Heart Failure Self Care Discussed
Heart Failure Self Care Discussed
Heart Failure Self Care Discussed
ORIGINAL RESEARCH
Structural equation model testing the situation-specific theory of
heart failure self-care
Ercole Vellone, Barbara Riegel, Fabio D’Agostino, Roberta Fida, Gennaro Rocco,
Antonello Cocchieri & Rosaria Alvaro
Accepted for publication 9 February 2013
Correspondence to E. Vellone:
e-mail: ercole.vellone@uniroma2.it
Ercole Vellone MSN RN
Research fellow
School of Nursing, University Tor Vergata,
Rome, Italy
Barbara Riegel DNSc RN FAAN
Professor
School of Nursing, University of
Pennsylvania, Philadelphia, USA
Fabio D’Agostino MSN RN
PhD candidate
School of Nursing, University Tor Vergata,
Rome, Italy
Roberta Fida PhD
Assistant Professor
Department of Psychology, “Sapienza”
University, Rome, Italy
Gennaro Rocco MSN RN
President
Center of Excellence for Nursing
Scholarship, Rome, Italy
Antonello Cocchieri MSN RN
PhD candidate
School of Nursing, University Tor Vergata,
Rome, Italy
Rosaria Alvaro MSN RN
Associate Professor
School of Nursing, University Tor Vergata,
Rome, Italy
VELLONE E., R I EGEL B . , D ’AGOST INO F . , F IDA R . , ROCCO G . , COCCH IER I A .
& ALVARO R . ( 2 0 1 3 ) Structural equation model testing the situation-specific
theory of heart failure self-care. Journal of Advanced Nursing 69(11), 2481–
2492. doi: 10.1111/jan.12126
Abstract Aim. To test the situation-specific theory of heart failure self-care with structural
equation modelling.
Background. Several authors have proposed theories on heart failure self-care,
but only the situation-specific theory of heart failure self-care by Riegel and
Dickson is focused on the process that patients use to perform self-care. This
theory has never been tested with structural equation modelling.
Design. A secondary analysis of data from a cross-sectional study.
Methods. Patients with heart failure were recruited in 21 cardiovascular centres
across Italy during 2011. Data were collected with a sociodemographic
questionnaire, chart abstraction for clinical data and the Self-Care of Heart
Failure Index v.6�2. Results. A sample of 417 participants was enrolled in the study (59% males,
mean age 72 years). The following propositions were tested and supported:
Symptom monitoring correlates with treatment adherence; symptom monitoring
and treatment adherence have a direct, positive relationship with symptom
recognition and evaluation that in turn have a direct, positive relationship with
treatment implementation; treatment implementation has a direct, positive
relationship with treatment evaluation. In addition, the following three
relationships were found: Symptom monitoring has a direct, positive relationship
with treatment implementation; symptom recognition and evaluation have direct,
positive relationships with treatment evaluation and symptom monitoring
correlates with treatment evaluation. [Correction added on 9th April 2013, after
first online publication: ‘. . .symptom monitoring correlates with treatment
implementation.’ has been corrected to read ‘. . .symptom monitoring correlates
with treatment evaluation.’]
Conclusion. The data support the situation-specific theory of heart failure self-
care with the addition of three new relationships that emerged from the analysis.
Results of this study lend further support to the use of the situation-specific
theory of heart failure self-care in research and practice.
© 2013 Blackwell Publishing Ltd 2481
JAN JOURNAL OF ADVANCED NURSING
Keywords: heart failure, nursing, self-care, structural equation modelling, symp-
tom monitoring, symptom recognition and evaluation, theory testing, treatment
adherence, treatment implementation
Introduction
Heart Failure (HF) is the most common cardiovascular dis-
ease in many countries worldwide (Caldarola et al. 2009,
Jiang & Ge 2009, Ntusi & Mayosi 2009, Norton et al.
2011). It is estimated that 6�6 million North Americans
(Roger et al. 2012) and 15 million Europeans (Anguita
Sanchez et al. 2008) are affected by HF. The prevalence of
HF is constantly increasing due to the ageing of the popula-
tion, improved treatment, and survival rates after myocar-
dial infarction and the continuing problem of poor control
of hypertension.
Heart failure patients experience lower quality of life
than patients affected by other chronic conditions (Juenger
et al. 2002, Iavazzo & Cocchia 2011, Burstrom et al.
2012) and are prone to frequent hospitalization and emer-
gency department visits for illness decompensation (Krum-
holz et al. 2009, Ross et al. 2010). Mortality remains high
with about the 30% of people with HF dying within the
first year after diagnosis (Barsheshet et al. 2010, Chen et al.
2011).
Self-care of HF is considered essential to improving
patients’ quality of life and reducing hospitalization,
mortality, and emergency department visits (Bird et al.
2010, Buck et al. 2012). In the last two decades several
authors have proposed theories of self-care for use in
research and clinical practice. While all these theories
identify the components and predictors of HF self-care,
only the situation-specific theory by Riegel and Dickson
(2008) has specifically focused on the process that HF
patients use in the performance of self-care (Figure 1).
Although this theory is widely cited no study testing the
relationships among the theoretical concepts was
located.
Background
Theories of self-care in heart failure
Meleis (2011) defines theory as a coherent vision of the
context, process, and outcomes associated with a specific
phenomenon. As demonstrated below, numerous nursing
investigators have proposed models of HF self-care with
variable attention given to these elements of theory.
In studying self-care behaviours of people with HF,
Jaarsma et al. (2000), used three sets of self-care limitations
from Orem’s theory of self-care: knowledge, judging and
decision making, and action and result achievement. Later,
Orem’s theory was used by Jaarsma et al. (2003) to develop
the European Heart Failure Self-care Behaviour Scale
(EHFScBS). In this effort, HF self-care was specified as
involving three constructs: complying with the regimen,
(e.g. daily weighing, sodium and fluid restriction), asking
for help (e.g. call the doctor/nurse in case of weight gain or
excessive fatigue), and adapting activities (e.g. resting).
These three constructs, although describing the components
of self-care, do not represent a theory of HF self-care where
concepts are linked with propositions to explain a process.
Granger et al. (2006) used the middle-range Trajectory of
Chronic Illness Theory (TCIT) by Strauss et al. (1984) to
integrate patients’ perspectives in self-care with those of HF
providers. The TCIT evolved from ethnographic work with
patients affected by chronic illnesses. This theory conceptu-
alizes relationships among factors contributing to the man-
agement of illness and the target therapeutic interventions.
According to this theory patients have their own perception
of the illness; they interpret and report symptoms and per-
ceive prescribed medications differently from healthcare
professionals. Using the TCIC, clinicians can integrate their
perspectives with those of patients. The principal concepts
Symptom monitoring
Symptom recognition
and evaluation
Treatment implementation
Treatment evaluation
Treatment adherence
Figure 1 The situation-specific theory of
heart failure self-care showing the rela-
tionship between Self-care Maintenance
and Self-care Management.
