Self-Care
Judith E. Hertz
INTRODUCTION
On the surface, self-care is simply taking care of one’s self to remain healthy. However, self-care within the context of living with a chronic illness is more complex. Self-care is required for successful management and control of chronic illnesses such as arthritis (McDonald-Miszczak & Wister, 2005; Yip, Sit, & Wong, 2004), heart disease (Burnette, Mui, & Zodikoff, 2004; Chriss, Sheposh, Carlson, & Riegel, 2004; Inglis, Pearson, Treen, Gallasch, Horowitz, & Stewart, 2006; Washburn, Hornberger, Klutman, & Skinner, 2005), diabetes (Berg & Wadhwa, 2007), HIV/AIDS (Mendias & Paar, 2007), asthma (Cortes, Lee, Boal, Mion, & Butler, 2004), and fecal incontinence (Bliss, Fischer, & Savik, 2005).
Self-care is also viewed as a pivotal concept in health promotion, disease prevention, and disease-screening programs (Haber, 2002; Potempa, Butterworth, Flaherty-Robb & Gaynor, 2010; Resnick, 2001, 2003). Furthermore, self-care has been viewed as essential to health in persons with chronic illnesses who receive care in nursing homes (Bickerstaff, Grasser & McCabe, 2003), home care (Sharkey, Ory, & Browne, 2005), and rehabilitation (Singleton, 2000), and during transitions from one healthcare setting to another (Coleman, Smith, Frank, Min, Parry, & Kramer, 2004). Finally, self-care is applicable globally and transculturally when discussing health status in persons with chronic illnesses (Borg, Hallberg, & Blomqvist, 2006; Cortes et al., 2004; Inglis et al., 2006; Leenerts, Teel, & Pendelton, 2002; McDonald-Miszczak & Wister, 2005; Wang, Hsu, & Want, 2001; Yip et al., 2004).
Despite the widespread belief that self-care is integral to persons living with chronic illness, there is little agreement about the meaning of self-care. Sometimes self-care is defined as adherence/compliance with treatment regimens (Chriss et al., 2004), whereas other times it is referred to as having the functional ability to carry out activities of daily living (ADLs) and instrumental activities of daily living (IADLs) (Burnette et al., 2004). Other definitions imply that self-care is the belief that one can implement disease-treatment regimens (i.e., self-efficacy) (McDonald-Miszczak & Wister, 2005; Yip et al., 2004) or that one can manage and report symptoms associated with an illness (Chriss et al., 2004; Edwardson & Dean, 1999; Musil, Morris, Haug, Warner & Whelan, 2001). The ability to meet basic holistic human needs and achieve self-actualization provides yet another perspective (Hertz & Rossetti, 2006; Mendias & Paar, 2007; Potempa et al., 2010). The meaning of self-care becomes even more complex, because
often it is equated solely to independent behaviors to care for self (Borg et al., 2006; Burnette et al., 2004); therefore, if one is dependent on others for assistance, as often happens when living with chronic illnesses, then it is implied that selfcare cannot exist. However, Naik and colleagues recognize this situation in their analyses and recommendations for assessing two aspects of autonomy related to self-care (Naik, Dyer, Kunik, & McCullough, 2009a, 2009b; Naik, Teal, Pavlik, Dyer, & McCullough, 2008).
often it is equated solely to independent behaviors to care for self (Borg et al., 2006; Burnette et al., 2004); therefore, if one is dependent on others for assistance, as often happens when living with chronic illnesses, then it is implied that selfcare cannot exist. However, Naik and colleagues recognize this situation in their analyses and recommendations for assessing two aspects of autonomy related to self-care (Naik, Dyer, Kunik, & McCullough, 2009a, 2009b; Naik, Teal, Pavlik, Dyer, & McCullough, 2008).
Although there is lack of agreement about the definition of self-care, there is implicit and explicit agreement that self-care is vital to individual health maintenance, disease prevention, and health promotion. When persons are living with chronic illnesses, the importance and need to care for self is further underscored.
KEY ISSUES AND FRAMEWORKS FOR VIEWING SELF-CARE WITHIN CHRONIC ILLNESS
The focus of this section is to compare and contrast the many definitions of self-care (or lack of self-care) with evidence to support each view, followed by a working definition of self-care. A self-care framework is presented, and key issues related to self-care in persons living with chronic illnesses are illustrated by reviewing the Healthy People 2020 objectives. The framework and key issues set the stage for application of the nursing process by highlighting important considerations for nurses to address when promoting self-care in clients.
Perspectives on Self-Care
Diverse perspectives of self-care are provided via research on self-care in various populations living with chronic illnesses. These include the idea that self-care means: 1) to comply or adhere to prescribed medical treatments for chronic illnesses; 2) to have a personal belief that one is capable of following disease treatment regimens; 3) to have the functional abilities to carry out daily activities including ADLs and IADLS independently; and 4) to self-determine how to meet one’s unique, personal basic human and self-actualization needs. Still others have addressed self-care as being multidimensional. Each perspective will be discussed.
Self-Care as Adherence with Medical Treatments
Haber’s (2002) critical analysis of federal initiatives regarding health promotion and aging emphasizes physical aspects and a medical orientation toward self-care and health promotion. Self-care is implied as adherence to recommended secondary prevention interventions through disease risk reduction (e.g., smoking cessation) and screening practices (e.g., mammograms).
Edwardson and Dean (1999) explored how selected demographic, social, situational, and symptom-experience factors influence the “appropriateness” of self-care responses to symptoms. In other words, the way persons manage symptoms is influenced by many factors. In this study, self-care was equated to medical management of symptoms. Healthcare professionals judged clients’ responses to symptoms as either “appropriate” or “inappropriate,” using an evidence-based algorithm. If persons did not seek professional care, used “unsafe” remedies, or did not follow guidelines from professionals, their response was considered “inappropriate.”
Sharkey, Ory, and Browne (2005) studied homebound older persons receiving meal delivery in North Carolina to identify the extent that older persons use strategies to reduce out-ofpocket medication expenses when self-managing their medications. From this perspective, lack of self-care was assumed to include noncompliance with medical treatment regimens. Twenty percent admitted to using one or more of the following behaviors to restrict medication use and costs: 1) taking less medicine than the prescribed amount, 2) going without the medication because of cost, 3) getting free drug samples from physicians, 4) obtaining a partial refill of a prescription, 5) taking the drug only when “needed,” or 6) buying only the most important medications. Although these results seem to be “anti-self-management” or “anti-self-care,” they highlight the need to address the concerns and perceptions of patients when trying to promote self-care. Sometimes caring for one’s self conflicts with recommended treatment regimens.
In reviewing the literature regarding health outcomes in persons living with chronic illnesses (diabetes, chronic obstructive pulmonary disease, or chronic heart disease), self-care was equated to self-management of the person’s disease state as well as adherence to medical treatment (Scollan-Koliopoulos & Walker, 2009; Sutherland & Hayter, 2009). The purposes of these reviews differed. Scollan-Koliopoulos and Walker were examining studies on the effects of previous exposure to diabetes in family members on self-care, referred to as a multigenerational timeline. Sutherland and Hayter’s review was focused on self-care as an outcome of nurse-managed care. Nonetheless, both review teams limited their perspective on self-care to self-management of a disease process according to recommended medical treatments.
Others differentiate self-care from selfmanagement (Ryan & Sawin, 2009). Self-care was linked primarily to carrying out ADLs without the advice of healthcare providers. Barlow, Sturt, and Hearnshaw (2002) also identified tasks performed by healthy people at home, including preventative strategies, as self-care. Self-management was viewed as daily tasks carried out at home by individuals to control or reduce the impact of disease on physical health. According to Ryan and Sawin, these behaviors must be learned and require assistance from health providers. After reviewing the literature on self-management programs for arthritis, asthma, and diabetes, Barlow and colleagues made recommendations for development of programs to promote self-management of other chronic health conditions.
In summary, self-care has been linked to compliance with recommended medical treatment. However, sometimes self-initiated behaviors may be in conflict with those recommendations. Learning to live with chronic illness most certainly involves following medical recommendations to reduce exacerbations. However, in some situations self-care is not the same as self-management of an illness or compliance with medical recommendations.
Self-Care as Belief in Being Able to Self-Manage
Typical disease self-management programs for arthritis, chronic heart disease, HIV/AIDS, diabetes mellitus, and asthma focus on monitoring and reporting symptoms as well as monitoring adherence to medical regimens. Research on self-management programs often attempts to identify how self-efficacy beliefs (i.e., belief that one is capable of self-managing one’s
treatment regimen) along with other psychological characteristics such as locus of control, perceived threat, or a sense of well-being and situational variables such as demographics, living arrangements, and overall health influence the ability to self-manage a health condition. Outcomes from these studies often look at symptom relief, functional ability status, changes in self-efficacy beliefs, and laboratory values indicative of “disease control.”
treatment regimen) along with other psychological characteristics such as locus of control, perceived threat, or a sense of well-being and situational variables such as demographics, living arrangements, and overall health influence the ability to self-manage a health condition. Outcomes from these studies often look at symptom relief, functional ability status, changes in self-efficacy beliefs, and laboratory values indicative of “disease control.”
An arthritis self-management program with older persons in Hong Kong introduced Tai Chi as a self-management technique. In this study, self-efficacy was greater, pain decreased, and motor strength increased in the intervention group (Yip et al., 2004) when compared with the control group receiving “usual care.” Selfeff icacy beliefs were linked to self-care approaches in disease self-management and to positive health outcomes.
A longitudinal study (McDonald-Miszczak & Wister, 2005) with a national Canadian sample also linked self-efficacy to the 11 arthritis self-management “self-care” behaviors of diet, exercise, sleep, self-help group participation, use of alternative remedies, modifications of environment, reading, stress reduction, meditation/prayer, consulting family/friends, and consulting others with the same condition. Self-efficacy beliefs did not predict the use of these 11 behaviors to manage arthritis. However, previous use of these behaviors (i.e., past experience) was a strong predictor of these prescribed self-care behaviors and supplemented self-efficacy beliefs.
Similarly, at the end of 3 months, previous use of self-care behaviors was a significant predictor of self-care in monitoring symptoms, following medical guidelines, reporting symptoms, and seeking help in a self-management program designed for persons with heart failure in a study conducted in the southwestern United States (Chriss et al., 2004). Other characteristics such as social support, education, gender, age, income, comorbidities, and symptom severity were not predictive of this type of self-care.
A descriptive correlational study was conducted with persons living with heart failure (Britz & Dunn, 2010). The relationship between self-care abilities (maintenance, management, and confidence) and multiple dimensions of quality of life was explored. Self-care confidence, similar to the concept of self-efficacy, was significantly related to physical, emotional, and overall quality of life.
These studies illustrate that previous lifestyle and experiences are predictive of how persons will manage chronic illnesses in terms of adhering to prescribed behaviors. Although some personal demographic characteristics, emotional state, and personal beliefs about being able to take control and manage a disease on a daily basis had some effect on following the prescribed behaviors, the strongest predictor was previous experience in using the behaviors. This leads one to believe that life experiences and personal values may be very important in determining each individual’s self-care behaviors.
Self-Care as Functional Abilities and Independence
Burnette and colleagues (2004) used functional abilities as an indicator of self-care in their study with a national sample of 597 persons diagnosed with coronary heart disease (CHD) compared to those without CHD. These researchers proposed that most of the everyday work of managing CHD relied upon self-care as opposed to professional care. They defined self-care as the active role persons play in determining outcomes
resulting from professional care. The coping strategies of behavioral change, environmental adaptations, and medical equipment use represented self-care strategies in their study. These strategies were also linked to functional abilities related to ADLs, IADLs, and mobility. Impaired functional abilities indicated a lack of self-care.
resulting from professional care. The coping strategies of behavioral change, environmental adaptations, and medical equipment use represented self-care strategies in their study. These strategies were also linked to functional abilities related to ADLs, IADLs, and mobility. Impaired functional abilities indicated a lack of self-care.
Borg and colleagues (2006) proposed that “older persons who are not able to manage daily life by themselves may have a different view of life satisfaction than those with preserved self-care capacity” (p. 608). Self-care capacity was defined as having functional abilities to carry out activities independently. This study’s findings imply that functional limitations are linked to self-care and that those limitations, more so than the presence of a chronic illness, can affect holistic health outcomes. Persons with functional limitations might need special assistance and attention to support their self-care practices to promote health.
The impact of functional abilities on selfcare and making autonomous decisions was also identified by Naik and colleagues (2009a, 2009b). They noted that some persons, particularly older adults, might have decisional autonomy capabilities in determining self-care, but lack the executional autonomy capabilities and functional abilities to actually follow through in carrying out self-care. Naik and colleagues (2008) proposed methods to assess these two dimensions of autonomy and self-care.
Self-neglect is inability to meet basic needs and is viewed as the opposite of self-care (Dyer, Goodwin, Pickens-Pace, Burnett, & Kelly, 2007). In older clients receiving adult protective services in the United States, the prevalence of selfneglect is 50.3% nationally. Dyer and colleagues developed a case definition of self-neglect based on characteristics of 538 cases. The mean age of these clients was 75.6 years, and 70% were women. Executive dysfunction, or the inability to execute specific complex tasks such as ADLs and IADLs independently, was at the root of selfneglect. Executive dysfunction was also associated with several chronic illnesses, including dementia, depression, diabetes, psychiatric illness, cardiovascular disease, and nutritional deficiency. Self-neglect—seemingly the converse of the definition of self-care—links self-care to the functional ability of acting independently.
CASE STUDY
You are employed in an ambulatory healthcare clinic in a rural healthcare system. One of your clients is Mrs. Smith, an 82-year-old widow who lives alone in a mobile home. Mrs. Smith was diagnosed with osteoarthritis more than 10 years ago and recently was diagnosed as being in the early stages of congestive heart failure. Mrs. Smith’s 55-year-old daughter and family live 50 miles from her home, and her 45-year-old son lives with his wife and four teenage children 10 miles away. Mrs. Smith recently fell on the steps leading into her home. She was transported by ambulance to the closest emergency department located within the healthcare system at which you are employed, about 40 miles from Mrs. Smith’s home. Luckily, Mrs. Smith did not fracture any bones when she fell. She was discharged but is now unable to drive a car and must use a walker because of severe leg pain. She has been taking five medications
for her arthritis and heart condition but her current pain is unrelieved. She has an appointment at your clinic 2 days after her discharge from the emergency department.
for her arthritis and heart condition but her current pain is unrelieved. She has an appointment at your clinic 2 days after her discharge from the emergency department.
Discussion Questions
1. How do you begin your assessment of Mrs. Smith? Why?
2. Identify at least one self-care goal related to each of Mrs. Smith’s diagnosed chronic illnesses.
3. What intervention strategies should be used to help Mrs. Smith achieve each self-care goal? Why did you choose these strategies?
4. List at least three self-care outcomes related to the identified self-care intervention strategies.
Self-Care as Self-Determined Behaviors That Meet the Individual’s Unique Needs
Singleton (2000) traced the history of self-care from Florence Nightingale to the present in an eloquent analysis of self-care. The analysis provided a framework for her study on how nurses encourage rehabilitation clients to care for themselves. She emphasized that self-care should be defined by how clients actually care for themselves, and that greater understanding is needed regarding the methods used by nurses to encourage clients to care for themselves in ways that meet their unique needs.
In a nurse-led, home-based multidisciplinary intervention with older persons after hospitalization for heart failure in South Australia, Inglis and colleagues (2006) incorporated unique self-determined behaviors in their definition of self-care. Although interventions were aimed at promoting adherence to medical treatments as a means of promoting self-care, the researchers also included special interventions to empower older persons to facilitate their self-determination. Thus, self-determination of self-care was emphasized.
The self-care practices of older persons who had fecal incontinence and who were enrolled in one health maintenance organization were investigated by Bliss and colleagues (2005). On average, these persons reported 2.3 chronic conditions with a range from 0-10, and 1.9 specific self-care practices with a range from 0-7. Self-care activities included diet modifications, use of panty liners, reduction in activities, and use of medications to stop diarrhea. Only 43% reported discussing this problem and their self-care practices with their healthcare providers. Only the self-care practice of diet changes was routinely discussed with providers. This emphasizes that sometimes the self-care carried out by persons with chronic illnesses truly is unique to meet personal needs, and that often these self-care practices are not discussed with healthcare providers.
In a 27-month longitudinal study with 387 randomly selected older community-dwelling
adults (Musil et al., 2001), arthritis and cardiopulmonary symptoms were assessed for consistent recurrence and their effects on well-being and symptom management with self-care. Selfcare was defined as the use of home remedies, over-the-counter medications, or changes in lifestyle, but did not include deciding when to seek professional help. There were differences in the use of self-care for persons with each diagnosis. Persons with arthritis and chronic pain complaints across time used self-care, whereas those with cardiopulmonary symptoms did not. It was concluded that patterns differ by the type of symptom and illness and that managing chronic illness is a complex phenomenon.
adults (Musil et al., 2001), arthritis and cardiopulmonary symptoms were assessed for consistent recurrence and their effects on well-being and symptom management with self-care. Selfcare was defined as the use of home remedies, over-the-counter medications, or changes in lifestyle, but did not include deciding when to seek professional help. There were differences in the use of self-care for persons with each diagnosis. Persons with arthritis and chronic pain complaints across time used self-care, whereas those with cardiopulmonary symptoms did not. It was concluded that patterns differ by the type of symptom and illness and that managing chronic illness is a complex phenomenon.
Essential dimensions of self-care and an integrated model were proposed after reviewing research on self-care conducted in Sweden and Finland (Leenerts et al., 2002). In the model, it was emphasized that self-care activities were related to the individual person’s unique view of health and the individual’s self-concept. The authors recommended that nurses incorporate the client’s personal beliefs about health into their teaching about self-care activities, and that nurses partner with clients to support meeting their personal needs. They also identified evidence-based outcomes of health promotion in aging individuals as connectedness to others, resource use, transcendence, and well-being. Self-care activities or skills were classified as communication, healthy lifestyle, building meaning in life, and socializing. They added that self-care takes place within the context of internal and external human environments.
In another study (Bickerstaff et al., 2003), activities that help nursing home residents transcend difficulties and live with contentment and satisfaction in life were identified. In this study, self-care meant activities that promoted holistic health. The 95 respondents, with an average age of 82.2 years, had lived in the nursing home from 3-177 months (M = 35.6 months) and reported a variety of self-care activities. They included 1) generativity activities through helping or reaching out to others and involving family; 2) introjectivity activities such as hobbies, travel, and lifelong learning; (3) temporal integration activities which were past-, present-, and future-based behaviors; 4) body-transcendence activities that incorporated flexibility and making changes in life; and 5) spirituality activities to develop relationships with self, others, and a higher being. These self-care activities encompassed more than a physical orientation to health and wellbeing and were based on the individual’s perception of needs.
Likewise, Wang and colleagues (2001) used focus groups to explore the perceptions of health-promoting self-care in communitydwelling, Taiwanese older adults. All but 4 of the 21 men and women participants were living with some type of chronic illness. The investigators identified five types of self-care activities that these older persons employed in caring for themselves. They included: 1) balancing or adjusting one’s health; 2) initiating or purposefully using self-care activities; 3) regularizing or maintaining a daily rhythm over time; 4) socializing or involving and connecting with society; and 5) sublimating or seeing the positive side and transcending their situations. They concluded that older adults in Taiwan viewed health and self-care activities as mind-body connections with holistic harmony rather than merely as physical health.
Maddox (1999) conducted a 3-year qualitative study of older women in three different age groups to identify their self-care activities and the meaning they assigned to health. The groups
were comprised of: 1) 12 nuns ages 72 to 104; 2) eight 55- to 76-year-old women who lived in single-family dwellings and worked in blue-collar occupations; and 3) five 55- to 86-year-old residents of an urban retirement community who were previously employed as domestic help or worked on farms or in factories. Their reported self-care activities included: 1) interactions with a being greater than one’s self; 2) acceptance of self; 3) humor; 4) flexibility; and 5) quality of being other-centered. It was pointed out that these self-care activities incorporated more than the traditional physical self-care activities of nutrition, exercise, and relaxation but also included holistic, spiritual, social, and emotional behaviors.
were comprised of: 1) 12 nuns ages 72 to 104; 2) eight 55- to 76-year-old women who lived in single-family dwellings and worked in blue-collar occupations; and 3) five 55- to 86-year-old residents of an urban retirement community who were previously employed as domestic help or worked on farms or in factories. Their reported self-care activities included: 1) interactions with a being greater than one’s self; 2) acceptance of self; 3) humor; 4) flexibility; and 5) quality of being other-centered. It was pointed out that these self-care activities incorporated more than the traditional physical self-care activities of nutrition, exercise, and relaxation but also included holistic, spiritual, social, and emotional behaviors.
Hertz and Rossetti (2006) also found that self-care actions or activities were unique for older persons with chronic illness who lived independently in apartments. Common themes and patterns were identified from the activities reported by the 14 male and female respondents. These themes represent types of self-care activities including: 1) adapting to life as an older adult by using coping strategies, assistive devices, and avoiding hassles; 2) meeting needs for affiliated individuation by balancing activities that meet needs for independence and time alone with those that meet needs for dependence and socialization; (3) using self-care knowledge to promote and strive for holistic health by using personal beliefs and values to promote quality of life and self-actualization; 4) self-managing health problems through seeking medical and alternative treatments and by sometimes avoiding medical intervention or treatment; and 5) preventing health problems and issues by following recommendations for screenings and health promotion and by taking safety precautions. The diversity of these individually determined self-care activities also reflect the multidimensionality of self-care.
Self-Care as a Multidimensional Concept
Beattie, Whitelaw, Mettler, and Turner (2003) proposed a model that uses community-based organizations such as area agencies on aging, faith-based organizations, and public health departments to promote health. The dimensions of self-care were implied to include reducing risks to illnesses, managing illnesses, and coping with functional limits.
Lubben and Damron-Rodriguez (2003) analyzed the World Health Organization’s Kobe Centre model for organizing health care at the community level for the older adult population. Within this model, self-care was differentiated from professional care (i.e., disease management) and social network care. The authors viewed self-care as multiple activities that prolonged active life and prevented functional declines. Recommendations were made initially to foster the individual’s self-care capacity by encouraging productive roles and self-direction, followed by building social network support that accommodates the diverse needs of older adults, and finally engaging community professional services for health care of older adults. Enhancing home and community environments is important because those environments are the contexts in which persons live.
Summary and Working Definition of Self-Care
In summary, there are diverse perspectives about what self-care means and evidence exists to support each perspective. Therefore, the working definition of self-care for this chapter incorporates these diverse perspectives.
Self-care has multiple dimensions, is selfdetermined, and is unique to each individual based on that person’s life experiences, values, beliefs, and personal characteristics and abilities, including biopsychosocial-spiritual and functional abilities. Self-care influences each individual’s holistic health. Self-care includes a variety of activities such as following prescribed medical treatments and lifestyle recommendations for chronic illnesses (e.g., take medications, monitor and report symptoms, smoking cessation, diet modifications); carrying out daily activities including ADLs, IADLS, and mobility (e.g., hygiene, dressing, toileting); adhering to recommended guidelines for disease prevention and health promotion (regular screenings, dietary guidelines, exercise); meeting basic needs (e.g., food, shelter, safety, socializing, individuation); and pursuing personal interests that promote spiritual well-being and self-actualization (e.g., meditation, prayer, hobbies, learning).
Self-care includes performing activities both independently and dependently. Furthermore, self-care can be supported and nurtured by nurses and other healthcare professionals. The following framework provides guidelines for promoting self-care in persons living with chronic illnesses.
Self-Care: A Framework for Assessment and Intervention
In nursing, Orem’s (2001) theory and perspective on self-care is frequently cited. The original focus of this theory was on patients’ self-care deficits or the inability to carry out self-care tasks required for physical health. Conversely, self-care agency is the capability to care for one’s self and emphasizes physical abilities. It is implied that healthcare professionals, including nurses, define for clients what self-care is needed and then carry out those activities for the client if the client lacks the capability to do so. Within this definition, there is logical incongruence. If self-care is caring for one’s self, then it makes sense that the client, rather than the nurse or other healthcare provider, should be the expert regarding what is needed. Therefore, a theory that is more congruent with the working definition of self-care is presented.
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