autonomous client, individualized, partnership client-healthcare provider, social

support, self-management skills, three domains, and lifetime task. Despite the cultural

sensitivity, which plays a major role in defining a concept, and the dynamic character of

a concept analysis, the research question has been answered.

45

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1

7. Appendix

7.1. Appendix 1- Concept list based on Walker & Avant (2014)

Concept Explanation

Concept “Concepts contain within themselves the attributes

or characteristics that make them unique from

other concepts. Thus, we speak of concepts as

containing defining characteristics or attributes

that permit us to decide which phenomena match

the concept and which do not; are mental

constructions.”

Attribute “Characteristics of the concept that appear over

and over again.”

“The defining characteristics, standing alone,

should immediately call the concept to mind.”

Model case “An example of the use of the concept that

demonstrates all the defining attributes of the

concept.”

“The model case should be a pure case of the

concept, a paradigmatic example, or a pure

exemplar.”

Additional case (borderline case, contrary case,

and invented case)

“Cases that are not exactly the same as the concept

of interest but are similar to it or contrary to it in

some ways.”

“This cases help you to decide what ‘counts’ as a

defining attribute for the concept of interest and

what doesn’t count.”

- Borderline case “It contains most of the defining attributes of the

concept being examined but not all of them. It

contains most or even all of the defining

characteristics but differ substantially in one of

them, such as length of time or intensity or

occurrence.”

2

- Contrary case “Clear examples of ‘not’ the concept.”

- Invented case “Contain ideas outside our own experience.”

Antecedents “events or incidents that must occur or be in place

prior to the occurence of the concept.”

Consequences “events or incidents that occur as a result of the

occurence of the concept; the outcomes of the

concept.”

Empirical referents “classes or categories of actual phenomena that by

their existence or presence demonstrate the

occurrence of the concept itself. They are the

means by which you can recognize or measure the

defining characteristics or attributes, not the entire

concept itself.”

1

7.2. Appendix 2 - Toelating consultatie en gebruik van inhoud

“De auteur en de promotor geven de toelating deze masterproef voor consultatie

beschikbaar te stellen en delen ervan te kopiëren voor persoonlijk gebruik. Elk ander

gebruik valt onder de beperkingen van het auteursrecht, in het bijzonder met betrekking

tot de verplichting uitdrukkelijk de bron te vermelden bij het aanhalen van resultaten uit

deze masterproef.”

Datum

(handtekening student) (handtekening promotor)

Freya De Zutter dr. prof. Van de Velde Dominique