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A Situation-Specific Theory of Heart Failure Self-care

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on 15 May 2014

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Transcript of A Situation-Specific Theory of Heart Failure Self-care

a mediator and/or a moderator of the relationship between self-care and outcomes
A Situation-Specific Theory of Heart Failure Self-care
Barbara Riegel, DNSc, CS, FAAN, FAHA; Victoria Vaughan Dickson, PhD, CRNP
간호정보학 석사박사통합과정 성수미
CONCEPTUAL CLARITY
self-care
self-management
self-monitoring
self-regulation
adherence
compliance
Self management
synonym for self-care
Creer and colleagues:

to describe patients who actively participate in treatment

Others:
to describe patients who make therapeutic, behavioral, and environmental adjustments in line with professional advice

Lorig and Holman:
as a process aimed at helping patients maintain a wellness perspective by engaging in a set of tasks:
medical management, behavioral management (maintaining, changing, and creating new meaningful behaviors or life roles), and emotional management (dealing with the emotional sequelae of having a chronic condition).
Self-management & Self-care
self-management <
self-care
more specific!
self care:
"...the things people do because of...
[a health problem]
."
Both self-care and self-management
: a proactive process, compliance with professional advice, close attention to one's body, and appropriate coping behavior.
the key difference
: in self-management, patients undertake tasks that are the traditional province of professionals, such as prescribing drug dosages.
Wilson et al
Self-monitoring
Wilde and Garvin
2 complementary components or attributes:
(1) awareness of bodily symptoms
(2) measurements, recording, and observations that inform cognition or provide information for independent action or consultation with care providers.
self-care
:as a strategy done to achieve a high level of self management
used relatively less often
under discussions of self-management
the
conceptual disarray
surrounding the term 'self-care'
the need for
more attention
!
Self care?
in nursing theory,
'Orem's theory of self-care'
depth and breadth
esoteric terms
obscure concepts
difficult to translate directly into clinical practice
'Self care'
over the past 30 years,
the time spent in individual patient encounters
to oversee the day-to-day care regimen
In the 1980s, health professionals began to study self care

'essential ingredient in successful disease management.
Background
Im and Meleis
Theory
Grand theory
eg) Orem's theories
of self-care deficit and self-care agency
Situation-specific theory
focuses on specific clinical phenomena seen in practice
Middle-range theory
more limited in scope and abstraction
organized
coherent
systematic articulations
explaining a large set of phenomena
more concrete and less abstract
limited to specific situations and/or specific populations
not universal or generalizable to other situations.
Im and Meleis
Crucial elements
a clear
link
: the theory, research and clinical practice
A conceptual scheme
based on
abstract thinking
,
memo or journal writing
,
dialogue
with colleagues, students, and research participants.
Self-Care of Heart Failure
Self-care maintenance
behavior used to maintain physiologic stability
-
symptom monitoring
and
treatment adherence
key concepts in the conceptual model:
maintenance
and

management
Symptom monitoring:
recognizing and interpreting symptoms
Treatment adherence:
following the advice of providers
to follow the treatment plan & live a healthy life style
Self-care management
decision-making response to symptoms
when they occur
Five stages of management:
recognizing
a status change
(eg. new swelling)
evaluating the change
in status
deciding to
take action
implementing a
treatment strategy
(eg. taking an extra diuretic dose)
evaluating the treatment
implemented
Symptom monitoring
and Treatment adherence
stage 2.
Symptom
Recognition
stage 3.
Symptom
Evaluation
stage 4.
Treatment
Implementation
stage 5.
Treatment
Evaluation
stage 1.
Self-care Maintenance
Self-care Management
Self-care Confidence
Self-Care of Heart Failure Model
환자가 증상자각을 할 수 있어야 다음 단계로 잘 넘어갈 수 있다.
self-care management process의 가정
2 major advances in our thinking
Naturalistic decision making:
The concept of confidence
(1) focusing on process rather than outcome,
(2) using decision rules that match the situation and the action,
(3) letting context influence decision making, and
(4) basing practical decisions on the empirical information available at the moment.
환자가 증상에 대해 decision making을 할 때, 얼마나 합리적이고 비판적인 사고를 할 수 있는 능력을 갖췄는지?
Person
Problem
Environment
[Decision Influences]
(expertise)
Knowledge
Experience
Skill
Compatibility w/ values
Decisions
about
self-care

What we think!
a core component of self-care itself?
다양한 가설제기의 가능성;
When(moderator,조정자) and how(mediator,중재자) confidence influences the relationship between self-care and outcomes?
따라서 Total self-care index를 만들기 위하여
SCHFI(Self-Care of Heart Failure Index)에 Maintenance, Management, confidence scale을 추가하지않고환자가 개별 영역에 대해 가지고 있는 self-care skill을 설명해주는 세분화된 scale을 사용하였다.
Proposition Testing
Theoretical Propositions
1. Symptom recognition is the key to successful self-care management
2. Self-care is influenced by knowledge, experience, skill and compatibility with values
3. Confidence mediates and/or moderates the influence of self-care on outcomes
이론적 명제
실험제의
Self-report data from the SCHFI
Self-Care of Heart Failure Index
composed of 15 items
rated on a 4-point response scale
divided into 3 scales(Maintenance, Management, Confidence)
Symptom monitoring
and Treatment adherence
stage 2.
Symptom
Recognition
stage 3.
Symptom
Evaluation
stage 4.
Treatment
Implementation
stage 5.
Treatment
Evaluation
stage 1.
Self-care Maintenance
Self-care Management
Self-care Confidence
Self-Care of Heart Failure Model
반영
Psychometric testing of the instrument was done
760 persons w/ HF from 7 sites in the US
mean[SD] age, 70.36[12.3] years, 51% male
한 개 이상의 scale에서 점수가 100점 만점 중 70점 미만일 경우 poor self-care로 간주
Symptom Recognition
Hypothesis:
The patients who were unable to recognize their symptoms
would be unsuccessful in subsequent steps in self-care management
Knowledge
Hypothesis:
self-care would be better in patients with more knowledge

Sample: 41 patients with chronic HF
male(63.4%), married(43.9%), white(68.3%), educated at a high school level or above(90.2%)
knowledge:
assessed using the Dutch Heart Failure Knowledge Scale
a 15-item self-report scale reflecting knowledge about HF
based on established patient education guidelines of the Netherlands Heart Foundation
low(≤12) knowledge groups
high(≥12) knowledge groups
Results
Maintenance
: low-knowledge groups > high- groups
Management
: high-knowledge groups > low- groups
Skill
In the same data set
self-care skill: assessed qualitatively using content analysis
expert
inconsistent
novice
maintenance & management
were
higher in experts
than in novice in HF self-care
SCHFI
Self-Care of Heart Failure Index
Experience
cut at the 2-month point
Previous research;
patients w/ HF have developed some expertise
regarding how to care for the illness after about 2 months
Patients newly diagnosed(<2months before)
Patients w/ some experience w/ HF(diagnosed≥2months before)
Sample:
in 129 patients at enrollment and at 3 and 6 months
elderly(mean [SD] age 72[11]years ),female(54%), married(60%),
white(68.3%), very poor (78.4% w/ < high school education)
134명의 Hispanic HF 환자를 무작위로 추출하여 전화 follow-up(n=69)과 일상 치료(n=65)를 받게 함
Bilingual Mexican American RN은 6개월동안 컴퓨터 소프트웨어를 이용한 표준화된 case management를 제공

A Dz management intervention:
Results:
Experienced patients reporting better management
than inexperienced patients
Values
related to choice
가이드의 역할
Sample:
36 of the 41 participants in the study
55.6% had positive values
44.4% voiced negative values
Results:
When scores on the SCHFI were compared,
Self-care maintenance was higher in those with positive values compared with those with negative values
example*,
“인생에서 중요한 것을 깨닫는다는 것은 다만 나의 삶의 초점을 가족, 친구, 믿음의 중요성에 두는 것을 말한다. 나는 영원히 살아있지 않을 것이기 때문에, 최선을 다하고 내가 가진 기회의 장점을 취하고, 감사하며 사는 것이 당연한 것이다. 나의 확고한 의지를 되새기며 나에게 주어진 하루 하루에 대해 주님께 감사 드리며 살고있다.”
Confidence as a Moderator
Hypothesis:
Higher levels of heart failure self-care
are associated with better economic outcomes,
but only when confidence is high

Sample:
134 patients
53.4 % female w/ a mean [SD] age 72[11]years ), mean(SD) EF of 43%(18%), mean NYHA functional class of 3.2, a mean Na + level of 139.7 mEq/dL
Control:
age, sex, baseline NYHA functional class, EF, Na+ level,
history of DM and renal Dz
Results:
24% of the variance in cost was explained
Control:
self-care and confidence as a moderator were added in a 2nd step
Results:
43.4% of the variance in cost was explained
self-care management
self-care confidence
the moderating effect of self-care confidence on management

significant predictors of HF inpatient costs
Confidence as a Mediator
Hypothesis:
Social Support
Self-care confidence
Outcomes
Sample:
117 outpatients with HF
40 % female w/ a mean [SD] age 56[14]years ), 50% African American, 50% married
Social support:
measured with a single item asking
" How would you rate the quality of the support you receive from others?"
(1) poor ~ (4) very good
SCHFI
Results:
Support was a significant determinant of self-care management
self-care confidence
support and confidence
were significant determinants of self-care management
Social Support
Self-care confidence
self-care management
Limitations
Secondary analysis of existing data sets

'Higher self-care maintenance in patients with lower knowledge scores'
require further study

Many of the results were not statistically significant. Further testing is essential.

'An important limitation of this situation specific theory'
It is a biomedically derived approach to health that focuses on a specific illness.
Important cultural, gender, and psychosocial influences on self-care are ignored.
Implications for Practice
For nurses,
In the future, we may eventually be able to identify patients most in need of an intervention to improve self-care.
Another important implication,
the need to use consistent terms so that we are able to communicate clearly about the subtleties of self-care
In conclusion,
Im and Meleis: several reasons for the seeming disconnect among theory, research, and practice
But,
one likely reason is
the tension between theoretical vision and clinical wisdom
Situation-specific theories such as the self-care of Heart Failure theory
one way of linking theory, research, and clinical practice
It is hoped that this theory might provide guidance for both clinical intervention and research
test:
using data from a study of peer mentoring for heart failure
we trained 9 persons w/HF to mentor 88 other HF patients.
sample of mentees:
elderly(mean [SD] age 73[12.6]years ),female(56.7%), unmarried(62.9%),
retired(81.4%), economically disadvantaged(48.1%), educated at th high school level of above(87.7%), a low or moderate level of comorbidity,w/ DM & HTN(80.5%)
Having recognized their HF symptoms fairly quickly(n=35)
Not- (n=59)
Results:
Treatment initiation scores & Treatment evaluation ability
patient who recognized their symptoms quickly
integrative approach to the development of situation-specific theories
situation-specific theory _
...187 articles published
+ clinical
...47 relevant articles were located
Self-care with specific patient populations
not described as situation-specific theory
Dodd
self-care was essential, proactive, learned behavior performed by patients
needing to prevent of respond to the adverse effects of chemotherapy
Leenerts and colleagues
self-care as a means to promote health and well-being as people age
The work by these investigators
our understanding of self-care
Self-care = patient responsibility
But,
more effective with the support of clinician
Situation-specific theories are...
[Components of naturalistic decision making]
Others have developed situation-specific theories.
(only the limits of human and English language)
'self-care in persons with cancer undergoing chemotherapy'
'Self-care' captures the essence of our philosophy and a key dimension of our practice.
It is important to encourage self-care in our patients,
as those who engage in self-care seem to have better outcomes.
we may be able to identify the patients most at risk for poor self-care.
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