Journal of Cardiovascular Nursing

Vol. 31, No. 3, pp 226Y235 x Copyright B 2016 Wolters Kluwer Health, Inc. All rights reserved.

The Situation-Specific Theory of

Heart Failure Self-Care
Revised and Updated
Barbara Riegel, DNSc, RN, FAHA, FAAN; Victoria Vaughan Dickson, PhD, RN, FAHA, FAAN;
Kenneth M. Faulkner, MS, RN, ANP-BC

Background: Since the situation-specific theory of heart failure (HF) self-care was published in 2008, we have
learned much about how and why patients with HF take care of themselves. This knowledge was used to
revise and update the theory. Objective: The purpose of this article was to describe the revised, updated
situation-specific theory of HF self-care. Result: Three major revisions were made to the existing theory: (1) a
new theoretical concept reflecting the process of symptom perception was added; (2) each self-care process
now involves both autonomous and consultative elements; and (3) a closer link between the self-care processes
and the naturalistic decision-making process is described. In the revised theory, HF self-care is defined as a
naturalistic decision-making process with person, problem, and environmental factors that influence the everyday
decisions made by patients and the self-care actions taken. The first self-care process, maintenance, captures
those behaviors typically referred to as treatment adherence. The second self-care process, symptom perception,
involves body listening, monitoring signs, as well as recognition, interpretation, and labeling of symptoms. The
third self-care process, management, is the response to symptoms when they occur. A total of 5 assumptions and
8 testable propositions are specified in this revised theory. Conclusion: Prior research illustrates that all 3 self-care
processes (ie, maintenance, symptom perception, and management) are integral to self-care. Further research
is greatly needed to identify how best to help patients become experts in HF self-care.
KEY WORDS: decision making, heart failure, self-care, self-management, theory

I n 2008, we published the original version of the

situation-specific theory of heart failure (HF) self-
care.1 Since that publication, the theory has been quoted
widely and used to support numerous studies of adults
with chronic HF, as discussed below. The theory also
was used to inform a middle-range theory of self-care
of chronic illness, a more generalizable theory with similar
elements.2 Designing the middle-range theory and study-
ing the literature citing the situation-specific theory led us
to conclude that this theory needs revision and updating.
The purpose of this article was to describe this revised,
updated situation-specific theory of HF self-care.
Barbara Riegel, DNSc, RN, FAHA, FAAN
Edith Clemmer Steinbright Professor of Gerontology, School of
Nursing, University of Pennsylvania, Philadelphia.
Victoria Vaughan Dickson, PhD, RN, FAHA, FAAN
Assistant Professor, College of Nursing, New York University.
Kenneth M. Faulkner, MS, RN, ANP-BC
PhD student, College of Nursing, New York University, and Clinical
Assistant Professor, School of Nursing, Stony Brook University, New York.
The authors have no funding or conflicts of interest to disclose.
Correspondence
Barbara Riegel, DNSc, RN, FAHA, FAAN, School of Nursing,
University of Pennsylvania, 418 Curie Blvd, Philadelphia, PA
19104-4217 (briegel@nursing.upenn.edu).
DOI: 10.1097/JCN.0000000000000244
In the original theory, self-care was defined as a
naturalistic decision-making process involving the choice
of behaviors that maintain physiologic stability (mainte-
nance) and the response to symptoms when they occur
(management). Self-care management was further de-
scribed as an active, deliberate decision-making pro-
cess. Confidence in one’s ability to perform self-care
(task-specific self-efficacy) was described as influenc-
ing the relationship between self-care and outcomes.
Note that, although self-care was said to be a naturalistic
decision-making process, decision making was discussed
only in relation to self-care management. Much has been
learned about HF self-care since 2008. That knowledge
led us to update the assumptions, the propositions, the con-
cepts reflecting self-care processes, and the manner in which
they interact to facilitate further growth in knowledge.
The Revised Theory
In this revised theory, self-care is defined as a naturalis-
tic decision-making process that influences actions that
maintain physiologic stability, facilitate the perception
of symptoms, and direct the management of those
symptoms. Specifically, self-care entails 3 separate but
linked concepts that reflect processes that often are

226

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.


mastered in sequence. The first self-care process is
maintenance, which captures treatment adherence and
healthy behaviors (eg, taking medications, exercising,
and following a salt restricted diet). The second self-
care process, symptom perception, involves both the
detection of physical sensations and the interpretation
of meaning.3 Specifically, symptom perception involves
body listening, monitoring signs, as well as recognition,
interpretation, and labeling of symptoms (eg, ‘‘Iyou
have to listen to your bodyI you have to listen to what
it tells youI the ringIif it gets real tight then I’ll know
I’m holding fluidI’’). Individual symptoms and the
interactions between symptoms influence the meaning
attributed to the symptom experience.4 The third self-
care process is management, or the response to symp-
toms when they occur (Figure 1). All 3 processes involve
both autonomous and consultative elements, discussed
further below.5
Differences Between the Original Theory
and the Revised Theory
This revised theory differs from the original situation-
specific theory of HF self-care in several ways. First, a
third major concept, symptom perception, has been
added. Symptom monitoring (ie, daily weighing) was
included within self-care maintenance in the original
theory on the basis of the common recommendation
that patients weigh themselves to monitor fluid reten-
tion. That is, daily weighing was seen as treatment ad-
herence. Symptom recognition was conceptualized as
initiating self-care management in the original theory
because patients who fail to recognize their symptoms
cannot respond to them. In this revised theory we in-
clude the new concept of symptom perception, which
includes both symptom monitoring and recognition in
addition to body listening, symptom interpretation, and
labeling.
Another major revision is the articulation of a dis-
tinction between autonomous and consultative self-
care behaviors. That is, some self-care behaviors are
thoroughly independent decisions, whereas others are
chosen in consultation with a caregiver or a provider.
For example, a patient who feels short of breath may
FIGURE 1. Diagram of the self-care process. The 3 constructs
of self-care maintenance, symptom perception, and self-care
management are illustrated as building on each other. Symptom
perception is a new addition to the theory.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Theory of Heart Failure Self-Care Revised 227
decide to forego eating salty foods (autonomous deci-
sion), but taking an extra water pill may necessitate a call
to the provider’s office (consultative decision). Vellone
et al5 referred to these as autonomous and provider-
director behaviors, but we have chosen the term con-
sultative to reflect the contributions of caregivers as
well as those of providers. All 3 self-care processes
have an autonomous and a consultative element.
A third major revision is the closer integration of nat-
uralistic decision making (NDM), which is discussed in
detail below. The NDM process exerts a strong influence
on each of the self-care processes of maintenance, symp-
tom perception, and management (Figure 2).6 The man-
ner in which self-care decisions made by patients with
HF are influenced by the NDM elements of person,
problem, and environment is described while acknowl-
edging how these decisions are influenced by knowl-
edge, skills, experience, and values. It should be noted
that, although person characteristics typically influence
the decision-making process, which subsequently in-
fluences self-care actions, this sequence is not always
linear and unidirectional. That is, effective self-care may
influence person characteristics, problem manifestations
(eg, depression associated with HF), and even the en-
vironment. A hypothetical example follows: patients
with HF who takes their medications consistently (a
maintenance behavior) may experience less fluid overload
(a problem manifestation). That stable, euvolemic state
may contribute to better cognition (a person character-
istic). The caregiver, sensing that the patient is thinking
better, may be less overprotective (an environmental char-
acteristic). Over time, this feedback loop can be expected
to promote self-efficacy (a person factor).
The New Concept of Symptom Perception
Bodily sensations are considered symptoms if the sen-
sation is labeled as abnormal, so symptoms are defined
as an aversively perceived internal state.7 The addition
of symptom perception is based on the seminal contri-
butions of Jurgens,8 who described somatic awareness
in patients with HF. Jurgens was one of the first inves-
tigators to explore why patients with HF have diffi-
culty in monitoring, recognizing, and interpreting their
symptoms. Since then, we have demonstrated that older
patients with HF have issues with sensing and inter-
preting early symptoms.9,10 Age-related impairment in
interoception, the process by which sensory nerve recep-
tors receive and process stimuli that originate inside the
body, has been suggested as one mechanism for poor
symptom perception in older persons with HF.9
Another issue complicating symptom perception is
the sheer volume of symptoms experienced by these
patients. Over the past few years, several investigative
teams have described how these symptoms cluster. Two
major symptom clusters have been identified across sev-
eral studies.11Y14 A physical symptom cluster typically
228 Journal of Cardiovascular Nursing x May/June 2016

Theorists of NDM contend that real-life decisions faced

FIGURE 2. The links between the situational characteristics,
the factors influencing the decision-making process, and
self-care actions are illustrated in this figure. The typical
direction (situation to process to action) is illustrated here.
includes shortness of breath, fatigue, and, sometimes,
difficulty in sleeping. An emotional cluster includes de-
pression, worry, and cognitive issues. These findings
suggest that consistent mechanisms may underlie these
clusters of symptoms. Understanding these mechanisms
may facilitate the abilities of clinicians to help patients
with HF to recognize and interpret their HF symptoms.
Self-Care as a Decision-making Process
As noted in the original theory, the performance of self-
care involves making decisions and naturalistic decision
making (NDM) captures that process well. Naturalistic
decision making is a theory that helps to explain how
individuals make decisions in real-world settings that
are meaningful and familiar to them.15 Other decision-
making theories focus on stagnant, fixed decision events
or decisions that can be planned or anticipated such as
the choice between 2 therapies for a specific diagnosis.16
daily are influenced by the interactions among the person,
the problem, and the setting or environment and, there-
fore, situation-specific.
Typically, naturalistic decision makers implement de-
cision rules to match the situation-specific decision with
an action. These decision rules are based on individual
experience and available empirical information. Natu-
ralistic decision making recognizes that real-world de-
cisions are made under conditions of uncertainty, time
constraints, and varied contexts. Therefore, a similar
situation may generate a different decision if the setting
and available information are different. This premise
of NDM is important because it explains why people
make inconsistent decisions about HF self-care. It also
helps us anticipate that even those who are normally
successful with self-care may fail at any time due to
circumstances.
The NDM characteristics17 shown in the Table illus-
trate the complexity of real-life decisions and, thus, the
applicability of NDM to HF self-care. Briefly, real-life
decision situations are ill-structured and rarely present
in a model or ‘‘textbook’’ form. They occur in dynamic
environments with incomplete information and amid
competing demands. These decisions must be made under
time pressure that can be highly stressful to those involved
and with life-threatening consequences (ie, high stakes).
In most NDM situations, there are multiple stakeholders
(eg, patient and caregiver) with varied levels of interest
and engagement in the decision and action. Decisions are
made within the context of these group goals (ie, family
goals, personal values of multiple individuals).

TABLE Examples of the Naturalistic Decision-making Characteristics of Self-care

NDM Characteristic
Ill-structured problems
Uncertain, dynamic
environments
Shifting ill-defined or
competing goals
Action/feedback loops
Time stress
High stakes
Multiple players
Organizational goals
and norms
Definition
Real-life decisions rarely present in model,
‘‘text-book’’ cases.
Decisions are made with incomplete or imperfect
information.
More than 1 purpose drives the decision, or
decisions may be embedded in broader tasks or
driven by larger goals.
Action and outcome are linked.
Decisions are made under the pressure of time,
high personal stress, potential for fatigue, and
loss of vigilance.
The risks associated with a decision may be
life-threatening.
Others may be involved directly or indirectly in
the decision.
Decisions made within an organization or group,
such as the family or social norms, and goals
include the group’s as well as the
individual’s values and goals.
Self-care Example
Deciding that a symptom is related to HF (eg,
feeling tired) when it is not a ‘‘typical’’ HF
symptom (eg, SOB) that the patient experiences
Deciding what to order in a restaurant when food
options have incomplete dietary information
Deciding when to take a diuretic given other
priorities (eg, important business meeting)
Deciding to take an extra diuretic reduces fluid
overload and improves symptoms
Deciding to manage symptoms in a timely manner,
even if it means unpleasant side effects, for
example, increased frequency of urination
Deciding to delay symptom management will result
in an emergency, life-threatening situation.
Family member roles and decisions about meal
preparation may make adhering to a low
salt diet difficult.
Patients decide to participate in family situations
where self-care (eg, dietary restriction,
medication adherence) is difficult, rather than
disrupt cultural traditions.

Abbreviations: RCT, randomized controlled trial; SOB, shortness of breath.

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.


Decisions about HF self-care are made daily, and
NDM is used at each stage of the self-care process. For
example, patients must decide on whether to take medi-
cation or what foods to eat, behaviors meant to maintain
physiologic stability, as well as actions that facilitate
detection of worsening HF through symptom moni-
toring and recognition. According to the NDM theory,
each unique decision will be made on the basis of past
experience and the information available at the mo-
ment. The ‘‘information’’ used in HF self-care decisions
may be objective (eg, salt content of foods, weight gain)
or subjective (eg, salty taste, feeling tired). Confounding
these decisions is the interaction of the person, the problem,
and the environment. Person characteristics (eg, age-related
cognitive decline, gender, and income), problem-specific
factors (eg, comorbid conditions), and environmental fac-
tors (eg, living situation, social support, and current milieu)
help to explain why NDM varies widely among individuals.
In the context of HF self-care, decisions must be made
about how to manage a symptom exacerbation, a sit-
uation that may have life-threatening consequences. Spe-
cifically, someone who decides not to actively manage
symptoms of increasing fluid retention in a timely manner,
rather deciding to ‘‘wait and see,’’18 risks rapid deteriora-
tion of cardiac status and even death. We have previously
delineated the process of managing symptoms as a
recognition-primed form of NDM.6 Recognition-primed
decisions19 emphasize situational awareness and mental
simulation of an action plan. On the basis of prior ex-
perience, situations are recognized as familiar (usually
based on external cues such as signs and symptoms) and
possible actions are mentally identified. These options
may be presented serially with the most common (pre-
viously successful) action first. For example, perhaps an
individual with HF rested the last time he or she exper-
ienced shortness of breath so that is considered to be a
good option this time. Mental evaluation of the adequacy
of the option is then performed to identify weaknesses
with the option and alternatives. If a weakness is iden-
tified (eg, I don’t have time to rest right now), then the
individual with HF mentally identifies another course
of action. Although recognition-primed decision making
is conceptualized as a serial approach, under pressure,
decision makers are able to act quickly while simulta-
neously evaluating options. In turn, successful experiences
(eg, symptom alleviation) support future recognition-
primed decision making situations through enhanced sit-
uational awareness and the mental simulation process. In
summary, the theory of NDM informs the situation-specific
theory of HF by furthering our understanding of why
patients make particular decisions regarding self-care.
Factors Influencing Decisions About
Self-Care
According to NDM, there are several factors influenc-
ing a decision about self-care, including experience,
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Theory of Heart Failure Self-Care Revised 229
knowledge, skill, and compatibility with values.15 Ex-
perience builds knowledge or skill in a particular content
area as a result of involvement in or exposure to the
matter or the phenomenon.20 Our work defining a ty-
pology of HF self-care identified experience both quan-
titatively and qualitatively21 as central to how patients
develop expertise in self-care. Cameron and colleagues22
also concluded that experience explained a significant
amount of the variance in self-care maintenance and
management even after controlling for other covariates.
Knowledge refers to the relevant information that
one is able to recall from memory and previously learned
material.23 Knowledge acquisition, the goal of most edu-
cational interventions, involves the complex cognitive
processes of perception, learning, communication, asso-
ciation, and reasoning. Knowledge acquisition is evi-
denced by the ability to interpret and explain meaning
when required. For example, patients who have 2 diag-
noses causing shortness of breath need to acquire knowl-
edge about the characteristics of that symptom so that
they can reason about which incident is caused by HF
and which is caused by the other illness (eg, pulmonary
disease).
Knowledge and experience with both the decision
and the action influence the decision-making process
by helping to identify patterns in situations and match
those patterns to a decision and an action. Without both
experience and knowledge about the situation, the de-
cision and the planned action as well as the meaningful-
ness of a situation may not be recognized. Failure to
recognize meaningfulness will impede mental simula-
tion of a plan and judgment regarding potential con-
sequences of the chosen self-care behavior.6,15
The importance of knowledge in HF self-care is well
documented as a determinant of self-care, especially
dietary sodium restriction24 and medication adherence.25
Thus, it is not surprising that patient education is a
primary goal of HF intervention programs. However,
despite a plethora of patient education interventions,
many have reported discrepancies between knowledge
attained and self-care behavior.26,27 This observation
reinforces our point that knowledge is only 1 factor af-
fecting self-care.
Skill in both making a decision and acting on the de-
cision once it is made is required to carry out a successful
self-care behavior. Skill is the ability to use one’s knowl-
edge readily and effectively to carry out a task or per-
formance.20 Skills are acquired as the result of practice
and experience in a process that usually occurs over time.28
In HF self-care, we have argued that requisite skills for
self-care include both tactical (‘‘how to’’) and situational
(‘‘what to do when’’) skills.29 For example, those who
lack skill in basic tasks associated with medication taking
(eg, reading labels) have lower medication adherence.30
Similarly, lack of skill in selecting low-sodium foods has
been reported as contributing to poor diet adherence.31
230 Journal of Cardiovascular Nursing x May/June 2016
Patients who lack skill in ‘‘what to do’’ when faced with
special circumstances, for example, during holidays or
vacation, are at risk for lapses in self-care maintenance.21
Similarly, even among those who weigh themselves daily,
lack of skill in evaluating the data obtained32 and using
it to manage symptoms (eg, diuretic titration) results in
poor self-care.33
Finally, the action or behavior chosen must be com-
patible with one’s values. Values can be defined broadly
as preferences concerning appropriate courses of ac-
tion or outcomes and reflect one’s sense of right and
wrong.34 Personal values serve as an internal reference
for what is good, important, or constructive.35 Personal
values are derived from cultural values, either in agree-
ment with or divergent from prevailing culture and social
norms.36 According to NDM, even decisions meeting
one’s internal reference point as ‘‘good’’ or ‘‘useful’’
may vary between individuals and situations because
of the influence of sociocultural factors. For example,
it may be more important for some persons to feel like
they are having a ‘‘normal’’ meal with friends than to
believe they are following the treatment plan.
Person Factors Influencing Decision Making
Person-related factors such as ethnicity or cultural iden-
tity,37 level of acculturation,38 socioeconomic status,39
and health literacy40 greatly influence self-care. How
one perceives, experiences, and copes with an illness
affects behavior through the power of social norms
and cultural beliefs.41 For example, low-income ethnic
minority patients have reported difficulty in dietary ad-
herence due to conflict with cultural food preferences,
cooking techniques, and family roles.42 Similarly, the
cultural meaning ascribed to HF and perceptions about
role-appropriate behavior in performing self-care also
influence daily self-care decisions. For example, those
with fatalistic beliefs about HF who decide to rest in
response to worsening HF symptoms may delay symp-
tom management or definitive treatment until wors-
ening symptoms prompt emergency care. The cultural
importance of spirituality and religious beliefs on self-
care has been well established in ethnic minority pop-
ulations with chronic disease.43
Self-efficacy has a powerful influence on the self-
care decisions made and actions taken by patients.
According to Bandura,44 self-efficacy is the confidence
that one has in the ability to perform a specific action
and persist despite obstacles. In general, self-efficacy is
influenced by experiential learning (ie, experience with
the situation), role modeling (ie, observing someone
else), social persuasion (ie, input from family, friends,
and providers), as well as physiological cues (ie,, symp-
toms). In HF, self-efficacy regarding the ability to per-
form self-care is illustrated in narrative accounts of
expertise and skill.21 Similarly, HF patients with higher
levels of self-efficacy report better self-care45 and have
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
better survival,46 psychological well-being, as well as
health-related quality of life (HRQL), compared with
those with low self-efficacy.47 We have reported that,
when faced with competing self-care instructions, patients
make decisions about behaviors in which to engage partly
on the basis of their self-efficacy.48 It may be that self-
efficacy reflects one’s experiences and skills and thereby
influences the NDM process of HF self-care.
Problem Factors Influencing Decision Making
Multimorbidity is common in patients with HF. In
elderly HF patients, HF virtually never occurs in iso-
lation.49 Living with more than 1 condition poses phys-
ical limitations and increases the need for support and
financial resources, which sap time and energy.50 Lack
of knowledge and the practicalities of obtaining care,
administering multiple medications, as well as dealing
with complex symptoms and treatments decrease the
ability to perform self-care. These same factors nega-
tively influence self-care by decreasing self-efficacy.48,51
Physical functioning is the ability to perform nor-
mal daily activities required to meet basic needs, fulfill
usual roles, as well as maintain health and well-being.52
Poor physical functioning may interfere with patients’
abilities to engage in activities such as grocery shopping,
visiting the pharmacy, and regular exercise. However,
studies on the association between physical functioning
and self-care have been mixed. Whereas some have
found that poor physical functioning is associated with
poor self-care maintenance,53 others have found that
poor physical functioning is associated with better self-
care management.54 That is, symptomatic patients were
more likely to engage in self-care than asymptomatic pa-
tients. We have previously suggested that patients with
HF may fail to engage in self-care until they experience
functional decline and worsening symptoms.55 Such in-
consistencies illustrate that the self-care process is in-
fluenced to varying degrees by person, condition, and
environmental factors.
Mild cognitive impairment (MCI) is prevalent in HF,
affecting as many as 58% of those with the syndrome.56
Individuals with MCI often present with subtle deficits
in memory, attention, and the ability to perform goal-
directed behavior.56,57 These deficits often do not influence
activities of daily living and do not meet the criteria for
dementia.57 However, persons with MCI have difficulty
in recognizing symptoms of an exacerbation when they
occur and are often unable to recall how to respond.58 As
a result, self-care fails and negative outcomes (eg, hospi-
talization, death) increase.59
Environmental Factors Influencing
Decision Making
Emotional support and tangible support are integral
to successful self-care.60 Owing to functional limitations,
patients with HF often need help with activities such as

cooking, shopping, remembering to take medications,
and symptom recognition.61 However, many patients
with HF live alone and are unable to access estab-
lished social services.62 Social norms influence whom
they are willing to ask for support,42 which can lead to
social isolation and poor self-care. For those who do
live with a caregiver, a growing body of research illus-
trates that dynamics within the dyad influence self-
care in subtle and complex ways.63,64
The preceding section addresses only a selection of
the many person, condition, and environmental factors
influencing HF self-care. Some topics have been ignored
because there are few data in the area. Others, such as
gender, are not discussed because few self-care differ-
ences have been identified between men and women.65
Others, such as access to care, do not fit cleanly within
a single topic. For example, living in a rural setting is
clearly an environmental characteristic that influences
access to care. However, those living in such areas are
often resilient as well as share strong cultural beliefs
and social norms (person factors), which promote self-
care. Clearly, we do not understand the major factors
contributing to poor self-care when person, problem,
and environmental factors interact. Understanding
such interactions will drive future interventions.
Theoretical Assumptions and Propositions
Specifying assumptions allows the reader to understand
what the theorist believes without evidence. An assump-
tion originally stated was that patients who are able to
recognize their symptoms will be better at subsequent
steps in the process.1 At this point, research methods
have developed to such an extent that this assumption
is now a testable proposition. Here, we state a more
comprehensive list of assumptions:
1. Human beings want to feel physically and emo-
tionally well and healthy.
2. Cognitively intact adults hold primary responsibil-
ity for their own health.66
3. All self-care involves decision making; persons who
do not engage in self-care have made a decision to
behave in the chosen manner.67
4. Self-care can be learned.
5. When person, problem, and environmental factors
interact, they contribute to self-care in unique ways.
In our original theory, we proposed 4 propositions:
(1) Symptom recognition is the key to successful self-
care management; (2) Self-care is influenced by knowl-
edge, experience, skill, and compatibility with values;
(3) Confidence mediates the influence of self-care on
outcomes; and (4) Confidence moderates the influence
of self-care on outcomes.1 Here, we extend and refine
this list of propositions. These propositions are testable;
doing so would add to the validity of this theory.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Theory of Heart Failure Self-Care Revised 231
1. Specific maintenance behaviors are influenced by
unique factors. For example, poor medication ad-
herence may be caused by inconsistency with one’s
values (eg, a dislike of taking medicines), lack of knowl-
edge (eg, not realizing the importance of regular dosing),
forgetting (common with sleep deprivation68,69), and
lack of habit formation.70 Dietary sodium adherence
is influenced by the quantity of food intake and ac-
cess to diverse food sources.71
2. Clusters of physical and emotional symptoms in-
fluence self-care in unique and important ways.72
3. Decisions about self-care may be conscious or sub-
conscious. Conscious and subconscious decisions
reflect choices driven by the interaction of person,
problem, and environmental factors.
4. Comorbid conditions impair abilities of patients
with HF to differentiate the cause of their symp-
toms51 and impair self-care self-efficacy.48
5. Self-care self-efficacy mediates and/or moderates the
relationship between predictors of self-care; the self-
care behaviors of maintenance, symptom perception,
and management; and/or outcomes. Higher self-care
self-efficacy is associated with better self-care and im-
proved HF outcomes.73,74
6. Moderate to high levels of HF self-care are needed
to improve outcomes.75Y77
7. As self-care self-efficacy increases, autonomous self-
care behaviors increase.
8. Mastery of self-care maintenance precedes mastery
of symptom perception, which precedes self-care man-
agement. That is, self-care appears to be a linear process
proceeding from maintenance, to symptom percep-
tion, to management. Management of symptoms is
the highest, most refined self-care behavior requir-
ing the most knowledge and skill.
Heart Failure Outcomes Are Influenced
by Self-care
There is emerging evidence that HF self-care can im-
prove both patient-reported (eg, HRQL, symptom sev-
erity) and clinical (eg, hospitalizations, mortality)
outcomes. Although the mechanism linking self-care
and outcomes is not entirely clear, it is hypothesized
that self-care influences the pathogenesis and delays
the progression of HF through 2 dominant mecha-
nisms. First, self-care partially deactivates and blocks
neurohormonal activity. Second, self-care mitigates the
systemic inflammatory response.78 Self-care mainte-
nance behaviors (eg, medication adherence) are asso-
ciated with partial neurohormonal deactivation and a
significant reduction in biomarkers of systemic inflam-
mation. Adherence to sodium restriction is posited
to be associated with a reduction in neurohormonal
activation.
232 Journal of Cardiovascular Nursing x May/June 2016
Collectively, effective self-care maintenance is asso-
ciated with fewer episodes of congestion as well as less
dyspnea and fatigue,79 the consequence of neurohor-
monal activation. Individuals who quickly and effec-
tively recognize (symptom perception) and manage
symptoms (management) are less likely to have high
levels of biomarkers of neurohormonal activation and
systemic inflammation,77 which cause HF progression.
Conversely, patients with poor self-care are more likely
to go to the emergency department80 or be hospital-
ized.81,82 Interestingly, the relationship between HF self-
care and outcomes may depend on the situational factors
of person, problem, and environment. For example, ob-
jectively measured medication adherence, a component
of self-care maintenance, predicts HF hospitalizations83
and event-free survival84 even in HF patients with multi-
morbidity (problem factor).
Although some have reported that better self-care
is associated with better HRQL,73,85 the literature in
this area is mixed. Lee et al75 described 2 trajectories
of self-care management and HRQL in a longitudinal
prospective study of adults with chronic HF, which
suggests that clinically relevant improvements in self-
care management are associated with an improvement
in HRQL. Interestingly, these changes were indepen-
dent of self-care maintenance. It may be that effective
FIGURE 3. Summary of search strategy used to identify articles reviewed.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
symptom management leads to fewer symptoms, bet-
ter functional status, and overall improved physical
well-being, a domain of HRQL. However, others have
described short-term, unsustained effects of self-care
interventions on HRQL.86 In a recent study testing a
skill-based self-care intervention in a clinically stable,
community-dwelling population, we saw no improve-
ment in HRQL.87 Rather, qualitative data suggested
that daily self-care, especially dietary adherence and
symptom monitoring, was burdensome to individuals.
Collectively, these results suggest that self-care can
lessen symptoms, increase functional capacity, improve
HRQL, and help patients to avoid clinical events (eg,
hospitalization). Further research is essential to illustrate
the level and type of self-care needed to improve specific
outcomes. That is, we do not know whether exercise is as
effective as medication adherence in avoiding hospi-
talization, for example.
How Can This Theory Be Used in Research?
Theory is constructed to describe a situation, explain
how elements of the theory are related to each other in
a specific situation, and make predictions about future
events. To achieve these goals, a theory is represented
by propositions suggesting ways in which the concepts

What’s New and Important
h A third concept, symptom perception, has been added
to the theory.
h Each process includes both autonomous and consultative
elements.
h This revised theory is more closely integrated with the
naturalistic decision-making elements of person, problem,
and environment and with the self-care decisions made
by patients with HF while acknowledging how these
decisions are influenced by knowledge, skills, experience,
and values.
are related, factors that influence the concepts, and
underlying mechanistic processes. To determine how the
theory is being used, we reviewed the existing literature.
Review of the Literature
The following electronic databases were searched to iden-
tify articles in which the theory was cited: CINAHL,
PubMed/Medline, PsycINFO, SCOPUS, EMBASE, and
the Cochrane Database of Systematic Reviews. The
phrase ‘‘Situation Specific Theory of Heart Failure Self-
Care’’ was used as the primary search term. Inclusion
criteria included peer-reviewed articles written in English.
No limitations due to date or type of article were im-
posed on this search. To ensure inclusion of all liter-
ature citing the theory, the references of articles were
scanned and the search was replicated in Google Scholar.
After removal of duplicates, 172 articles remained. All
titles and abstracts were reviewed to determine relevance.
Dissertations, commentaries, editorials, letters to the edi-
tor, psychometric evaluations of instruments, translations
of instruments, studies investigating conditions other
than HF, studies in languages other than English, book
chapters, and research protocols were excluded.
Eighty-five relevant articles were retained (Figure 3).
The full text of each article was retrieved and reviewed
twice. Information on study purpose, use of the theory,
sample size, sample characteristics, and key findings
were extracted for all research articles. For literature
reviews, the number of articles included in the review
was extracted in place of the sample size. All data were
summarized in a table of evidence (available from the
authors). The information obtained in this search was
used to determine how the theory is being used and to
identify areas needing further clarification and expansion.
The review of the literature illustrated that many
people are referencing the theory but are not really
testing it or using it in practice. Those studies testing
the theory have focused predominately on testing a
single hypothesis derived from the theoretical propo-
sitions. Admittedly, the early propositions we specified
were simple and much of the theory testing to date
mirrors the simplicity of that early work. However, if
the ultimate goal of theory is to describe how the con-
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Theory of Heart Failure Self-Care Revised 233
cepts behave together as a group in specific situations
so that we can predict how the future will unfold, users
are encouraged to consider testing theoretical propo-
sitions as a group.
Example of How to Test the Theory
A proposition of the situation-specific theory is that self-
efficacy mediates or moderates relationships involving
self-care. The performance of both self-care maintenance
and management is thought to be influenced by self-
care confidence.1 In a test of the theory, we studied the
links between comorbidity, self-efficacy, and self-care.
Using a mixed-methods design, we tested the moderat-
ing effect of comorbidity on the relationship between
self-efficacy and self-care in adults with HF.48 That is,
we asked the question of whether the influence of self-
efficacy on HF self-care is influenced by the number and
severity of comorbid conditions. We demonstrated a sig-
nificant relationship between comorbid conditions and
self-care. In the qualitative data, self-efficacy emerged as
an important variable influencing self-care by shaping
how individuals prioritized and integrated multiple and
often competing self-care instructions. Hence, we tested
comorbidity as a moderator of the effect of self-efficacy
on self-care. We found that comorbidity influenced the
relationship between self-efficacy and self-care mainte-
nance but not the relationship between self-efficacy and
self-care management. On the basis of these results, it
appears that comorbidity may have more of an influence
on treatment adherence and healthy behaviors than on
symptom management. This example illustrates how per-
son and problem factors interact with knowledge and
skills to influence the decisions made by patients about
self-care. Limitations of this study included the cross-
sectional nature of the analysis. Future studies that are
prospective and longitudinal would greatly expand what
we know about HF self-care as would studies testing the
situation, process, and action links shown in Figure 2.
In conclusion, research on HF self-care suggests that
all 3 self-care processes (ie, maintenance, symptom per-
ception, and management) are integral to self-care. Know-
ing how person, problem, and environmental factors
influence the everyday decisions made by patients illus-
trates why mastering self-care is challenging for patients.
Clearly, learning how to perform self-care will require
more than a brief discussion with a provider. Further
research is greatly needed to identify how best to help
patients become experts in taking care of themselves.
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