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EDITOR’S PERSPECTIVE Towards Self-Care

A big portion of our work as nurses is dedicated to educating our patients with self-care strategies to help them regain their health, promote wellness, and prevent illness and hospitalization. In fact, no other health care discipline focuses on self-care as much as nursing does. Interventions related to this profes-sional nursing responsibility include educating patients regarding their illness, symptom identification and control, medication management, adherence to follow-up consultations, nutrition counseling, exer-cise and physical activity, etc. But what are some of the barriers nurses face with self-care initiatives?

Self-care has been articulated quite considerably since the 1950s by Dorothea Orem in her general nursing theory on the concept of self-care deficit. Fawcett (2001, p. 34) considers Orem “a pioneer in the development of distinctive nursing knowledge.” Her self-care deficit theory in nursing (SCDTN) has been used extensively as the framework in countless research, in the development and revision of nursing curricula, and in the fundamental configuration of many nursing practice settings. Comley (1994) lists three sub-theories of the SCDTN, namely: (1) self-care deficit; (2) self-care; and, (3) nursing systems. Self-care deficit is the sub-theory that explains inadequacies in a person’s ability to care for oneself, necessitating some form or degree of assistance. An example might be evident in a patient who is unable to independently perform personal hygiene because of a fractured ulna. The sub-theory of self-care refers to all self-management approaches learned or adopted to maintain one’s equilibrium, balance, and functioning. Being able to use a rolling walker to ambulate around the house exemplifies a (learned) self-care behavior. And finally, nursing system is the sub-theory that emerges when a nurse extends a helping hand to an individual to address identified self-care limitations and to regulate functioning, de-velopment, and well-being. This sub-theory can be demonstrated by a home care nurse who reaches out to a newly-discharged patient for medication teaching and management.

The World Health Organization (1998) defines self-care as “activities that individuals, families, and communities perform in order to enhance their health, prevent diseases, limit illnesses, and restore health.” Denyes, Orem, and Bekel (2001) further describe self-care to be deliberate, whereby actions are sought out to address functional, physiologic, and developmental requirements within and around the structure of the individual. Orem’s theory further emphasizes the essence of the “view” of self-care by the individual – attending to AND dealing with oneself. In any self-management strategy, the individual (the self) is both agent and object of self-care. It is acted upon by the same person to oneself. A review of prior research on self-care reveals some important findings and recommendations to im-prove our understanding and approach to self-care. Jaarsma et al. (2013) examined self-care behaviors of patients diagnosed with heart failure, employing secondary analysis of data from 15 countries. The researchers found that there is considerable variability in heart failure self-management across countries involved in the studies, with significantly poor adherence to self-care behaviors regardless of nation. Jaarsma et al. (2013, p. 117) also reported that self-care related to medication adherence and exercise was the same in most countries, but behaviors pertaining to weight monitoring, salt restriction, and annual flu immunizations differ. Their review recommended that self-care approaches be more focused on specific behaviors that address particular problem issues than the usual general educational programs. Addition-ally, the authors suggested that healthcare systems and policies around the world be more supportive of the challenges and particular needs of the population when it comes to planning and implementing self-management projects.

Another review was conducted by Gao and Yuan (2011) focusing on self-care programs aimed at cancer patients. The authors searched the databases for self-management programs designed for cancer patients during a 10-year period. Six self-care projects were identified and examined in terms of their

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effectiveness. The authors found some deficiencies in these programs particularly in the areas of de-scribing the facilitator training process. There was little information described in the reports to ascertain the quality of their training. The cancer programs did not consider cultural differences and its effect on self-care. These programs also covered patient and clinician-related outcomes, excluding other measures such as healthcare utilization. The authors recommended more individualized and dynamic self-care programs that keep with the pace and advances in cancer diagnosis and management. A meta-analysis of research studies on self-care among the elderly in Thailand conducted by Klainin and Ounnapiruk (2010) showed very strong associations between self-care behaviors and self-concept, social support, and self-efficacy. The self-concept variable includes patient’s beliefs, values, and at-titudes, as well as self-esteem and body image. In most studies reviewed, the authors concluded that elderly individuals with stronger self-concept tended to have better self-care engagement and adherence. Senior patients who have a supportive family network were more successful with self-management. Fi-nally, individuals who have a higher level of self-efficacy (belief in their ability to perform certain tasks and behaviors) are more likely to be successful with self-care even in the midst of challenges. Goodman, Firouzi, Banya, Lau-Walker, and Cowie (2013) conducted a longitudinal survey of pa-tients with a primary diagnosis of heart failure in terms of their perception of their illness, self-care behaviors, and quality of life during two time points (2 and 6 months) after discharge. While symptom control improved six months after, majority of the respondents believe their illness were not in their con-trol and self-care maintenance was not associated with self-care management. The authors concluded that self-care programs should be more participative and patient-centered; integrate patient values, be-liefs and perceptions; provide patients with positive reinforcements to increase their self-confidence; and assist them in identifying problems and devising solutions to these challenges. Another study focused on costs of an Internet-based asthma self-management intervention in com-parison to the traditional self-care approaches (van der Meer et al., 2011). While it has been established that self-care programs available on the Internet are useful and effective, cost-effectiveness has not been factored in prior studies. The researchers concluded that Internet-accessible asthma initiatives are as cost-effective as the usual self-management programs, demonstrating that electronic strategies can be another format that is equally as successful. Self-care is essential to individuals with deficits as it helps them regain their independence and maintain their sense of self-worth. Educating self-care to patients and members of their support system is also relevant to nursing professionals as it is a fundamental core of nursing. Yet, it is evident from pre-vious researches that enhancements are necessary when planning and implementing self-management programs. Special consideration should be taken to devise self-management strategies that are individu-alized, patient-centered and specific. These should also be planned hand-in-hand with patients and their support network to be able to integrate their values, beliefs, self-concept, and perception of their illness. One should also consider influences related to culture, geographic location, and healthcare system when developing self-care programs. Nurses must always aim for programs that are dynamic and evidence-based, those that are in line with current advances in diagnosis and nursing management, as well as those that incorporate technology and Internet-enhanced programs into the self-care mix. Integrating these factors into self-management strategies require careful, collaborative, calculated, and creative thinking on the part of nurses. We are nurses and we should be able to rise to the callings of our basic professional responsibilities.

REFERENCESComley, A. (1994). A comparative analysis of Orem’s self-care model and Peplau’s interpersonal theory.

Journal of Advanced Nursing, 20, 755-760. doi: 10.1046/j.1365-2648.1994.20040755.x

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Denyes, M., Orem, D., & Bekel, G. (2001). Self-care: A foundational science. Nursing Science Quar-terly, 14(1), 48-54. doi: 10.1177/089431840101400113.

Fawcett, J. (20n01). The nurse theorists: 21st century updates–Dorothea E. Orem. Nursing Science Quarterly, 14(1), 334-38. doi: 10.1177/08943180122108021.

Gao, W. J., & Yuan, C. R. (2011). Self-management programme for cancer patients: A literature review. International Nursing Review, 58, 288-295. doi: 10.1111/j.1466-7657.2011.00907.x

Goodman, H., Firouzi, A., Banya, W., Lau-Walker, M., and Cowie, M. (2013). Illness perception, self-care behaviors, and quality of life of heart failure patients: A longitudinal questionnaire survey. Inter-national Journal of Nursing Studies, 50, 945-953. doi: 10.1016/j.ijnurstu.2012.11.007.

Jaarma, T., Stromberg, A., Ben-Gal, T., Cameron, J., Driscoll, A., Duengen, H., . . . ,Riegel, B. (2013). Comparison of self-care behaviors of heart failure patients in 15 countries worldwide. Patient Educa-tion and Counseling, 92(1), 114-120. doi: 10.1016/j.pec.2013.02.017.

Klainin, P., and Ounnapiruk, L. (2010). A meta-analysis of self-care behavior research on elders in Thai-land: An update. Nursing Science Quarterly, 23(2), 156-163. doi: 10.1177/0894318410362788.

Van der Meer, V., van den Hout, W., Bakker, M., Rabe, K., Sterk, P., Assendelft, W., . . . , on behalf of the SMASHING (Self-Management in Asthma Supported by Hosptials, ICT, Nurses and General Practi-tioners) Study Group. (2011). Cost-effectiveness of internet-based self-management compared with usual care in asthma. PLoS ONE, 6(11), e27108.

World Health Organization (1998). Definition of self-care. The role of the pharmacist in self-care and self-medication. Retrieved from http://apps.who.int/medicinedocs/en/d/Jwhozip32e/3.1.html.

Edmund J. Y. Pajarillo, PhD, RN BC, CPHQ, NEA BCEditor-in-Chief, JNPARR