Diabetes mellitus constitutes a serious public health problem. The prevalence of diabetes mellitus is increasing . The total number of people with diabetes is expected to increase from 171 million in 2000 to 366 million in 2030 . The most significant demographic change of diabetes prevalence world-wide appears to be the increase in the proportion of people older than 65 years . In the Netherlands, type 2 diabetes accounts for about 90% of all diabetes cases .
Western countries should establish a health-care system that meets the needs of the population . Shared-care is an approach to provide needs-based care for chronically ill people . In the Netherlands, several types of shared-care models have been implemented  in order to treat people with diabetes. In the Maastricht shared-care model, diabetes patients have been allocated to three types of care pathways: (a) patients with complicated health problems that may require radical medical decisions are referred to a medical specialist; (b) general practitioners provide basic care for the less complex cases and home health-care nurses provide the essential daily diabetes care; and (c) the diabetes specialist nurse (DSNs) has an intermediate position between the medical specialist and the general practitioner. DSNs work independently with their patients and are responsible for the care of the ones whose health status is stable but complex . These patients require medium-intensity care . DSNs function in both hospitals and primary care settings. This nurse-led, shared-care programme consists of a diabetes outpatient department at Maastricht University Hospital and specialty clinics in general practices. DSNs follow the agreed guidelines and protocols . The tasks of the DSNs are to provide direct patient care, to organize and coordinate care (including medical care) for individual patients, and to provide advice and health education to patients and other care providers . The result is that this particular nurse-led, shared-care setting is characterized by a mix of specific medical care and advanced nursing practice .
One of the goals of nurse-led, shared-care is to encourage people with diabetes to be active participants in their own care [5, 8]. A literature review of the patient's perception of autonomy showed that autonomy has empirically been studied in the hospital, the nursing home, and home health care, but not in this particular setting . Specifically, people with type 2 diabetes are required to manage many aspects of diabetes themselves on a life-long basis. The responsibility for day-to-day disease management shifts from health-care professionals to the individual . Self-management places a large burden on patients . It is a complex task involving diet, skin care, medication and insulin administration, exercise and rest, self-monitoring, and consulting health-care professionals. This requires researchers to take the self-management of chronically ill people into consideration as a general experience in their lives .
Our study is part of an ongoing research project regarding the autonomy of people with type 2 diabetes in a nurse-led, shared-care setting [9, 10, 14]. The long-term purpose of this project is first, to identify what issues need particular attention to foster patient autonomy in diabetes care provided by DSNs and second, to formulate recommendations to promote patient autonomy on the individual as well as policy level. The design of the ongoing research project is qualitative explorative which focuses on patient autonomy as perceived by older adults with type 2 diabetes mellitus. In a previous article we report how people with type 2 diabetes who are being cared for by a DSN in a nurse-led, shared-care unit view autonomy . The core category 'competency in shaping one's life' describes how people with diabetes exercise their autonomy. Competency is the individual repertoire of skills that includes recognizing the possibilities and having the abilities, capacities, and expertise that allow people to shape their own lives. This implies that people with diabetes initiate and complete various daily actions, which are, in fact, dimensions of autonomy. To shape one's life means that a person actively strives towards a form of autonomy that is exactly right for only this particular person. Autonomy is based on characteristics that are unique to this person, and it is flexible with regard to changing health conditions and life situations. Shaping one's life is a construct of joining various dimensions of autonomy. Thus, the combination of the dimensions of autonomy is not fixed, but rather a mix of what seems most appropriate at a given time. We found seven dimensions of autonomy: identification, self-management, welcomed paternalism, self-determination, shared decision-making, planned surveillance, and responsive relationships. Each of the seven dimensions gives a different outline of competency for shaping one's life. In this article we focus on the dimension self-management.
During the interviews and analysis, we became aware of the dynamic character of the seven dimensions of autonomy. Therefore, we investigated the processes that underlie these dimensions. Most of the dimensions are shaped by more than one process, and the analysis provided a vast amount of data. To do justice to our findings, we chose to classify them for presentation. According to Sandelowski , qualitative findings can be grouped along temporal, thematic, event, or subject lines. We have chosen to make a thematic cut since self-management is very important to people with diabetes. In this study we define self-management as encompassing activities pertaining to taking care of one's health and diabetes. Self-management includes skills for activities of daily living (regular foot care) and the instrumental activities of daily living necessary for the treatment regimen (preparing diet meals, contacting the nurse). Self-management also refers to decision-making. Skills for effective self-management activities and deciding on self-management issues are intertwined .
In relation to nursing, Orem  describes three phases of self-care: the investigative, judgmental, and decision-making phases. Price  reports a diabetes self-management model for adults with type 1 diabetes that has two phases. Phase one, which consists of getting regulated, has four stages: trying it out, figuring it out, trial and error, and basic routine. Phase two consists of being regulated, with two substages: basic routine and applies basic routine to new diabetic situations. Ellison and Rayman  describe the experience of self-management of women with type 2 diabetes, who are expert self-managers. They move through three phases: management-as-rules, management-as-work, and management-as-living. Paterson and Thorne  describe the development of self-management expertise of people with type 1 diabetes. The four phases are passive compliance, naïve experimentation, rebellion, and active control. Paterson and Thorne  report how people with type 1 diabetes who are experts make everyday self-care decisions regarding unanticipated blood glucose levels. The five components in both familiar and unfamiliar situations are assessment of risk, comparative analysis, diagnosis, choice of action, and evaluation. Thorne et al.  did a secondary data analysis of how persons with expertise in self-managing type 1 and type 2 diabetes, HIV/AIDS, and multiple sclerosis learn everyday self-management decision-making. The authors identify three phases: assuming control, fine-tuning, and evaluating.
Research has focused mainly on people with type 1 diabetes and women with type 2 diabetes who are expert self-managers. It is less well understood how the "average" older adult person with type 2 diabetes manages diabetes. Additionally, the literature generally focuses on the development of self-management expertise, while we start from the notion of patient autonomy. Therefore, we want to answer the research question: "What are the processes through which older adults self-manage their diabetes in the context of autonomy?". The purpose of this article is to report an empirically grounded conceptualization of self-management in the context of autonomy of people with type 2 diabetes. This research is primarily not about the sufficiency of self-management in terms of outcomes such as well-regulated glycaemia control instead our attention centres on the personal understanding of the self-management of people with diabetes. Nevertheless, medical issues such as good blood results are part of the patient's experience of self-management.