Sense of Security Mediates the Relationship Between Self-care Behavior and Health Status of Patients With Heart Failure: A Cross-sectional Study : Journal of Cardiovascular Nursing

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Sense of Security Mediates the Relationship Between Self-care Behavior and Health Status of Patients With Heart Failure

A Cross-sectional Study

Ingadottir, Brynja PhD, CNS, RN; Jaarsma, Tiny PhD, RN; Norland, Kristján MSc; Ketilsdóttir, Auður MSc, CNS, RN

Author Information
The Journal of Cardiovascular Nursing ():10.1097/JCN.0000000000000981, March 8, 2023. | DOI: 10.1097/JCN.0000000000000981
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Security is a basic human need that is difficult to maintain in situations when life or health are threatened.1 Security is related to terms such as safety, certainty, and dependability2 and is well known within health sciences as a basic need according to Maslow's3 hierarchy of needs, rated second after physiological needs. A contemporary and good example of such a situation when life or health is threatened is the COVID-19 pandemic, which has globally caused uncertainty about the future. It threatened both the safety and independence of our daily lives and can therefore be said to have threatened people's sense of security.

In recent years, the concept of sense of security has emerged as an important aspect of care of patients with advanced illness. Sense of security has been defined as the “effect of a subjective impression of an individual concerning the fulfillment of their need for security.”1(p146) Patients develop a sense of security when their needs for predictability of events concerning themselves and their environment are fulfilled, based on the conviction about the relative stability of their personal situation, including their health condition.1 When patients are convinced about the effectiveness of their treatment, they experience a sense of control over events and their own life, and their sense of security increases, which in turn contributes to their engagement in cooperation with providers. This may lead to increased effectiveness of treatment and may further reinforce the patient's sense of security.1

Sense of security is very relevant for patients with chronic disease because they live with constant or periodic insecurity.4 Insecurity, the feeling of not being safe, can arise when there is a change in health status and people lose their sense of control over the situation. Insecurity is a synonym for instability, that is, the feelings caused by the possibility of a sudden change in the present situation. Most chronic diseases have periods of stability and instability and often require adaptation of treatment and lifestyle during the illness trajectory. Heart failure is a chronic condition characterized by complex symptoms causing repeated and sudden exacerbations that often lead to hospitalization.5 It can be difficult to manage, and the trajectory can be hard to predict, with periods of symptom instability leading to feelings of uncertainty.6 Generally, the prognosis is poor, complicated by the fact that most patients are older and have multiple comorbidities.7 Comorbidities, multiple symptoms, and the constant challenge of managing the necessary but complex pharmacological and nonpharmacological treatment of heart failure cause uncertainty and a lack of predictability. Subsequently, these factors become a potential source of suffering and insecurity for patients and their families.

Self-care, that is, the “process of maintaining health with health promoting practices,”8 is essential for patients with heart failure because it is associated with several positive health outcomes such as better quality of life, and lower mortality and readmission rates.9 To support and improve patients' self-care has become a fundamental part of the multidisciplinary long-term management of chronic heart failure in outpatient services,9 but nevertheless, self-care is often a challenge for patients. Many factors have been identified as affecting self-care in heart failure, including support from others, access to care, confidence, and cognition.8,10 In patients with heart failure, well-known demographic (eg, age), clinical (eg, depression, lower left ventricular ejection fraction), and environmental (social support, income, and use of healthcare) factors are associated with lower self-care behaviors.11

The terms “health status,” “health-related quality of life”, and even “quality of life” are often used interchangeably in the literature, and many measures of health-related quality of life actually measure self-perceived health status.12 According to Rumsfeld et al,13 patient-reported health status includes symptom burden, functional status, and health-related quality of life (the perception of a discrepancy between actual and desired functional status and the overall impact of disease on well-being for a given patient) and is an important measure of health.14 The trajectory of heart failure is often described as variable, with functional decline during periods of deterioration in the patient's HF status.14 Common consequences of chronic heart failure on everyday life are social isolation, losing a sense of control, and living in fear.15 The concept of self-efficacy, which first was defined by Bandura,16 plays an important role in this context and refers to the confidence persons have in their capacity to undertake behavior(s) that may lead to desired outcomes. Self-efficacy and knowledge contribute to effective self-care and health status through the patients' perceptions of how to prevent the exacerbations of heart failure and manage complications when they arise, and their confidence in doing so.17–19

Among the treatment goals of heart failure management are improvements in clinical status, functional capacity, and quality of life. Heart failure management should be patient centered, multidisciplinary, flexible, and provided by competent staff, and should include patient education with a special focus on self-care, psychosocial support, follow-up after discharge, and easy access to care.20 Although inconclusive, there are indications that there is an association between self-care and the health status of patients with heart failure and that depression, anxiety, and personality type are explanatory factors in that relationship.21 Better quality of life and lower readmission rates and mortality have also been found among those patients who report more effective self-care.22–24 Controversially, in their systematic review, Sedlar et al11 did not find a significant relationship between self-care behavior and health-related quality of life.

The concept of sense of security is of interest to healthcare professionals because it is often the goal or purpose of nursing and other healthcare professions and it has been proposed that sense of security can be increased through care.25 However, it is not a well-understood concept and has just recently been added to the agenda of interest for researchers. The available research comes mainly from the palliative care setting where it has identified factors associated with greater sense of security, such as better social support, economic status, and self-efficacy as well as a lower level of symptom intensity and better quality of life.21,26 This evidence, which has a close resemblance to the associated factors of self-care, is interesting and raises the question of what role, if any, sense of security plays in effective self-care. Although several factors have been identified as influencing self-care in chronic illness, sense of security has not been studied in that context.

In this study, we propose the hypothesis that there is a positive correlation between self-care behavior, sense of security, and the health status of patients and that sense of security mediates the relationship between self-care behavior and health status in patients with heart failure who receive care at a multidisciplinary outpatient clinic. Therefore, the objectives of this study were to (1) assess self-care behavior, sense of security, and the health status of patients with heart failure; (2) examine the relationship between self-care behavior, sense of security, and health status; and (3) identify the mediating role of sense of security in the relationship between self-care behavior and the perceived health status of patients with heart failure.



This was a cross-sectional survey study, and data were collected in the period of 2014–2017 with mailed questionnaires and from electronic patient records.


The study was conducted in a 600-bed university hospital in Iceland, which runs the country's only specialized cardiac units and outpatient heart failure clinic.

Data Collection

We merged data from a cross-sectional study (2014) with the baseline data of a longitudinal cohort study (2015–2017). The inclusion criteria of these studies were the same. For the cross-sectional study, all eligible patients (N = 227) were invited to join the study. For the longitudinal study, all consecutive patients who were referred to the heart failure clinic (2015–2017) were invited to participate after their first visit to the clinic. Included were patients 18 years or older, who understood Icelandic, had no documented cognitive impairment, and could complete the questionnaires independently or with help from a family member/friend or a research assistant. An information letter, questionnaires, and a prepaid return envelope were sent to eligible patients.


Self-care was measured with the Heart Failure Self-care Behavior (EHFScB-12) Scale, a 12-item validated instrument with response options on a 5-point scale from 1 (completely agree) to 5 (completely disagree).27 Scores are standardized from 0 to 100, and higher scores indicate better self-care.28 A threshold of ≥70 and <70 is defined as adequate and inadequate self-care, respectively.29 The subscale “consulting behavior” is the sum score of 4 items in the scale; possible raw scores are 4 to 20, with higher values indicating a greater likelihood of contacting healthcare providers for guidance in response to increased feet swelling, weight gain, fatigue, and dyspnea.30 On an item level, low self-care is defined as the proportion of patients who score 1 to 3 on each item.31 The internal consistency (Cronbach α) of the scale in this study was 0.72.

Sense of security was measured with “Sense of Security in Care–Patients' Evaluation (SEC-P),” a 15-item validated instrument where each item begins with “How often….” and response options are on a 6-point Likert-like scale (1, never, to 6, always).32 There are 3 subscales: Care Interaction (8 items, eg, “How often is healthcare available when you need it”), Identity (4 items, eg, “How often can you do what is most important to you in your daily life”?), and Mastery (3 items, eg, “How often do you feel healthcare personnel have adequately informed you about what to expect in your care”?). Scores are standardized from 0 to 100, and higher scores indicate better sense of security. To explore sense of security on the item level, low sense of security is defined as the proportion of patients who score 1 to 3. The internal consistency of the instrument (Cronbach α) in this study was 0.89.

Perceived health status was measured with the Kansas City Cardiomyopathy Questionnaire (KCCQ), a well-established and validated 23-item, self-administered instrument that quantifies physical function, symptoms (frequency, severity, and recent change), social function, quality of life, and self-efficacy and knowledge. An overall summary score can be derived from the physical function, symptom (frequency and severity), social function, and quality of life domains. For each domain, validity, reproducibility, responsiveness, and interpretability have been independently established.17 Scores are transformed to a range of 0 to 100, in which lower scores represent more severe symptoms and/or limitations and lower self-efficacy and overall health status, whereas scores of 100 indicate no symptoms, no limitations, and excellent quality of life, self-efficacy, and overall health status. The scores are frequently summarized in a 25-point range, representing health status as very poor to poor (score, 0–24), poor to fair (score, 25–49), fair to good (score, 50–74), and good to excellent (score, 75–100).

Sociodemographic (age, sex, marital status, household income, education) and clinical (New York Heart Association functional class, left ventricular function [ejection fraction %], comorbidities, previous cardiac treatment, and implanted devices) variables were collected from patient medical charts and self-report. In addition, symptoms of anxiety and depression were assessed with the Hospital Anxiety and Depression Scale (HADS)33 which consists of 2 independent subscales, HADS-A (symptoms of anxiety) and HADS-D (symptoms of depression). Each subscale has 7 items with a possible total score of 0 to 21. The Icelandic version of HADS has previously been validated.34

Statistical Analysis

Descriptive statistics (mean and standard deviation, median and interquartile range, frequencies, and proportions [%]) were used to describe the sample characteristics and scores of sense of security (SEC-P), self-care (EHFScB-12 Scale), and health status (KCCQ). Pearson's coefficient was used to assess the correlation between the scores of EHFScB-12 Scale, SEC-P, KCCQ, age, New York Heart Association functional class, and sex. First, linear regression was used to model the association between self-care and sense of security, adjusted for New York Heart Association functional class, age, and sex.

Second, for the mediation analysis, procedures from Baron and Kenny35 were used to show that sense of security functions as a mediator variable. We estimated 3 regression models: (1) we regressed the mediator (sense of security) on the independent variable (self-care), (2) we regressed the dependent variable (health status) on the independent variable, and (3) we regressed the dependent variable on both the independent variable and the mediator. To establish mediation, one must show (1) significant associations in the first 2 regression models and (2) that the mediator has a significant association with the dependent variable in the third regression model, whereas the effect of the independent variable on the dependent variable is smaller in the third regression model than in the second model.35

In all 3 regression models of the mediation analysis, we controlled for age, sex, and New York Heart Association functional class. To address missing data for the New York Heart Association functional class variable (10% missing) and total score for self-care, EHFScB-12 (7% missing), in our regression models, multiple imputation with the mice package in R was used. The imputed data sets were analyzed separately, and the results were pooled to obtain overall estimates. The level of statistical significance was set at P < .05. R statistical software (version 3.6.2) was used to perform the statistical analysis.

Ethical Considerations

The study conforms with the principles outlined in the Declaration of Helsinki36 and received approval from the National Bioethics Committee (14-107-S1), the Data Protection Authority (2014040651), and the medical chief at the university hospital. All participants received an information letter in which they were informed that returning a filled-out questionnaire was regarded as consent to participation in the study.


The final sample consisted of 220 patients. Of 227 eligible patients in the cross-sectional study, 124 accepted the invitation to participate (55% response rate). Of 171 eligible patients in the longitudinal study, 96 accepted the invitation to participate (57% response rate).

The characteristics of the patients are presented in Table 1. Their mean (SD) age was 73.6 (13.8) years, and 70% were male. In total, 34% had basic education or lower, 65% were retired, and 14% were on a disability pension. Most patients (49%) were in New York Heart Association functional class III, followed by 35% in class II.

TABLE 1 - Demographic and Clinical Characteristics of the Patients (N = 220)
n (%)
Age, mean (SD), y 73.6 (13.8)
 Male 154 (70)
 Basic education or lower 74 (34)
 Started or completed college 105 (48)
 Started or completed university 33 (15)
 Missing 8 (4)
 Employed (by self or others) 38 (17)
 Retired 144 (65)
 Disability pension 30 (14)
 Missing 8 (4)
No. household members
 1 38 (17)
 2 or more 174 (79)
 Missing 8 (4)
Marital status
 Single 38 (17)
 Married/cohabiting 144 (65)
 Divorced/widowed 30 (14)
 Missing 8 (4)
Total household incomea per month
 €0–€1950 68 (31)
 €1950–€3900 93 (42)
 €3900–€5800 27 (12)
 €5800 or more 10 (5)
 Missing 22 (10)
 Previous MI/ischemic heart disease 133 (60)
 Atrial fibrillation/flutter 113 (51)
 Hypertension 97 (45)
 Heart valve disease 60 (27)
 Diabetes mellitus 52 (24)
 Chronic obstructive pulmonary disease 44 (20)
 Dilated cardiomyopathy 40 (19)
Previous invasive cardiac treatment
 Device therapyb 85 (48)
 Revascularizationc 92 (47)
 Valve surgery 15 (1)
Left ventricular function
 HFpEF (≥50%) 44 (20)
 HFmrEF (40%–49%) 49 (22)
 HFrEF (<40%) 120 (55)
 Missing 7 (3)
NYHA functional class
 I 9 (4)
 II 77 (35)
 III 107 (49)
 IV 4 (2)
 Missing 23 (10)
Symptoms of anxiety,d mean (SD) 9.6 (5.7)
Symptoms of depression,d mean (SD) 7.4 (3.1)
Abbreviations: HFmrEF, heart failure with midrange ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; MI, myocardial infarction; NYHA, New York Heart Association.
aConverted to euros (€) from Icelandic Krona, using currency rate at the time of data collection.
bPacemaker, cardiac resynchronization therapy, or implanted defibrillation device.
cPercutaneous coronary intervention, coronary artery bypass grafting, or both.
dMeasured with the Hospital Anxiety and Depression Scale.

The mean (SD) total score of self-care was 57.2 (22.0). The lowest self-care was found in physical activity (56.4% of patients reported a low exercise level), followed by restricting salt intake (42.2% reported not restricting sodium); 37.1% did not weigh themselves regularly, and 33.5% did not receive flu shots. The best self-care was with medication adherence, because only 1.9% of patients had difficulties with it. The mean (SD) score of consulting behavior was 10.2 (4.7). Table 2 presents the scores for self-care, sense of security, and health status.

TABLE 2 - Self-care, Sense of Security, and Health Status of Patients
Mean (SD) Median (IQR)
Self-care (0–100)
 Total score 57.2 (22.0) 58.3 (34.0)
Sense of security (0–100)
 Total scale 83.2 (15.2) 85.5 (15.3)
 Care interaction 84.6 (15.8) 89.4 (17.0)
 Identity 83.6 (15.6) 86.4 (18.2)
 Mastery 81.1 (18.3) 87.5 (25.0)
Health status (0–100)
 Overall summary scorea 57.9 (24.7) 58.1 (38.1)
 Clinical summary scoreb 59.9 (25.2) 61.3 (41.7)
 Physical limitation score 55.4 (28.9) 58.3 (47.9)
 Quality of life score 56.0 (26.8) 58.3 (41.7)
 Social limitation score 55.7 (31.5) 56.2 (62.5)
 Self-efficacy score 86.2 (19.6) 87.5 (25.0)
  Symptom stability 58.4 (23.1) 50.0 (25.0)
  Symptom frequency 64.9 (25.9) 67.7 (39.6)
  Symptom burden score 63.0 (26.3) 66.7 (41.7)
 Total symptom score 63.9 (25.4) 66.2 (38.5)
Self-care was measured with the 12-item European Heart Failure Self-care Behavior Scale, sense of security was measured with the Sense of Security in Care–Patients' Evaluation, and health status was measured with the Kansas City Cardiomyopathy Questionnaire (KCCQ).
Abbreviation: IQR, interquartile range.
aIncludes the physical limitation, symptoms, quality of life, and social limitation domains of the KCCQ.
bIncludes the symptoms and physical limitations domains of the KCCQ.

The mean (SD) total score for sense of security was 83.2 (15.2), and for the subscales, Care Interaction scored the highest (Table 2). Figure 1 presents the proportion of patients experiencing a low sense of security on the item level.

Low sense of security at the item level (proportion of patients). Patterns refer to subscales: Care Interaction (white dots), Mastery (stripes), and Identity (black dots). HP, healthcare providers.

The perceived health status of patients was fair to good in all domains (mean [SD] range, 55.4 [28.9] to 64.9 [25.9]), except for self-efficacy, which was good to excellent (mean [SD], 86.2 [19.6]), and the overall summary score was 57.9 (±24.7) (Table 2).

Self-care behavior was correlated with sense of security, both the total scale (r = 0.28, P < .001) and all 3 subscales (Table 3). Regression analysis showed that self-care was associated with sense of security and 8.2% of the variance in self-care was explained in the model when adjusted for New York Heart Association functional class, age, and sex (Table 4).

TABLE 3 - Correlation Between Sense of Security and Self-care
SEC-P Total SEC-P Care Interaction SEC-P Identity SEC-P Mastery Self-carea
SEC-P total 1.00 0.92b 0.85b 0.76b 0.28b
SEC-P, Care Interaction 0.92b 1.00 0.61b 0.50b 0.28b
SEC-P, Identity 0.85b 0.61b 1.00 0.71b 0.19c
SEC-P, Mastery 0.76b 0.50b 0.71b 1.00 0.21c
Self-carea 0.28b 0.28b 0.19c 0.21c 1.00
Abbreviation: SEC-P, Sense of Security in Care–Patients' Evaluation.
aEuropean Heart Failure Self-care Behavior.
bP < .001.
cP < .01.

TABLE 4 - Multiple Regression Estimates for the Effects of Sense of Security, New York Heart Association Class, Sex, and Age on Self-care
Predictor b 95% CI P
Sense of security 0.42 0.18–0.66 .00074
NYHA class −2.0 −7.4 to 3.4 .47
Sex −2.9 −9.4 to 3.7 .39
Age 0.29 0.05–0.52 .016
R 2 0.099
R 2 (adjusted) 0.082
Abbreviations: CI, confidence interval; NYHA, New York Heart Association.

The mediation analysis shows that self-care was associated with health status (β = 0.19, P = .005) in a regression model. Sense of security was associated with self-care (β = 0.14, P = .00072) in a separate regression model. Regressing health status on both self-care and sense of security, the association of sense of security remained significant (β = 0.25, P = .025), whereas self-care had a smaller effect (β = 0.15, P = .026) than in the first regression model, indicating a mediating effect of sense of security (Figure 2).

The mediation effect of sense of security on the relationship between self-care and health status.

Sex (β = −2.8, P = .35) and age (β = 0.04, P = .73) did not have a significant association with health status. However, New York Heart Association functional class (β = −22.0, P = 3.2 × 10−16) was associated with health status. Overall, 36% of the variance in health status was explained.


This is the first study focusing on the mediating role of sense of security when exploring health status as an outcome of self-care. We proposed the hypothesis that there is a positive correlation between self-care behavior, sense of security, and the health status of patients and that sense of security mediates the relationship between self-care behavior and health status in patients with heart failure who receive care at a multidisciplinary outpatient clinic. The study results support these hypotheses and indicate that the patient's sense of security does indeed play a role in the ultimate outcome of self-care, that is, the overall health status of patients.

Sense of security in this population of patients with heart failure was rather high, measured by both the total score and the 3 subscales. Literature and research are scarce on the concept of sense of security, and there is limited research available to compare the results with. The sense of security for patients with heart failure was similar to that of patients with cancer in palliative care and outpatient geriatric patients.32,37 Perception of a secure care interaction scored the highest, indicating quality of care. Care interaction refers to being able to trust in the availability of staff and services, and their competence to provide symptom relief.25 For the current study, the high score for care interaction may be explained by the participants receiving outpatient services from a clinic providing interdisciplinary care led by specialized heart failure nurses. It would be interesting to assess the sense of security among patients who are not receiving such care, because many patients with heart failure only meet their cardiologist infrequently and may be struggling with their condition without sufficient support, which might decrease their sense of security. In addition, compared with patients, relatives have reported both a lower sense of security38 and a similar sense of security39 in a dyadic comparison within palliative care, and their perspective is important to explore further within heart failure care because relatives have unique needs for care and play an important role in the self-care of patients.

As comparative research is lacking, it is possible to look at a concept closely related to sense of security, that is, uncertainty. Many factors can contribute to uncertainty, for example, a feeling of loss of control when patients are unclear about disease treatment and outcome and need better knowledge. Both Chen et al40 and Dudas et al41 have studied uncertainty in illness among patients with heart failure. In Chinese patients with heart failure, uncertainty and depressive symptoms mediated the relationship between symptom distress and health-related quality of life.40 Dudas et al41 found that Swedish patients with heart failure who received person-centered care experienced less uncertainty in illness than those who received usual care, referring to both ambiguity about illness severity and the complexity of treatment and the system of care.

Self-care was inadequate, or well below the cutoff of 70 (57.2 ± 22.0). Compared with results from an international study where low self-care of patients with heart failure was assessed in 15 countries,31 the results in the current study are similar for exercise (56% compared with 36%–90%, which is the range for different countries) and sodium restriction (42% compared with 18%–91%) but rather on the low side for weight monitoring (37% compared with 24%–89%) and receiving flu shots (34% compared with 16%–75%), whereas the best self-care was reported for medication adherence (2% low self-care compared with 0%–19% in other countries).

The association between self-care and health status was significant in the current study, but overall, the literature has been inconclusive so far. Sedlar et al11 reviewed 30 studies that assessed factors related to self-care in heart failure (self-care measured with the EHFScB Scales). They found 8 studies that measured the association with health-related quality of life, and the results showed a consistent nonsignificant association with self-care. The authors concluded that health-related quality of life could not improve unless there is an improvement in functioning. This notion is further supported in a recent study where both cardiac systolic function and self-care were shown to be the primary determinants for the quality of life.42 In the current study, the overall self-care score was higher than in the studies included in the review of Sedlar et al.11

The health status that was reported by Icelandic patients in this study was fair to good (within the range of 50–75) for all the scores in KCCQ except the self-efficacy score, which was 86 out of 100, indicating that self-efficacy may be an important contribution to both the association between health status and self-care, and health status and sense of security. Self-efficacy reflects confidence in the ability to perform self-care in heart failure,43 and the association between self-efficacy and self-care is well documented.44–46

Sense of security had a mediating effect in the relationship between self-care and health status; that is, it contributed to the positive effects of self-care on the health status of patients. The emerging evidence on the importance of self-care on patients' health has revealed the many factors that affect self-care. These include both individual factors (eg, stressors, societal support, and self-efficacy) and societal factors (eg, access to resources, basic needs, quality of healthcare),47 some of which are also thought to contribute to sense of security25 and subsequently lead to better health status. According to the middle range theory of self-care in chronic illness, decision making and reflection are the underlying processes of self-care, and self-care may be sufficient or insufficient, reasoned, and reflective, or automatic and mindless.8 We suggest that even if self-care is sufficient and reflective, it can be driven by fear instead of a feeling of security.48 Therefore, if self-care is not performed with a sense of security, even when it is sufficient, the ultimate outcome of patient-reported and perceived health status will be worse than if a sense of security is experienced by the patient. Liberska1 suggests that patients who lack a sense of security are not convinced that they can control their situation or influence their health and they have limited access to personal resources. Therefore, restoring their sense of security includes helping them understand that they can influence their situation and have control over their lives and health. We suggest that sense of security in patients with heart failure can be supported with specialized nursing care and quality patient-provider communication, including patient education in multidisciplinary heart failure management programs that provide holistic and person-centered care. Such care includes focusing on the individual patient's needs for knowledge and support, previous experience, personal strengths and motivation, and the use of normalization when explaining, educating, and giving instructions to patients. The need for new teaching strategies to support self-care skill development in patients heart failure has been identified,18 and an example of novel teaching strategies that could fit that purpose is the use of serious games.49 However, to realize such optimal organization of care, the qualifications of healthcare professionals, and their confidence in their own professional role and experience must be acknowledged as contributing factors.50

There are imminent changes in healthcare worldwide. There is an increased need for healthcare resulting from aging populations and the increased prevalence of chronic illnesses. Simultaneously, there is not only a shortage of healthcare professionals globally but also increased availability and use of eHealth solutions. All these factors may lead to less direct and physical contact between patient and provider in the future. Consequently, self-care will become more important in the future than ever before, and it will change because patients will not only need to perform self-care behavior but also will learn to navigate and acquire proficiency in using eHealth solutions in their self-care. Because they may lack confidence in doing so, it is important to establish and ensure patients' sense of security in healthcare on all levels (micro-meso-macro) because self-care behaviors are affected by variables that operate at all levels.47

Future research should focus on interventions to improve sense of security through organization of care that emphasizes quality patient-provider interaction and communication, including patient education and navigation, and through measures to improve self-efficacy. It would also be interesting in the future to explore sense of security in other patient populations with chronic illness.

There are some limitations to this study that should be acknowledged. Reliable data were not available on how long the participants had been given a diagnosis of heart failure, but such information would have improved the data and would have been interesting to include in the analysis. In addition, all the participants in the study were registered at the outpatient clinic, and it remains unknown how they compare with other patients with heart failure in the country who do not have access to such services. Although this limits the generalizability of the results, it should also be noted that the outpatient clinic is the only one in the country and serves nationwide patients with heart failure and symptoms. Furthermore, because data collection for the longitudinal study took quite a long time, the study was sensitive to bias from changes in the provided services of the clinic. However, the services remained stable, and no significant changes, as evaluated by the authors, were made during the data collection.

As regards the SEC-P instrument, this is a rather new instrument and it was not specifically designed for the population of patients with heart failure. Moreover, its psychometric properties need to be assessed in other populations than palliative care, and to date, its use has been limited. It is therefore difficult to compare the results of the current study with those of other studies. Finally, we acknowledge the well-known potential bias of social desirability in self-reported surveys such as the current study.


Sense of security in patients with heart failure is an important part of daily life and contributes to better health status. Heart failure management should not only support self-care but also aim to strengthen sense of security through a positive care interaction (provider-patient communication) and the promotion of patients' self-efficacy, and by facilitating access to care.

What’s New and Important

  • Promoting patients' sense of security is among the goals of nursing care within HF management, but the concept is understudied.
  • Sense of security in patients with HF was associated with better self-care and contributed to better health status.
  • To strengthen sense of security, healthcare providers can promote a positive care interaction with patients, support their self-efficacy, and facilitate access to care.


The authors thank all the patients who participated in the study and Anchor English for their proofreading services.


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health status; heart failure; self-care; uncertainty

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