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An Update on the State of the Science One Decade Later

Riegel, Barbara PhD, RN, FAAN; Moser, Debra K. PhD, RN, FAAN

doi: 10.1097/JCN.0000000000000517

Barbara Riegel, PhD, RN, FAAN Edith Clemmer Steinbright Professor of Gerontology, School of Nursing, University of Pennsylvania, Philadelphia.

Debra K. Moser, PhD, RN, FAAN Professor and Linda C. Gill Chair of Cardiovascular Nursing, University of Kentucky, Lexington.

The authors have no funding or conflicts of interest to disclose.

Correspondence Barbara Riegel, PhD, RN, FAAN, School of Nursing, University of Pennsylvania, 418 Curie Blvd, Philadelphia, PA 19104–4217 (

“Effective health care depends on self-care; this fact is heralded as a discovery…” Ivan Illich

“Caring for myself is not self-indulgence, it is self-preservation, and that is an act of political warfare.” Audre Lorde

Healthcare providers, administrators, and policy makers do not usually view self-care with the passion reflected in these quotes by philosopher and life-long critic of Western institutions, Ivan Illich, or former New York poet laureate, feminist, and civil rights activist, Audre Lorde. Perhaps they should, given how fundamental self-care is to the maintenance of health and the management of chronic illnesses.1,2 Indeed, many researchers and clinicians believe that optimizing the self-care abilities of individuals at risk for, or with, cardiovascular disease could have a more profound effect on reducing preventable disease, hospitalization, and mortality than emphasizing optimal drug therapy alone.

The World Health Organization defines self-care as “activities individuals, families, and communities undertake with the intention of enhancing health, preventing disease, limiting illness, and restoring health … these self-care activities are derived from the pool of both professional and lay experiences, knowledge and skills … they are undertaken by lay people on their own behalf, either separately or in participative collaboration with professionals.”2 Among patients with cardiovascular disease, this often translates into the need to follow a specific diet, manage stress, maintain a healthy body weight, take all medications as prescribed, monitor for and act upon escalating symptoms, manage other co-morbid conditions, maintain functional capacity by exercising, perform preventative activities such obtaining immunizations, stop smoking and avoid secondhand smoke, control alcohol intake, and traverse the complex healthcare system. To effectively do all of this requires patients to acquire the appropriate self-care knowledge, skills, motivation, and confidence to engage in these activities routinely. In addition, they need to engage in these activities while contending with multiple barriers (eg, impaired cognitive function, impaired functional ability, impaired sensory function, depression, poor health literacy, and limited economic and social resources) to their success.

Given the apparent importance of self-care, and the activities and skills required of patients it seems clear that teaching and supporting self-care should be a major activity in our healthcare system. The Journal of Cardiovascular Nursing (JCN) has consistently stressed the importance of self-care over the years, with the first commentary emphasizing self-care written by Herbert Benson in 1996.3 In that commentary, Benson bemoaned the devaluing of self-care in the process of healing, advocating that clinicians embrace self-care on an equal basis with pharmaceuticals and surgery.

After this early commentary, we published 2 insightful articles describing the current evidence related to adherence and self-care maintenance behaviors among heart failure patients4 and the ability of healthcare providers to support patients in performing self-care.5 In describing interventions developed and tested to enhance self-care in the heart failure population, Evangelista and Shinnick4 argued that effective interventions must integrate strategies that motivate, empower, and encourage patients to make informed decisions and assume responsibility for self-care. However, Albert5 noted at approximately the same time that that there was little evidence that providers had acquired sufficient knowledge of self-care principles to effectively help patients reach their self-care goals with education and outcomes monitoring.

In just a single decade, the picture has changed drastically! In 2008, we published an editorial summarizing the state of the science of heart failure self-care, noting that the number of articles on self-care was growing exponentially.6 In the ensuing decade, we have seen continuing growth in submissions to JCN related to self-care. In that decade, we have published on both theory7,8 and the measurement of self-care.9–18 A trend in submissions to JCN has been descriptions of self-care in a wide variety of special populations.19–26 Authors have described the factors associated with self-care, including ethnicity,27 culture,28 living arrangements,29 sleep,30 depressive symptoms,27,31,32 health literacy,33,34 comorbid conditions,27 cognition,35–37 and social support.38–41 Confidence has been shown repeatedly to be a major factor influencing self-care.34,39,42,43

A systematic review of intervention approaches by Harkness and colleagues44 found that both perception- and action-based strategies effectively improved self-care. Consistent with these categories, the interventions published in JCN have addressed skill building,45 education,46,47 family involvement,43,48 motivational interviewing,49,50 and patient activation.51 In recent years, we have published several technology-based approaches to improving self-care.52–57 Exciting areas of development in self-care include attention to caregivers who promote self-care of patients.12,40,41,43,58

A notable failure of recent randomized controlled trials of cardiac self-care interventions has highlighted the need to better understand the intricacies of self-care.59–61 Several JCN authors have delved into the process of self-care with articles on self-care decision-making,62 symptom monitoring,63 symptom perception,64,65 and hypothetical cardioprotective mechanisms by which self-care could influence outcomes.66 Lee and colleagues67 subsequently contributed to validation of this theory, demonstrating that better self-care management was associated with reduced odds of myocardial stress and systemic inflammation over and above pharmacological therapy and other common confounding factors.

Self-care has been shown to improve thoracic impedance,68 hospitalization,31,63 quality of life,42,69,70 and survival.71 Others have noted that patterns of self-care are related to outcomes. Specifically, in a study by Vellone and colleagues,72 patients who were consistently high in treatment adherence and consulting behaviors were less clinically compromised, had the best quality of life, and had the lowest hospitalization rates. Patients low in adherence and in consulting behaviors were more clinically compromised and had worse mental quality of life. Outcomes were variable in those with inconsistent adherence patterns depending on whether consulting behaviors were high or low, demonstrating the importance of both elements of the pattern.

At all levels, and in all its manifestations, cardiovascular disease requires extensive and effective engagement in self-care to achieve optimal outcomes. Unfortunately, healthcare providers still do not emphasized self-care and most patients do not perform self-care behaviors well.73–80 It is not enough to say “follow this, do that” and it is not enough to just ask about activities performed. In spite of the early call by Benson3 to integrate self-care with pharmaceutical and surgical therapies, patients and providers still believe that pharmacologic interventions are more effective than lifestyle change.81,82 More research is needed if we are to unequivocally demonstrate that self-care is as effective as the therapies focused on in clinical guidelines. With this goal in mind, the Journal of Cardiovascular Nursing will continue to publish high quality research on the topic of self-care. We encourage researchers to join the movement to demonstrate the power of self-care to improve outcomes of patients with cardiovascular disease.

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