Secondary Logo

Journal Logo

Self-care

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
DEPARTMENTS: Editorial
Free

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 (briegel@nursing.upenn.edu).

“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.

Back to Top | Article Outline

REFERENCES

1. Riegel B, Moser DK, Anker SD, et al. State of the science: promoting self-care in persons with heart failure: a scientific statement from the American Heart Association. Circulation. 2009;120(12):1141–1163.
2. World Health Organization. Health Education in Self-Care: Possibilities and Limitations. Geneva: World Health Organization; 1983.
3. Benson H. Commentary: self-care, the three-legged stool, and remembered wellness. J Cardiovasc Nurs. 1996;10(3):1–3.
4. Evangelista LS, Shinnick MA. What do we know about adherence and self-care? J Cardiovasc Nurs. 2008;23(3):250–257.
5. Albert NM. Promoting self-care in heart failure: state of clinical practice based on the perspectives of healthcare systems and providers. J Cardiovasc Nurs. 2008;23(3):277–284.
6. Riegel B. Foreword: self-care of heart failure: what is the state of the science? J Cardiovasc Nurs. 2008;23(3):187–189.
7. Riegel B, Dickson VV. A situation-specific theory of heart failure self-care. J Cardiovasc Nurs. 2008;23(3):190–196.
8. Riegel B, Dickson VV, Faulkner KM. The situation-specific theory of heart failure self-care: revised and updated. J Cardiovasc Nurs. 2016;31(3):226–235.
9. Lin CY, Pakpour AH, Broström A, et al. Psychometric properties of the 9-item European heart failure self-care behavior scale using confirmatory factor analysis and Rasch analysis among Iranian patients. J Cardiovasc Nurs. 2018;33(3):281–288.
10. Cameron J, Worrall-Carter L, Driscoll A, Stewart S. Measuring self-care in chronic heart failure: a review of the psychometric properties of clinical instruments. J Cardiovasc Nurs. 2009;24(6):E10–E22.
11. Riegel B, Lee CS, Dickson VV, Carlson B. An update on the self-care of heart failure index. J Cardiovasc Nurs. 2009;24(6):485–497.
12. Vellone E, Riegel B, Cocchieri A, et al. Validity and reliability of the caregiver contribution to self-care of heart failure index. J Cardiovasc Nurs. 2013;28(3):245–255.
13. Han HR, Lee H, Commodore-Mensah Y, Kim M. Development and validation of the hypertension self-care profile: a practical tool to measure hypertension self-care. J Cardiovasc Nurs. 2014;29(3):E11–E20.
14. Han HR, Song HJ, Nguyen T, Kim MT. Measuring self-care in patients with hypertension: a systematic review of literature. J Cardiovasc Nurs. 2014;29(1):55–67.
15. Dickson VV, Lee C, Yehle KS, Abel WM, Riegel B. Psychometric testing of the self-care of hypertension inventory. J Cardiovasc Nurs. 2017;32(5):431–438.
16. Kang X, Dennison Himmelfarb CR, Li Z, Zhang J, Lv R, Guo J. Construct validity of the Chinese version of the Self-care of Heart Failure Index determined using structural equation modeling. J Cardiovasc Nurs. 2015;30(3):222–228.
17. Siabani S, Leeder SR, Davidson PM, et al. Translation and validation of the self-care of heart failure index into Persian. J Cardiovasc Nurs. 2014;29(6):E1–E5.
18. Silveira LCJ, Rabelo-Silva ER, Avila CW, Beltrami Moreira L, Dickson VV, Riegel B. Cross-cultural adaptation of the self-care of hypertension inventory into Brazilian Portuguese. J Cardiovasc Nurs. 2018;33(3):289–295.
19. Macabasco-O'Connell A, Crawford MH, Stotts N, Stewart A, Froelicher ES. Self-care behaviors in indigent patients with heart failure. J Cardiovasc Nurs. 2008;23(3):223–230.
20. Moser DK, Watkins JF. Conceptualizing self-care in heart failure: a life course model of patient characteristics. J Cardiovasc Nurs. 2008;23(3):205–218; quiz 219–220.
21. Song M. Diabetes mellitus and the importance of self-care. J Cardiovasc Nurs. 2010;25(2):93–98.
22. Zambroski C. Self-care at the end of life in patients with heart failure. J Cardiovasc Nurs. 2008;23(3):266–276.
23. Young L, Kupzyk K, Barnason S. The impact of self-management knowledge and support on the relationships among self-efficacy, patient activation, and self-management in rural patients with heart failure. J Cardiovasc Nurs. 2017;32(4):E1–E8.
24. Siabani S, Driscoll T, Davidson PM, Najafi F, Jenkins MC, Leeder SR. Self-care and its predictors in patients with chronic heart failure in Western Iran. J Cardiovasc Nurs. 2016;31(1):22–30.
25. Delgado JM, Ruppar TM. Health literacy in older Latinos with heart failure: a systematic review. J Cardiovasc Nurs. 2017;32(2):125–134.
26. Shin NM, Choi J, Cho I, Park BJ. Self-management program for heart healthy behavior among middle- and old-aged Korean women at risk for metabolic syndrome. J Cardiovasc Nurs. 2017;32(6):E8–E16.
27. Schnell-Hoehn KN, Naimark BJ, Tate RB. Determinants of self-care behaviors in community-dwelling patients with heart failure. J Cardiovasc Nurs. 2009;24(1):40–47.
28. Dickson VV, McCarthy MM, Howe A, Schipper J, Katz SM. Sociocultural influences on heart failure self-care among an ethnic minority black population. J Cardiovasc Nurs. 2013;28(2):111–118.
29. Lee KS, Lennie TA, Yoon JY, Wu JR, Moser DK. Living arrangements modify the relationship between depressive symptoms and self-care in patients with heart failure. J Cardiovasc Nurs. 2017;32(2):171–179.
30. Redeker NS. Sleep disturbance in people with heart failure: implications for self-care. J Cardiovasc Nurs. 2008;23(3):231–238.
31. Xu J, Gallo JJ, Wenzel J, et al. Heart failure rehospitalization and delayed decision making: the impact of self-care and depression. J Cardiovasc Nurs. 2018;33(1):30–39.
32. Auld JP, Mudd JO, Gelow JM, Hiatt SO, Lee CS. Self-care moderates the relationship between symptoms and health-related quality of life in heart failure. J Cardiovasc Nurs. 2018;33(3):217–224.
33. Chen AM, Yehle KS, Plake KS, Murawski MM, Mason HL. Health literacy and self-care of patients with heart failure. J Cardiovasc Nurs. 2011;26(6):446–451.
34. Dennison CR, McEntee ML, Samuel L, et al. Adequate health literacy is associated with higher heart failure knowledge and self-care confidence in hospitalized patients. J Cardiovasc Nurs. 2011;26(5):359–367.
35. Currie K, Rideout A, Lindsay G, Harkness K. The association between mild cognitive impairment and self-care in adults with chronic heart failure: a systematic review and narrative synthesis. J Cardiovasc Nurs. 2015;30(5):382–393.
36. Davis KK, Himmelfarb CR, Szanton SL, Hayat MJ, Allen JK. Predictors of heart failure self-care in patients who screened positive for mild cognitive impairment. J Cardiovasc Nurs. 2015;30(2):152–160.
37. Dolansky MA, Hawkins MAW, Schaefer JT, et al. Cognitive function predicts risk for clinically significant weight gain in adults with heart failure. J Cardiovasc Nurs. 2017;32(6):568–575.
38. Gallagher R, Luttik ML, Jaarsma T. Social support and self-care in heart failure. J Cardiovasc Nurs. 2011;26(6):439–445.
39. Salyer J, Schubert CM, Chiaranai C. Supportive relationships, self-care confidence, and heart failure self-care. J Cardiovasc Nurs. 2012;27(5):384–393.
40. Buck HG, Hupcey J, Wang HL, Fradley M, Donovan KA, Watach A. Heart failure self-care within the context of patient and informal caregiver dyadic engagement: a mixed methods study. J Cardiovasc Nurs. 2018.
41. Shawler C, Edward J, Ling J, Crawford TN, Rayens MK. Impact of mother-daughter relationship on hypertension self-management and quality of life: testing dyadic dynamics using the actor-partner interdependence model. J Cardiovasc Nurs. 2018;33(3):232–238.
42. Buck HG, Lee CS, Moser DK, et al. Relationship between self-care and health-related quality of life in older adults with moderate to advanced heart failure. J Cardiovasc Nurs. 2012;27(1):8–15.
43. Chen Y, Zou H, Zhang Y, Fang W, Fan X. Family caregiver contribution to self-care of heart failure: an application of the information-motivation-behavioral skills model. J Cardiovasc Nurs. 2017;32(6):576–583.
44. Harkness K, Spaling MA, Currie K, Strachan PH, Clark AM. A systematic review of patient heart failure self-care strategies. J Cardiovasc Nurs. 2015;30(2):121–135.
45. Dickson VV, Melkus GD, Dorsen C, Katz S, Riegel B. Improving heart failure self-care through a community-based skill-building intervention: a study protocol. J Cardiovasc Nurs. 2015;30(4 suppl 1):S14–S24.
46. Boyde M, Peters R, Hwang R, Korczyk D, Ha T, New N. The self-care educational intervention for patients with heart failure: a study protocol. J Cardiovasc Nurs. 2017;32(2):165–170.
47. Clark AP, McDougall G, Riegel B, et al. Health status and self-care outcomes after an education-support intervention for people with chronic heart failure. J Cardiovasc Nurs. 2015;30(4 Suppl 1):S3–S13.
48. Dunbar SB, Clark PC, Quinn C, Gary RA, Kaslow NJ. Family influences on heart failure self-care and outcomes. J Cardiovasc Nurs. 2008;23(3):258–265.
49. Paradis V, Cossette S, Frasure-Smith N, Heppell S, Guertin MC. The efficacy of a motivational nursing intervention based on the stages of change on self-care in heart failure patients. J Cardiovasc Nurs. 2010;25(2):130–141.
50. Riegel B, Dickson VV, Hoke L, McMahon JP, Reis BF, Sayers S. A motivational counseling approach to improving heart failure self-care: mechanisms of effectiveness. J Cardiovasc Nurs. 2006;21(3):232–241.
51. Shively MJ, Gardetto NJ, Kodiath MF, et al. Effect of patient activation on self-management in patients with heart failure. J Cardiovasc Nurs. 2013;28(1):20–34.
52. Cajita MI, Hodgson NA, Budhathoki C, Han HR. Intention to use mHealth in older adults with heart failure. J Cardiovasc Nurs. 2017;32(6):E1–E7.
53. Li X, Chen C, Qu MY, et al. Perceptions and acceptability of receiving SMS self-care messages in Chinese patients with heart failure: an inpatient survey. J Cardiovasc Nurs. 2017;32(4):357–364.
54. Palacios J, Lee GA, Duaso M, et al. Internet-delivered self-management support for improving coronary heart disease and self-management-related outcomes: a systematic review. J Cardiovasc Nurs. 2017;32(4):E9–E23.
55. Melin M, Hagglund E, Ullman B, Persson H, Hagerman I. Effects of a tablet computer on self-care, quality of life, and knowledge: a randomized clinical trial. J Cardiovasc Nurs. 2018.
56. Radhakrishnan K, Jacelon C. Impact of telehealth on patient self-management of heart failure: a review of literature. J Cardiovasc Nurs. 2012;27(1):33–43.
57. Evangelista LS, Lee JA, Moore AA, et al. Examining the effects of remote monitoring systems on activation, self-care, and quality of life in older patients with chronic heart failure. J Cardiovasc Nurs. 2015;30(1):51–57.
58. Vellone E. First steps toward a theory of caregiver contribution to self-care in heart failure. J Cardiovasc Nurs. 2017;32(6):584–586.
59. Grady KL, de Leon CF, Kozak AT, et al. Does self-management counseling in patients with heart failure improve quality of life? Findings from the Heart Failure Adherence and Retention Trial (HART). Qual Life Res. 2014;23(1):31–38.
60. Jaarsma T, van der Wal MH, Lesman-Leegte I, et al. Effect of moderate or intensive disease management program on outcome in patients with heart failure: Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure (COACH). Arch Intern Med. 2008;168(3):316–324.
61. Jaarsma T, Lesman-Leegte I, Hillege HL, et al. Depression and the usefulness of a disease management program in heart failure: insights from the COACH (Coordinating study evaluating Outcomes of Advising and Counseling in Heart failure) study. J Am Coll Cardiol. 2010;55(17):1837–1843.
62. Xu J, Abshire M, Han HR. Decision making among persons living with heart failure. J Cardiovasc Nurs. 2016;31(5):E1–E9.
63. Lee KS, Lennie TA, Dunbar SB, et al. The association between regular symptom monitoring and self-care management in patients with heart failure. J Cardiovasc Nurs. 2015;30(2):145–151.
64. Lee S, Riegel B. State of the science in heart failure symptom perception research: an integrative review. J Cardiovasc Nurs. 2018;33(3):204–210.
65. Reeder KM, Ercole PM, Peek GM, Smith CE. Symptom perceptions and self-care behaviors in patients who self-manage heart failure. J Cardiovasc Nurs. 2015;30(1):E1–E7.
66. Lee CS, Tkacs NC, Riegel B. The influence of heart failure self-care on health outcomes: hypothetical cardioprotective mechanisms. J Cardiovasc Nurs. 2009;24(3):179–187; quiz 188–179.
67. Lee CS, Moser DK, Lennie TA, Tkacs NC, Margulies KB, Riegel B. Biomarkers of myocardial stress and systemic inflammation in patients who engage in heart failure self-care management. J Cardiovasc Nurs. 2011;26(4):321–328.
68. Rathman LD, Lee CS, Sarkar S, Small RS. A critical link between heart failure self-care and intrathoracic impedance. J Cardiovasc Nurs. 2011;26(4):E20–E26.
69. Grady KL. Self-care and quality of life outcomes in heart failure patients. J Cardiovasc Nurs. 2008;23(3):285–292.
70. Seto E, Leonard KJ, Cafazzo JA, Masino C, Barnsley J, Ross HJ. Self-care and quality of life of heart failure patients at a multidisciplinary heart function clinic. J Cardiovasc Nurs. 2011;26(5):377–385.
71. Song EK, Moser DK, Kang SM, Lennie TA. Self-reported adherence to a low-sodium diet and health outcomes in patients with heart failure. J Cardiovasc Nurs. 2016;31(6):529–534.
72. Vellone E, Fida R, Ghezzi V, et al. Patterns of self-care in adults with heart failure and their associations with sociodemographic and clinical characteristics, quality of life, and hospitalizations: a cluster analysis. J Cardiovasc Nurs. 2017;32(2):180–189.
73. Cameron J, Worrall-Carter L, Page K, Riegel B, Lo SK, Stewart S. Does cognitive impairment predict poor self-care in patients with heart failure? Eur J Heart Fail. 2010;12(5):508–515.
74. Dickson VV, Buck H, Riegel B. A qualitative meta-analysis of heart failure self-care practices among individuals with multiple comorbid conditions. J Card Fail. 2011;17(5):413–419.
75. Jaarsma T, Stromberg A, Ben Gal T, et al. Comparison of self-care behaviors of heart failure patients in 15 countries worldwide. Patient Educ Couns. 2013;92(1):114–120.
76. Lee CS, Riegel B, Driscoll A, et al. Gender differences in heart failure self-care: a multinational cross-sectional study. Int J Nurs Stud. 2009;46(11):1485–1495.
77. Moser DK, Dickson V, Jaarsma T, Lee C, Stromberg A, Riegel B. Role of self-care in the patient with heart failure. Curr Cardiol Rep. 2012;14(3):265–275.
78. Cameron J, Worrall-Carter L, Riegel B, Lo SK, Stewart S. Testing a model of patient characteristics, psychologic status, and cognitive function as predictors of self-care in persons with chronic heart failure. Heart Lung. 2009;38(5):410–418.
79. Horowitz CR, Rein SB, Leventhal H. A story of maladies, misconceptions and mishaps: effective management of heart failure. Soc Sci Med. 2004;58(3):631–643.
80. Bentley B, De Jong MJ, Moser DK, Peden AR. Factors related to nonadherence to low sodium diet recommendations in heart failure patients. Eur J Cardiovasc Nurs. 2005;4(4):331–336.
81. Schoenberg NE, Traywick LS, Jacobs-Lawson J, Kart CS. Diabetes self-care among a multiethnic sample of older adults. J Cross Cult Gerontol. 2008;23(4):361–376.
82. Schoenberg NE, Drungle SC. Barriers to non-insulin dependent diabetes mellitus (NIDDM) self-care practices among older women. J Aging Health. 2001;13(4):443–466.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved