self-care theories and concepts

Self-Care theories and concepts

Which terms /concepts do you know related to self-care?

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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

Self-Care and psychology: counselling, beliefs,

barriers for self care

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)

Conceptual Framework of Orem’s Theory

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






2008)

Grand theory

Middle range 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






2008)

Grand theory

Middle range theory


Middle Range Theory of Self-Care

of Chronic Illness

Riegel, Jaarsma, Strömberg, 2012

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


OTHER THEORIES OF SELF-

CARE AND SELF-

MANAGEMENT

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

Self and Family Management Framework

Grey et al, 2006

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


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).


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


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


IllnessThose behaviors used

by patients with a

chronic illness to


emotional stability

The process of



symptoms


and symptoms when

they occur


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.


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.


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


DISCUSSION

HOW DO THESE CONCEPTS OF SELF-CARE

MAINTENANCE, SELF-CARE MONITORING, AND

SELF-CARE MANAGEMENT APPLY TO YOUR

PATIENT POPULATION?


Illness



Illness

Those behaviors used by

patients with a chronic

illness to maintain

physical and emotional

stability


Middle Range Theory of Self-Care: Heart

failure


Medication adherence

Flu shot

Exercise

Middle Range Theory of Self-Care: Surgery

Nutrition

Dental care

Skin care

Smoking cessation



Illness

The process of



symptoms

Riegel, Jaarsma, Strömberg, 2012, in press


Failure

Monitor weight

Monitor symptoms

Heart rate



Pain

Signs of infection

Fatigue

Sleep problems

Anxiety

GI problems

Bladder problems

Nausea and appetite


Middle Range Theory of Self-Care in chronic

illness


and symptoms when

they occur

Riegel, Jaarsma, Strömberg, 2012,

Change diuretics

Call doctor/nurse



failure

---

Medication

Plan rest and mobility

Hydration

Adjust diet, supplements

Wound care

Relaxation

Seek support

Contact healthcare providers




Illness

Those behaviors used

by patients with a

chronic illness to


emotional stability

The process of



symptoms


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

Brynja Ingadottir

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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