gms | German Medical Science

Background: Heart failure is a common and serious debilitating clinical syndrome. International studies report that heart failure frequently requires readmission to hospital, many of which are attributed to poor self-care. Readmissions could be greatly reduced if patients were enabled to engage in on-going self-care. International consensus guidelines recommend on-going self-care including dietary adherence, fluid restriction or symptom monitoring. Nurses are required to help patients cope with these complex care needs. Although self-care is ultimately a patient responsibility, nurses help patients learn how to monitor and interpret symptoms, set priorities or make decisions about their care. Theories are important in this, as they provide nurses with a vehicle to guide their decisions or make assumptions about factors influencing a health problem. Yet, a specific theory on barriers and facilitators for self-care in heart failure patients is still absent in spite of existing meta-summary findings that could be integrated to produce a qualitative meta-synthesis represented in the form of a situation-specific theory.

Research question: How can statements of findings derived from our systematic review and qualitative meta-summary be integrated interpretively so that they form a situation-specific theory?

Method: Resulting in a new situation-specific theory, we employed meta-synthesis techniques to integrate statements of findings pertaining to barriers and facilitators to heart failure self-care that were derived in our previous study through meta-summary techniques. Meta-syntheses are integrations that are more than meta-summaries in that they offer novel interpretations of findings on a more abstract level, commonly represented in the form of a situation-specific theory. The development process of our theory is based on an integrative approach. First, all members of the synthesis group received a list containing all statements of findings pertaining to barriers and facilitators to heart failure self-care. Through open coding similar statements of findings were grouped together to form categories and concepts arising directly from the literature (‘in vivo concepts’). With the help of axial coding these categories and concepts were put back together in new ways by making connections between categories using sematic relations. Another approach involved the use of ‘imported concepts’ where concepts are borrowed from other disciplines. At the end of the synthesis meeting a first draft of the theory was developed consisting of in vivo and imported concepts. Each concept was supported by statements of findings; arrows depicted the dynamic relationships between concepts. In a next step, the theory was validated by another researcher who was not involved in the synthesis group. Finally, to further condense the content of the theory, we engaged in a critical dialog with an external expert in theory development.

Findings: According to the proposed situation-specific theory, self-care behaviour is the result of a patient’s decision-making process. This process is mainly influenced by two key concepts: ‘self-efficacy’ and the ‘patient’s disease concept of heart failure.’ The theory focuses on the patient acting on the basis of both key concepts. Numerous inhibitive and facilitative factors have been identified influencing these two key concepts as well as the decision-making process itself, thereby either enabling or hampering the execution of effective heart failure self-care. For example, negative emotions, attitudes and beliefs, uncertainty, incomplete knowledge, comorbidities or adverse effects of self-care functioned as inhibitive factors while sense of control/commitment or increased knowledge served as facilitative factors.

Discussion: When comparing our newly developed theory with an existing theory on self-care, there are three main differences in relation to the:

1.

philosophical base (qualitative paradigm vs. post-empiricism),

2.

level of abstraction (situation-specific theory vs. middle-range theory) and

3.

focus of the theory (focus on barriers and facilitators to self-care in heart failure patients vs. theory of self-care of chronic illness).

Practical implications: The new situation-specific theory provides a useful framework within which nurses are able to systematically and comprehensively study the factors that influence the execution of effective self-care. The theory should be useful to clinicians and scientists in their efforts to promote positive health outcomes resulting in fewer hospitalisations.