Terminology
• Self-care
• Self-care deficits
• Self-management
• Self-care management
• Self-care behaviors
• Self-regulation
• Compliance
• Adherence
• Self-efficacy
• Self-monitoring
• Self-care maintenance
What is Self-Care?
• The predominant form of medical and health care across the
world
• Most individuals spend 1-2 hours/year with a health care
provider
• The other 7,500+ waking hours are spent in self-care
What is Self-Care?
• The World Health Organization defines self-care as “activities
individuals, families, and communities undertake [either
separately or in collaboration with professionals] with the
intention of enhancing health, preventing disease, limiting
illness, and restoring health” (p. 2).
World Health Organization. Health education in self-care: Possibilities
and limitations. Geneva, Switzerland: World Health Organization; 1983.
More Definitions of Self-Care
• A process in which a lay person acts on his/her own behalf in
the promotion of health, disease detection, prevention and
treatment (Levin, 1979; 1983)
• An individual’s behavioral response to illness symptoms and
basic coping strategies and action to maintain health (Dean et
al, 1986)
• A decision-making process; reactive behavioral response to
symptoms of illness and everyday health needs (Haug et al,
1989)
Why focus on Self-Care?
• Increasing number of chronic patients
• Burden to patients and families
• Burden to health care and society
• Changing profile of patients
• Older, comborbid
• Call for autonomy
• Changing profile of health care (providers)
• Multidisciplinary approach
• Call for prevention (primary and secondary)
• Call for efficiency (day surgery)
The changing profile of the patient
• Live longer
• Have more comonbidities
• Try to cope with their illness
• Integrate in dialy life and work
• Organized / Informed
• ’Demand’ for self care / right to self-care
Disciplinary Perspectives on Self-Care
• Medicine: consumer performance of activities traditionally
performed by physicians (e.g., blood glucose testing, BP
measurement)
• Nursing: actions taken in response to the need to maintain life,
to grow and develop, and to cope with the effects of disease or
injury
• Psychology: seeks to understand how people stay healthy, why
they become ill, and how they respond when they get sick
Gantz, 1990
Disciplinary Perspectives on Self-Care
• Health education: Information, knowledge, and motivation
needed to perform healthy behaviors
• Sociology: Environment (society) in which healthy behaviors
can be selected and maintained
• Public Health: Environment conducive to safe living and access
to services that offer protection
• Business, insurance: Product line to reduce health care costs
Gantz, 1990
Characteristics of Self-Care
• Situation and culture specific
• Involves the capacity to act and make choices
• Influenced by knowledge, skills, values, motivation,
locus of control, self-efficacy, etc.
• Focuses on aspects of health care under an
individual’s control
Gantz, 1990; Hoy et al, 2007
Levels of Theory
• Grand theory
• Dorothea Orem’s self-care theory
• Middle-range theory
• Self-care of chronic illness (Riegel, Jaarsma, Strömberg, 2012)
• Situation-specific theory
• Situation-specific theory of heart failure self-care (Riegel & Dickson,
2008)
Grand theory
Middle range theory
Situation specific theory
Orem’s Self-care Deficit Theory
• Based on the concepts of:
• Self-care (the practice of activities that individuals initiate
and perform on their own behalf in maintaining life, health
and well-being.”8, p.117)
• Self-care agency (the individual’s ability to perform self-care
activities)
• Self-care requisites or demands (the actions or measures
used to provide self-care)
• Therapeutic self-care demand (the self care actions to be
performed in order to meet self care requisites)
Orem’s Self-care Deficit Theory
• The central focus of Orem’s Grand Theory of Nursing
• Explains when nursing is needed
• Describes and explains how people can be helped through
nursing
• Results when the self-care agent (patient) can’t meet her/his
self-care needs or perform self-care
• Nursing meets these self-care needs through acting for the
person, guiding, teaching, supporting, manipulating the
environment
Major Strengths and Weaknesses of
Orem’s Self-care Theory?• Strengths
• Focus on the importance of self-care to nurses
• Relevant to nurses in clinical practice in a variety of settings,
including hospitals
• Weaknesses
• Esoteric terms
• Assumes that every patient wants to care for himself/herself
• Difficult to use in community settings with well persons
• Focused on nurses to the exclusion of other professionals
Meleis, 2007
Is Self-care a Term or Concept that is Familiar
in All Populations? • Brazil: Yes, it is familiar.
• Australia: Self-care is a term familiar to health professionals
and perhaps those with a chronic condition who are enrolled in
a disease management program, but not a concept that is
familiar to the wider population.
• Germany: Self-care is not a well know term/concept in the
general population. Maybe some aspects of self-care are
known, but not the concept itself.
• Spain: Not yet, but we an others are trying to introduce this
concept progressively.
• Italy: No, self-care is not a familiar concept in Italy.
Is Self-care a Term or Concept that is Familiar
in All Populations? • Japan: Yes, it is; self-care or self-management is often used.
• Israel: Self-care is a new concept that is not yet too familiar in our population.
• Netherlands: Self-care is a concept that is used by several health care professions (nursing, medicine, physical therapy). It is also used to describe medications that people have to buy for themselves (e.g. over-the-counter medicines).
• Sweden: Self-care is a well-known word, but it has a general meaning, less about disease-specific self-care.
• Taiwan: People don’t think they can do much to change their disease so self-care is not discussed.
• Thailand: Self-care is one of our national health policies. More than 10 years ago self-care was added to the National Health Plan Act.
Levels of Theory
• Grand theory
• Dorothea Orem’s self-care theory
• Middle-range theory
• Self-care of chronic illness (Riegel, Jaarsma, Strömberg, 2012)
• Situation-specific theory
• Situation-specific theory of heart failure self-care (Riegel & Dickson,
2008)
Grand theory
Middle range theory
Situation specific theory
Situation-Specific Theory of
Heart Failure Self-Care
• Self-care is defined as a naturalistic
decision-making process involving the
choice of behaviors that maintain physiologic
stability (maintenance) and the response to
symptoms when they occur (management).
Riegel, et al, 2011
Levels of Theory
• Grand theory
• Dorothea Orem’s self-care theory
• Middle-range theory
• Self-care of chronic illness (Riegel, Jaarsma, Strömberg, 2012)
• Situation-specific theory
• Situation-specific theory of heart failure self-care (Riegel & Dickson,
2008)
Grand theory
Middle range theory
Situation specific theory
Middle Range Theory of Self-Care of Chronic
IllnessThose behaviors used
by patients with a
chronic illness to
maintain physical and
emotional stability
The process of
observing oneself for
changes in signs and
symptoms
The response to signs
and symptoms when
they occur
Riegel, Jaarsma, Strömberg, 2012
Individual and Family Self-Management
Theory• Middle-range theory
• Definition: the purposeful incorporation of health-related
behaviors into an individual or family’s daily functioning
• Self-management is a complex dynamic phenomenon with 3
dimensions: context, process, and outcomes
• Factors in the contextual dimension influence individual and
family engagement in the process of self-management and
directly impact outcomes
• Improvement of individual and family outcomes translate to
improved outcomes for healthcare practitioners and systems
Ryan et al, 2009
Framework for the Study of Self- and Family
Management of Chronic Conditions• Both individuals and families participate in the management of
chronic conditions
• Framework developed to guide research efforts of members of
the Center for Self-Management Interventions at the Yale
School of Nursing
• Risk and protective factors influence individuals’ and families’
abilities to manage chronic illness
• Interventions can address risk and protective factors or focus
on altering self- and family management behaviors with the
goal of improving outcomes
Grey et al, 2006
Differentiating Self-Care from Related
Concepts• Adherence, compliance: The extent to which patients follow the
regimen prescribed by their health care providers.
Osterberg & Blaschke, 2005
Differentiating Self-Care from Related
Concepts• Self-monitoring: “awareness of symptoms or bodily sensations
that is enhanced through periodic measurements, recordings
and observations to provide information for improved self-
management” (Wilde & Garvin, 2007, p.343).
How Does Self-Care Confidence Differ from
Self-Efficacy?• Self-care confidence is confidence in one’s ability to engage in
self-care maintenance and self-care management (Riegel et al,
2009).
• Self-efficacy is confidence in one’s ability to perform a specific
task (Bandura, 1982)
• Self efficacy is the self confidence and persistence one has
while performing a specific action, despite barriers (van der Bijl
& Shortridge-Baggett, 2001)
van der Bijl, J. & Shortridge-Baggett, L.
The theory and measurement of the self-
efficacy construct. Sch. Inq. Nurs. Pract.
15, 189–207 (2001).
Differentiating Self-Care from Related
Concepts: Self-Management• “Self-management refers to the individual’s ability to manage
the symptoms, treatment, physical, and psychosocial consequences and life style changes inherent in living with a chronic condition.
• Efficacious self-management encompasses ability to monitor one’s condition and to effect the cognitive, behavioral and emotional responses necessary to maintain a satisfactory quality of life. Thus, a dynamic and continuous process of self-regulation is established” (Barlow, et al, 2002, p.178).
• “Self-management relates to the tasks that an individual must undertake to live well with one or more chronic conditions. These tasks include gaining confidence to deal with medical management, role management, and emotional management” (Adams, Greiner, Corrigan, 2004, p. 57)
Middle-Range Theory of Self-Care of Chronic
Illness• Self-care is defined as a process of maintaining health through
health promoting practices and managing illness
• Self-care is performed in healthy and diseased states
• Focused on the process of self-care rather than specific
activities
• Goal: to codify the behaviors and processes used by individuals
dealing with a chronic illness diagnosis
• Focused on the individual performing self-care (rather than
nurses)
• Key concepts include self-care maintenance, self-care
monitoring, and self-care management
Riegel, Jaarsma, Strömberg, 2012
Development
• Prior work : own and others
• Discussion among authors
• Refine concepts and propositions of the situation specific theory
on heart failure
• Develop new model
• Major change: self-care monitoring as a bridge between self-
care maintance and self-care management
• Clarify various concepts related to self-care
• Workshop with colleagues to discuss and refine
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Factors Affecting Self-Care
• Experience and skill
• Motivation
• Cultural beliefs and values
• Confidence
• Habits
• Functional and cognitive abilities
• Support from others
• Access to care
Self-Care Maintenance
• In healthy persons:
• Healthy life style
• In chronic illness:
• Behaviors often mirror the recommendations of providers with
smoking cessation, exercise training, diet, coping with stress,
taking medication as prescribed (treatment adherence)
• The activities benefit from reflection about the usefulness
of the behavior, vigilance in performance of the behavior,
and an on-going evaluation of benefits and the effectiveness
of the activities
Self-Care Monitoring
• Routine, vigilant body monitoring, surveillance, or “body listening”
• Weighing, prophylactic dental visits, etc.
• Goal: recognition that a change has occurred
• In chronic illness, monitoring that is systematic and routine produces
the best outcomes:
• Asthma -- monitoring peak flow
• Diabetes -- checking blood sugar
• Heart failure -- weighing daily
• Mental illness -- monitoring emotions
• Criteria for effective self-care monitoring:
1. Clinically significant changes over time in the condition must be possible
2. A method of reliably detecting these changes must exist
3. A reasonable action must be possible in response
Self-Care Management
• Response to changes in physical and emotional signs/symptoms
• Entails treatment implementation and the evaluation of treatment
• Treatments are often specific to the signs and symptoms of a
particular chronic illness:
• Asthma: use a bronchodilator for shortness of breath
• Diabetes: eat for low blood glucose
• Heart failure: take an extra diuretic for shortness of breath
• Self-care management requires attention to the effectiveness of
a treatment to evaluate whether or not that approach should be
tried again in the future
Middle Range Theory of Self-Care of Chronic
IllnessThose behaviors used
by patients with a
chronic illness to
maintain physical and
emotional stability
The process of
observing oneself for
changes in signs and
symptoms
The response to signs
and symptoms when
they occur
Riegel, Jaarsma, Strömberg, 2012
Assumptions: Premises Accepted Without Proof
1. There are differences between general self-care and illness-
specific self-care.
We focus on the self-care that occurs in the context of a chronic
illness.
General self-care is a dynamic, subjective process influenced by
age, gender, culture, education, socioeconomic status, etc.
Self-care that occurs in association with a chronic illness is
circumscribed (restricted within limits)and influenced by others.
Assumptions: Premises Accepted Without Proof
2. Decision making requires the ability to focus attention, to think,
sufficient capacity for working memory and the ability to
understand and weigh information.
1. Self-care for patients with multiple comorbid conditions may
be conflicting when self-care is considered for each illness
separately.
• Self-care is complex for patients trying to incorporate advice from
multiple providers.
Assumptions: Premises Accepted Without Proof
3- Self-care for patients with multiple comorbid conditions may be
conflicting when self-care is considered for each illness separately.
Self-care is complex for patients trying to incorporate advice from
multiple providers.
Propositions of the Middle-Range Theory
of Self-Care of Chronic Illness1. There are core similarities in self-care across different chronic
illnesses
2. Previous experience increases the quality of self-care
3. Self-care that is purposive but unreflective limits mastery of self-care in complex situations
4. Misunderstandings, misconceptions, and lack of knowledge all contribute to insufficient self-care
5. Mastery of self-care maintenance precedes mastery of self-care management
6. Monitoring for changes in signs and symptoms is necessary for self-care management
7. Evidence-based self-care produces better outcomes than self-care that is not evidence-based
Riegel, Jaarsma, Strömberg, 2012
DISCUSSION
HOW DO THESE CONCEPTS OF SELF-CARE
MAINTENANCE, SELF-CARE MONITORING, AND
SELF-CARE MANAGEMENT APPLY TO YOUR
PATIENT POPULATION?
Middle Range Theory of Self-Care of Chronic
Illness
Those behaviors used by
patients with a chronic
illness to maintain
physical and emotional
stability
Riegel, Jaarsma, Strömberg, 2012
Middle Range Theory of Self-Care: Heart
failure
Riegel, Jaarsma, Strömberg, 2012
Medication adherence
Flu shot
Exercise
Middle Range Theory of Self-Care: Surgery
Nutrition
Dental care
Skin care
Smoking cessation
Riegel, Jaarsma, Strömberg, 2012
Middle Range Theory of Self-Care of Chronic
Illness
The process of
observing oneself for
changes in signs and
symptoms
Riegel, Jaarsma, Strömberg, 2012, in press
Middle Range Theory of Self-Care: Heart
Failure
Monitor weight
Monitor symptoms
Heart rate
Riegel, Jaarsma, Strömberg, 2012, in press
Middle Range Theory of Self-Care: Surgery
Pain
Signs of infection
Fatigue
Sleep problems
Anxiety
GI problems
Bladder problems
Nausea and appetite
Riegel, Jaarsma, Strömberg, 2012, in press
Middle Range Theory of Self-Care in chronic
illness
The response to signs
and symptoms when
they occur
Riegel, Jaarsma, Strömberg, 2012,
Change diuretics
Call doctor/nurse
Riegel, Jaarsma, Strömberg, 2012
Middle Range Theory of Self-Care: Heart
failure
---
Medication
Plan rest and mobility
Hydration
Adjust diet, supplements
Wound care
Relaxation
Seek support
Contact healthcare providers
Riegel, Jaarsma, Strömberg, 2012
Middle Range Theory of Self-Care: Surgery
Middle Range Theory of Self-Care of Chronic
Illness
Those behaviors used
by patients with a
chronic illness to
maintain physical and
emotional stability
The process of
observing oneself for
changes in signs and
symptoms
The response to signs
and symptoms when
they occur
Riegel, Jaarsma, Strömberg, 2012,
Self-caremaintenance
Self-care monitoring
Self-care management
Maintenance
LVAD care
• LVAD system operation
– System maintenance
– Secure adequate power
• Percutaneous lead care
– Lead immobilization
– Wound management
Life style
• Hygiene and personal care
• Adhere to medication
• Adaption of physical activity
– Physical exercise
– Restriction from certain activities
– Sexual activity
• Nutrition, diet and alcohol
• Smoking cessation
• Sleep and rest
• Optimization of caregiver wellbeing
Monitoring
• LVAD device/system
• LVAD lead + wound (infection)
• Symptoms and signs
– HF symptoms and signs
– Volume status
– Blood pressure
• Side effects + complications
– Infection
– Bleeding
– Neurologic events
• Psychological distress
• Caregiver burden
Management
• Handling alarms
• Contact the LVAD /HF team
• Adaptation of percutaneous lead + wound management
• Adjustment of medication, rest, and diet
• Coping
Assignment group work
• Work in a group and make a figure of all kinds of related
concepts to self-care: e.g self-care, self-management,
adherence, self-monitoring, self-care confidence etc….
• First brainstorm and search literature about all these terms and
then start relating them in a figure. Draw a figure in powerpoint,
word or on paper….
• We will discuss it in the seminar
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