Journal of Cardiovascular Nursing

Vol. 30, No. 2, pp 121Y135 x Copyright B 2015 Wolters Kluwer Health, Inc. All rights reserved.

A Systematic Review of Patient Heart Failure

Self-care Strategies
Karen Harkness, PhD, RN, CCN(C); Melisa A. Spaling, MEd; Kay Currie, PhD, RN;
Patricia H. Strachan, PhD, RN; Alexander M. Clark, PhD, RN
Downloaded from https://journals.lww.com/jcnjournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3Le0ic6pTQVBfkAx6Wfv//RvM7YqyUIDirp9B7FEzKei31cFpxLAaeg== on 03/10/2019

Background: Self-care is at the foundation for living with a chronic condition such as heart failure (HF). Patients with
HF express difficulty with translating self-care knowledge into understanding ‘‘how’’ to engage in these activities and
behaviors. Understanding the strategies that patients develop to engage in self-care will help healthcare providers (HCPs)
improve support for unmet self-care needs of HF patients. The purpose of this systematic review was to highlight
strategies that HF patients use to accommodate self-care recommendations into the reality of their daily lives.
Methods: A systematic review using qualitative meta-synthesis was carried out. Included studies had to contain a
qualitative component and data pertaining to self-care of HF from adults older than 18 years and be published as full
papers/theses beginning 1995. Ten databases were searched until March 19, 2012. Results: Of 1421 papers
identified by the search, 47 were included. Studies involved the following: 1377 patients, 45% women, mean
age of 67 years (range, 25Y98 years), 145 caregivers, and 15 HCPs. Approaches to self-care reflected both
perception- and action-based strategies and were a means to effectively manage HF. Although HF patients often
expressed difficulty on how to integrate self-care recommendations into their daily lives, they developed
intentional, planned strategies that harnessed previous experiences. Conclusions: Healthcare providers must
appreciate that patients view self-care as an ‘‘adaptation’’ that they undertake to maintain their independence and
quality of life. In addition, HCPs must recognize that because self-care is a process of learning over time from
experience, an individualized approach that emphasizes how to self-care must be adopted for patients to develop
the necessary HF self-care skills.
KEY WORDS: heart failure, meta-synthesis, self-care

Karen Harkness, PhD, RN, CCN(C) Background

Clinician Scientist, School of Nursing, Heart Function Clinic,
McMaster University, and Hamilton Health Sciences, Hamilton,
Ontario, Canada.
Melisa A. Spaling, MEd
Research Assistant, Faculty of Nursing, University of Alberta,
Edmonton, Alberta, Canada.
Kay Currie, PhD, RN
Reader, School of Health & Life Sciences, Glasgow Caledonian
University, Scotland, United Kingdom.
Patricia H. Strachan, PhD, RN
Associate Professor, School of Nursing, McMaster University,
Hamilton, Ontario, Canada.
Alexander M. Clark, PhD, RN
Professor, Faculty of Nursing, University of Alberta, Edmonton,
Alberta, Canada.
Dr Harkness is supported by a Research Early Career Award with the
Hamilton Health Sciences, Ontario, Canada.
This study was funded by the Canadian Institutes of Health
Research-Knowledge Synthesis Grant 2010.
Supplemental digital content is available for this article. Direct URL
citations appear in the printed text and are provided in the HTML
and PDF versions of this article on the journal’s Web site
(www.jcnjournal.com).
Correspondence
Alexander M. Clark, PhD, RN, Level 3, Edmonton Clinic Health
Academy, 11405 87 Avenue, Edmonton, AB, Canada T6G 1C9
(alex.clark@ualberta.ca).
DOI: 10.1097/JCN.0000000000000118
What strategies do patients use to self-care for heart
failure (HF)? Although this self-care should be focused
around particular types of tasks or domains (including
weight monitoring, taking multiple medications, symp-
tom management, physical activity, smoking cessation,
and diet restriction), self-care is also recognized to be
a complex process. For example, a common approach
conceives self-care in HF as ‘‘the decisions and strat-
egies undertaken by the individual in order to maintain
life, healthy functioning, and well being.’’1(p364) In this
context, HF self-care can be conceptualized not only
as an outcome that can be measured2,3 but also as a
complex naturalistic process.4Y7 This is corroborated
by the recent American Heart Association Scientific
Statement which views HF self-care in terms of ‘‘natu-
ralistic decision-making’’ to emphasize that self-care is
a process, undertaken in the real-world setting, influ-
enced by individual, contextual, and situational factors.8
Understanding strategies that patients use to engage
in self-care recommendations is important because this
syndrome causes widespread and avoidable personal suf-
fering and contributes to unsustainably high healthcare

121

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122 Journal of Cardiovascular Nursing x March/April 2015

costs.9 Heart failure is associated with high mortality,
frequent hospitalizations, and an economic strain on
the healthcare system.9 Heart failure is extremely com-
mon as it affects a large and growing proportion of the
ageing population in high-income countries.10 In the
United States, approximately 5.7 million people have
HF, with more than 500 000 newly diagnosed cases
each year.10 Furthermore, HF also places a heavy finan-
cial burden on the healthcare system and is one of the
most costly chronic conditions in developed countries.9
It is estimated that the cost of HF consumes between
1.1% and 1.9% of total healthcare spending in devel-
oped countries, with 50% to 74% of the HF costs attri-
buted to hospitalization or long-term institutional care.9
Strategies to improve clinical outcomes and decrease
the burden of HF are clearly needed.
Consensus guidelines for the treatment of patients
with HF from North America and Europe state that
self-care is a key component of daily HF management.11Y13
However, despite this importance, most patients have
difficulties with engaging in the necessary activities rec-
ommended in the clinical guidelines. Current evidence
has identified various personal, psychosocial, and con-
textual factors that influence self-care8,14Y19; however,
the strategies that patients and caregivers use to enact
self-care recommendations are less understood. Insight
that goes beyond the known facilitators and barriers to
self-care and extends to understanding the strategies that
patients develop to engage in self-care is required to help
healthcare providers (HCPs) better understand the self-
care needs of HF patients. Generation of such knowl-
edge is best suited for a qualitative research design20
because qualitative research methods examine the com-
plexities of self-care processes and behaviors as they
occur in natural settings from the perspectives of those
engaged in care and can then capture the ‘‘insider’’
perspectives of those most closely involved.21 This im-
portant, yet currently untapped, body of knowledge is
critical to improving understanding about the nature
and complexity of HF self-care needs and to develop-
ing more effective support, health services, and inter-
ventions that are responsive to the needs of patients.
The purpose of this study was to conduct a meta-
synthesis of qualitative research literature exploring
self-care needs in HF to highlight the strategies that
patients use to accommodate self-care recommenda-
tions into the reality of their daily lives.
via titles and abstracts) as being related only to ‘‘self-
care.’’ This is vital when reviewing qualitative research
of HF because studies are often framed in general terms
(eg, ‘‘patient experiences’’) but may contain themes and
data relating to self-care.
Study Selection
To be included in this review, studies had to report pri-
mary qualitative data wholly or as part of mixed-methods
designs, contain population-specific data or themes from
adults older than 18 years, reasonably seen to pertain to
self-care, be published in the English language, and be
published as full papers/theses during or after 1995. The
search strategy combined general and specific terms relat-
ing to HF and qualitative design and was used to search
the following databases until March 19, 2012: Ovid
MEDLINE, Ovid EMBASE, Ovid PsycINFO, CSA Socio-
logical Abstracts, Ovid AARP Ageline, EBSCO Academic
Search Complete, EBSCO CINAHL, EBSCO SocINDEX,
ISI Web of Science, and Scopus. A comprehensive range of
terms and synonyms associated with HF were used along
with a filter designed to identify the full range of quali-
tative methods (See Table Supplemental Digital Content 1,
http://links.lww.com/JCN/A6). We also searched Proquest
Dissertations and Theses database, scanned the reference
lists of recent papers, and consulted with colleagues.
All papers identified by the systematic search were
screened for relevancy first by their titles/abstract.
Papers that seemed to be potentially relevant were then
full-text screened against the inclusion criteria (Figure).

Methods
This review is an analysis of qualitative research stud-
ies that were focused on the complex factors and pro-
cesses that influence self-care. Qualitative meta-synthesis
has been used to understand various aspects of health
around disease management22,24 and, importantly, is FIGURE. Flow of studies from identification to inclusion.
HF indicates heart failure.
not dependent on using studies that self-identify (eg,

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.


The meta-synthesis approach of Noblit and Hare25
was used to synthesize data from relevant studies. This
interpretive approach to synthesis involved first extract-
ing verbatim data or themes related to self-care from
studies into a paper-based matrix. Before commencing
the review, self-care was defined as the decisions and
strategies undertaken by the individual to maintain life,
healthy functioning, and well-being.1(p364) To support
consistent interpretation among the team, data or themes
were interpreted to be relevant if ‘‘findings related to any
process, phenomena, or construct that pertains to the
self-care of HF in patients or support of self-care by lay
caregivers as described by HF patients.’’ The coding of
themes was paper based: 4 reviewers (A.M.C., K.H.,
P.H.S., and K.C.) examined the relationships between
concepts identified in the findings from the matrix.
Second-order interpretations of common or reoccurring
concepts were derived, noted comprehensively, and in-
terpreted in the context of study quality and setting.
The main concepts identified during the second stage
were then used to reinterpret each paper and reconsider
the relationships between the papers. The results of this
synthesis are the findings of the review.
The quality of all included studies was assessed using
the criteria from the Critical Appraisal Skills Programme
Qualitative Appraisal Tool25 (See Table, Supplemental
Digital Content 2, http://links.lww.com/JCN/A7). Studies
were ranked low, moderate, or high quality based on key
methodological questions from the Critical Appraisal Skills
Programme tool but were not excluded on the basis of low
quality. Both screening and quality appraisal involved
independent assessment by two reviewers and any dis-
agreements were resolved by discussion among the re-
search team.
Results
Search Results
Of 1421 papers identified (Figure), 47 met the criteria
for inclusion in the review of patients’ self-care strategies
(Table). Main reasons for exclusion were that papers
did not contain data on HF self-care or did not have a
qualitative methodology. Studies involved 1377 patients
(45% women; mean age, 67 years; age range, 25Y98
years), 145 caregivers, and 15 HCPs. With some excep-
tions, populations were predominantly white and urban
dwelling. Most studies were conducted in the United
States (n = 25), and overall, study quality was mod-
erate (n = 30), with common study weaknesses being
superficial analyses of themes, overreliance on conve-
nience sampling, and insufficient description of sample
characteristics (Table).
Patients used various strategies to accommodate self-
care recommendations and HF into the reality of their
daily lives. In general, engaging in self-care required
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Review of Patient Heart Failure Self-care Strategies 123
both perception-based and action-based strategies and
was often described by patients in the context of adapt-
ing to stressors associated with living with a chronic
condition. Furthermore, strategies were complex, inten-
tional, and planned, and represented coherent approaches
undertaken by patients that harnessed previous experi-
ences and were a means to manage living with HF.
Perception-Based Self-care Strategies
Living with HF is viewed as a life-changing event be-
cause it imposes significant stressors for patients on both
their physical capabilities and sense of self.28,41,50,57,65
Patients often go through a phase of acceptance and
adjustment as they have to modify their expectations
about life, adjust their lifestyles to HF, and place HF
in some context.65 In response to stressors experienced
by HF patients, coping mechanisms and resources are
mobilized and can subsequently influence patient self-
care strategies.73 Coping mechanisms found to facil-
itate or interfere with engagement in self-care fell into
two main strategic approaches: a perception-based strategy
or action-based strategy.
A perception-based strategy can be described as a
cognitive, emotional, or psychosocial response to help
adjust or cope with living with the chronic condition,
leading to a gradual redefinition of the self and enabling
a person to get on with life.30,52,65 Many patients with
HF accepted that it was possible to maintain a good
quality of life, although this often required a reeval-
uation of what they truly valued.27,29,36,59,69 This type
of strategy may be embedded in perceptions that reflect
cultural beliefs, social norms, or spirituality.33,36,52,59,66,74
Emerging evidence suggests that perception-based strat-
egies may support self-care adherence. For example,
one person described the realization that he needed to
‘‘take his HF serious’’ and accept this diagnosis.61 He
continued to miss family events that were important
to him because of worsening HF. This loss brought him
to consider his personal value of family involvement
and acceptance of his HF; this supported subsequent
self-care behaviors.61 Another person shared his strat-
egy for engaging in self-care in terms of the self-help
principles in the context of ‘‘going to AA; the Twelve
Steps. You have to accept, I have a problem I have to
do something about, and start doing it.’’41(p162)
Some patients reported perception-based strategies
that seemed as a rejection of self-care, such as denying35,59
or ignoring symptoms53 and smoking or binge eat-
ing.43,46,72 For example, one person described an emo-
tional reaction and its impact on adherence to dietary
restrictions,
Considering how I used to be and nowIthat has changed
drasticallyI. I find it very hard sometimes to deal withIit’s
very emotional. This morning after I got into the office
for a while I just, uh, cried for a little bit, a sense of
124 Journal of Cardiovascular Nursing x March/April 2015

TABLE Quality Appraisal and Methodological Descriptions of Included Studies (n = 47)

Sample Pt, Mean
Author Quality HP, Cg Age and/or
(Study Rank Main Strengths (+) and Sampling (Male/ Range
Setting) (L/M/H) Weaknesses (j) Method/s Strategy Female) (Sex)
Bennett M + Congruity between research FG Convenience 23 Pt (16/7) 60 Pt only
et al26 methodology, data analysis,
(United States) and interpretation of results;
detailed description of analysis
procedures
j Did not provide sufficient sample 18 Cg (17/1)
characteristics (NYHA class, age
range); difficult to assess the
generalizability of the analyses
Boren27 H + Congruity between research SSI Convenience 15 Pt (0/15) 28Y76
(United States) methodology and interpretation
of results; strong grounded
theory approach
j Discusses not only data collected
in the study data but also data
collected within the author’s
nurse practice
Brannstrom M + Detailed presentation of themes UI Convenience 15 HP (11/4) 37Y65
et al28 and subthemes; participants
(Sweden) are adequately represented in
the themes/findings
j Participants recruited from single
site; limited description of data
analysis
Buetow L + Data analysis procedures are well SSI Convenience 62 Pt (NR) NR
et al29 described; large sample size
(New Zealand)
j Difficult to generalize results;
lacks description of sample and
rationale for sampling strategy
Costello and M + Congruity between research SSI Purposive 6 Pt (3/3) 30Y73
Boblin30 methods and data collection 6 Cg (NR)
(Canada) procedures; analysis done by
2 researchers
j Small sample size; analysis and
interpretation of results seem
superficial
Dickson et al31 M + Congruity between conceptual SSI; survey Purposive for 41 Pt (26/15) 25Y65
(NR) basis for study, research NYHA II or
methodology, theoretical III, younger
framework, and interview age
methods
j Sample may be too small to draw
conclusions about typology;
analysis procedures described
but not illustrated
Dickson et al32 M + Clear conceptual basis for study; SSI; survey Purposive 41 Pt (26/15) 49
(NR) integration of qualitative and 25Y65
quantitative findings
j Small sample size limits strength
of quantitative evidence; sample
predominantly white, male
Dickson et al33 M + Congruity between research SSI; survey Purposive 30 Pt (18/12) 59.6
(United States) methodology and methods;
26Y98
detailed description of data
integration and triangulation; use
of a theory-driven interview guide
j Lack of researcher reflexivity; very few
sample interview questions provided
(continues)

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

 Review of Patient Heart Failure Self-care Strategies 125

TABLE Quality Appraisal and Methodological Descriptions of Included Studies (n = 47), Continued
Sample Pt, Mean
Author Quality HP, Cg Age and/or
(Study Rank Main Strengths (+) and Sampling (Male/ Range
Setting) (L/M/H) Weaknesses (j) Method/s Strategy Female) (Sex)
Europe and L + Qualitative approach gives voice to SSI Convenience 20 Pt (20/0) 59
Tyni-Lenne34 men’s experiences of living 43Y73
(NR) with HF
j Lacks theoretical framework (eg,
no explicit use of gender theory);
quote identifiers are not used so
it is difficult to know if the
sample is adequately represented
Falk et al35 M + Clear description of data analysis; SSI Purposive 17 Pt (12/5) 72
(Sweden) provides sample data for all 55Y83
main categories
j Interview questions not provided;
illustrative quotes are sometimes
rather mundane
Freydberg M + Strong rationale for theoretical SSI Purposive 42 Pt (NR) 76
et al36 (Canada) framework; detailed description
30 Cg (NR) 65Y85
of sample recruitment, data
collection, analysis procedures,
and limitations indicative of rigor
j Authors state that the interview
guide was informed by current
guidelines yet this is not
apparent in findings
Gary37 M + Theoretical framework informs SSI Convenience 32 Pt (0/32) 68 Pt only
(United States) interview questions; provides
quotes and frequency counts
for each topic
j Interview guide may limit
qualitative data generation;
unclear how representative the
data are of the sample
Glassman38 M + Detailed systematic research UI Convenience; 5 Pt (3/2) 77.2
(United States) approach; use of independent purposive 60Y85
auditor to verify transcripts
j Small sample; quotes seem to
draw from few participants;
data seem repetitive
Granger et al39 M + Congruity between theoretical SSI Purposive 6 Pt (5/1) 58 Pt only
(United States) framework and interview guide
6 HP (3/3)
and approach to analysis; unique
focus on patient-physician dyads
j Findings seem to be congruent
with data collection and analysis,
yet there are little patient data to
substantiate results
Helleso et al40 M + Basic interpretive descriptive SSI Convenience 14 Pt (6/8) 79.6
(Norway) approach; rationale for data 71Y93
collection approach
j Sample not well described; quote
identifiers not used; themes
seem superficial
Hopp et al41 M + Detailed descriptions of data FG; interviews Convenience 35 Pt (NR) 74.3
(United States) analysis strategies ensure
trustworthiness; focus on
unique population (ethnic
minority)

(continues)

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

126 Journal of Cardiovascular Nursing x March/April 2015

TABLE Quality Appraisal and Methodological Descriptions of Included Studies (n = 47), Continued
Sample Pt, Mean
Author Quality HP, Cg Age and/or
(Study Rank Main Strengths (+) and Sampling (Male/ Range
Setting) (L/M/H) Weaknesses (j) Method/s Strategy Female) (Sex)
+/j Interview guide appended yet 960Y93
it is unclear if questions were
piloted or how they were
derived (eg, from the literature)
Horowitz et al42 H + Robust theoretical framework; SSI Purposive 19 Pt (10/9) 52Y89
(United States) rigorous sampling methods;
detailed description of analysis
and sample characteristics;
recommendations and
conclusions seem to flow from
the interpretation of the data
j None identified
Hoyt43 H + Congruity between iterative SSI Convenience 11 Pt (5/6) 67
(United States) research process and creative
50Y81
approach to analysis; patient
demographics are well described
j Sampling seems to be
convenience not purposive
Jurgens et al44 L + Congruity between methodology SSI Convenience 77 Pt (40/37) 75.9
(United States) and mixed methods used to
collect data
j Participants are not adequately
represented (limited qualitative
data presented), small sample
size limits the generalizability
of the quantitative data
Kaholokula L + Focus on ethnic minority groups FG Convenience 11 Pt (5/6) 65.9 Pt
et al45 (United living with HF; rationale for use
25 Cg (4/21) 50.5 Cg
States) of theoretical model
j Findings/discussion does not
adequately represent caregiver
participants; does not adequately
describe sample (NYHA class, age
range), research questions not
stated; does not report ethical
approval of the study
Lough46 (NR) M + Congruity between the SSI Purposive 25 Pt (12/13) 71
methodology and data analysis;
66Y91
novel conceptualization of HF
self-care as work
j Researcher position not stated
Mahoney47 M + Congruity between methods and SSI Purposive 16 Pt (12/4) 67.7
(United States) analysis of data; participants Pt only
12 Cg (NR)
selected from multiple sites;
use of a pilot study
j Conclusions seem somewhat
simplistic
Mead et al48 M + Congruity between research FG Convenience; 387 Pt 41% Q65
(United States) questions and data collection purposive (84/198:
methods; very large sample 105 sex not
size; patients recruited from described)
multiple sites; participants are
adequately represented in the
data through illustrative quotes
j Lack of age- or sex-based
descriptive analysis
Meyerson and M + Research design and overall study Written Convenience 27 Pt (NR) 75
Kline49 (United are well described anecdotal
States) records
(continues)

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 Review of Patient Heart Failure Self-care Strategies 127

TABLE Quality Appraisal and Methodological Descriptions of Included Studies (n = 47), Continued
Sample Pt, Mean
Author Quality HP, Cg Age and/or
(Study Rank Main Strengths (+) and Sampling (Male/ Range
Setting) (L/M/H) Weaknesses (j) Method/s Strategy Female) (Sex)
j Conclusions/findings are based on
anecdotal records written during
an HF self-care intervention; the
study would likely be more
rigorous if interviews had been
conducted with patients to
triangulate the case note data
Ming et al50 M + Sufficient description of sample; SSI Purposive 20 Pt (15/5) 56.5
(Malaysia) patients seem to be adequately
27Y75
represented (via use of
supporting quotes from
participants)
j Theoretical basis not described;
the interview guide or sample
interview questions are not
provided
Reid et al51 H + Congruity between the research SSI Convenience 50 Pt (33/17) 67.1
(United methodology and data collection 29 Cg 41Y80
Kingdom) methods; large sample size Pt only
j Patients recruited from outpatient
HF clinics (these patients may
already be receiving support for
medication management)
Rerkluenrit et al52 M + Congruity between grounded SSI Purposive; 35 Pt (19/16) NR
(Thailand) theory approach and data theoretical
collection and analysis methods;
participants are adequately
represented; good use of
illustrative quotes
j Despite use of grounded theory
approach, authors do not
identify a core variable
Riegel and M + Basic interpretive descriptive Structured Convenience 26 Pt (17/9) 74.4
Carlson53 design and approach to analysis interviews;
(United States) j Unsure about rigor of qualitative FG
design; minimal description or 59Y91
interpretation of quotes
provided for themes
Riegel et al54 H + Congruent methodology, data Structured Theoretical 29 Pt (18/11) NR
(United States) analysis, and interpretation of interviews
results; theory-driven purposive
sampling
j Lacks information on age and
number of participants in
NYHA class III or IV
Riegel et al55 M + Congruity in mixed-methods design SSI Purposive 29 Pt (21/8) 68.7
(Australia) and triangulation of qualitative
and quantitative data
j Participants are not adequately
represented in results (limited
use of quotes)
Riegel et al56 M + Congruity in mixed-methods SSI Purposive 27 Pt (19/8) 68.7
(Australia) approach; detailed steps
35Y94
indicate rigorous design
jLow proportion of women in sample;
qualitative themes seem to draw
upon quantitative results
M SSI Convenience 25 Pt (24/1) 70.4

(continues)

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128 Journal of Cardiovascular Nursing x March/April 2015

TABLE Quality Appraisal and Methodological Descriptions of Included Studies (n = 47), Continued
Sample Pt, Mean
Author Quality HP, Cg Age and/or
(Study Rank Main Strengths (+) and Sampling (Male/ Range
Setting) (L/M/H) Weaknesses (j) Method/s Strategy Female) (Sex)
Rodriguez et al57 M + Discusses intercoder reliability;
(United States) patient sample is representative 53Y87
of whole NYHA spectrum
j Sample is largely men and white
and was predetermined (not
based on thematic saturation);
description of data analysis
process lacks details
Rogers et al58 M + Congruity between methodology UI Purposive 27 Pt (20/7) 69
(United and well-described method
Kingdom) 38Y94
j Low proportion of women in
sample; examples of emergent
themes are not provided
Scott59 M + Congruity in research methods, SSI Convenience 20 Pt (NR) 71.3
(United States) questions, data analysis, and 18 Cg (NR) Cg only
interpretation of results
j Study is more quantitative than
qualitative; researcher position
not stated
Scotto60 L + Congruity between research SSI Convenience 14 Pt (9/5) 63
(United States) methods and research questions 42Y84
j Analysis seems superficial;
themes seem to reflect nursing
theory, not data; purports to
be phenomenology but the
process followed is generic
interpretive descriptive
Scotto61 H + Congruity in methodological SSI Convenience 14 Pt (9/5) 63
(United States) approach; clear conceptualization 42Y84
of self-care and sampling rationale
j None identified
Seto et al62 L + Provides sample interview Survey; SSI Convenience 94 Pt (74/20) 54.6
(Canada) questions and detailed
demographic characteristics
of participants
j Interviews may lack depth given
their very short duration; no
details on qualitative data analysis;
no details on triangulation of
quantitative and qualitative data
Sloan and H + Focus on cognitive impairment is SSI Purposive 12 Pt (10/2) 43Y81
Pressler63 unique; congruity between
(United States) theoretical/philosophical
perspectives and data analysis
j Sample is literate and socially
supported, findings may not be
representative of larger population
Stromberg et al64 H + Congruity between methodology SSI Purposive 25 Pt (17/8) 46Y93
(Sweden) and data collection methods
j Interview questions use sophisticated
language, which may not be
understood by participants;
superficial examples might have
more complex interpretations
Stull et al65 M + Congruity between theoretical SSI Convenience 21 Pt (17/4) 61
(United States) framework (interactionist
perspective) and data analysis
and interpretation
(continues)

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 Review of Patient Heart Failure Self-care Strategies 129

TABLE Quality Appraisal and Methodological Descriptions of Included Studies (n = 47), Continued
Sample Pt, Mean
Author Quality HP, Cg Age and/or
(Study Rank Main Strengths (+) and Sampling (Male/ Range
Setting) (L/M/H) Weaknesses (j) Method/s Strategy Female) (Sex)
j Triangulation of data in analysis is 29Y79
not apparent
Tierney et al66 M + Participants were recruited from SSI Purposive 22 Pt (15/7) 68.9
(United multiple sites; team-based
53Y82
Kingdom) approach to analysis enhances
trustworthiness of the findings
j Sample is mostly male; unclear
why patients with NYHA class
IV were excluded
Van der Wal M + Identifies specific, practical issues SSI Purposive 15 Pt (9/6) 70
et al67 into supporting self-care
(Netherlands) j The term compliance is dated 42Y87
(addressed by authors) but may
influence approaches to data
collection and/or analysis;
themes seem to overlap and
are very broad
Weierbach68 M + Congruity in research methods, SSI; case Convenience 20 Pt (9/11) 74.6
(United research questions, data note
65Y90
States) analysis, and interpretation review
of results
j Discussion is brief and seems
superficial
Winters69 L + Specifies a theoretical framework SSI Purposive 22 Pt (15/7) 70
(United j Limited description of analysis 38Y88
States) procedures; limited representation
of participants; themes not
supported by illustrative quotes
Wu70 L + Basic interpretive descriptive SSI; structured Convenience; 16 Pt (9/7) 60.4
(United approach; participants are interviews purposive
41Y84
States) adequately represented in
the results
j Interview guide is specific and
directed; themes seem simplistic
Wu et al71 M + Clear description of sample and SSI Convenience 16 Pt (9/7) 60.4
(United methods; conclusions seem to flow
41Y84
States) from the analysis/interpretation
of data
j Limited description of setting and
recruitment strategies; reliance
on convenience sampling
Zambroski72 H + Congruity in research methodology, SSI Purposive 11 Pt (5/6) 67
(United methods, and data analysis;
States) strong rationale for creative use
of metaphor; participants are
adequately represented; use of
illustrative quotes to support
themes; participants recruited
from multiple sites
j Several interview questions
provided but entire interview
guide not included

Abbreviations: Cg, caregivers; FG, focus group; HF, heart failure; HP, health professionals; L, low; M, medium; H, high; NR, not reported; NYHA, New York
Heart Association; Pt, patient; SSI, semistructured interviews; UI, unstructured interviews.

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

130 Journal of Cardiovascular Nursing x March/April 2015
hopelessnessII’m not capable of doing the walking that
I used to doII feel a sense of inadequacyI; Sometimes
you just get fed up and I think that was just a day that I
had a real down spiraling. I just ate what I wanted. I put
salt on everything and just didn’t care.54(p239)
Emotional reactions such as anxiety and depression
can have a negative impact on engaging in self-care.48,54,75,76
Nevertheless, emotional reactions such as fear or anxiety,
which tend to be viewed as maladaptive coping strate-
gies, may also have a positive influence on self-care. For
example, patients report increases in vigilance of symp-
tom monitoring and adherence to following advice from
the healthcare team in response to feelings of anxiety,56
fear of dying,35 or fear of hospitalization.49,64,77 It was
not clear in the reviewed studies if patients were aware
that such behaviors were congruent with self-care recom-
mendations and/or engaged in these behaviors intermit-
tently or continuously.
Action-Based Self-care Strategies
An action-based self-care strategy represents as an ad-
justment of daily tasks or lifestyle to maintain inde-
pendence and quality of life.31,32,41,60,68 For example,
some patients addressed feelings of uncertainty by learn-
ing how to monitor and respond to their symptoms and
developing a relationship with their primary HCPs.69
Others would develop action-based strategies that inte-
grated HF management into their everyday life routines
to improve self-care.54,61,67 Many patients describe action-
based strategies such as learning how to ‘‘pace’’ their
activities or ‘‘listen to their bodies’’ to help optimize their
ability to maintain physical activity.27,31,32,34,35,53,65,72,78
Over time, patients viewed such action-based strate-
gies as a normal part of their daily routine.51,52,60 One
patient describes deliberate actions to continue em-
ployment while living with HF:
I pack my lunch and I usually exercise at lunch by
walking 3 miles. My coworkers walk with meI.
Sometimes I do delay my LasixA pill, but only by 2 hours
if I have a morning conference meetingI. Managing my
heart failure is extremely important, extremely
importantI. I want to be able to function as normally
as possible and I want to be able to continue to work.31(p71)
However, it was not clear if these self-care action
strategies were maintained over time given fluctua-
tions in daily life or internal resources (eg, self-care was
seen as tiring). One study reported that patients did get
tired of weighing themselves daily and stopped this
activity, even though they knew they should not.62
Other studies reported that alterations to established
life routines could reduce adherence to medication
regimens.37,38,60
We have a team meeting every two weeks, and I have to
be there. Bright and early, and I normally don’t get up
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
that early, and often I forget to take it, Even though I’ve
got it on the counter there.38(p81)
Action-based strategies also included enlisting the
help of caregivers for assistance with self-care activities.
Caregiver assistance ranged from simple reminding to
taking over some of the responsibilities such as orga-
nizing medications, buying groceries and preparing
meals according to dietary guidelines, monitoring
symptoms, and navigating the healthcare system as
needed.27,40,42,43,45,51Y53,55,56,59,63,74,75,79 Although
some patients felt they did not want to be a burden
to caregivers, at the same time they recognized their
inability to manage self-care activities without care-
giver help.36
One patient explained:
I was a little bit afraid of everything but then my kids and
the husband was so helpful soIeducate your own family
about [heart failure]Icause they know what’s going on
and help me with the food, with the exerciseII think it’s
better.45(p286)
Self-care Strategies; Observable or
Hidden Work
In general, engaging in self-care requires both perception-
based and action-based strategies and was often de-
scribed by patients in the context of adapting to stressors
associated with living with a chronic condition. How-
ever, planning and working through such strategies by
HF patients may or may not be evident to those around
them. Patients reported a wide variety of creative, well-
planned, and deliberate self-care action strategies that
could be observed by others.31,32,53 Daily activities were
modified to control symptoms, including bathing,68
grocery shopping,35 cleaning the house,27 meal prepa-
ration,27,45,52,67 and participating in leisure activities.66
A patient described her strategy to overcome her poor
stamina as she found an efficient way to accomplish
important tasks so she was not wasting energy:
I do most of the cooking. We live in this house and we
have got this nice roomy kitchen and I’ve got a clerical
chair and I just whip around the kitchen in this clerical
chair. It is what I need to do. It works.27(p78)
Conversely, cognitive tasks associated with self-care
were often unobservable by others. These include deci-
phering symptoms and deciding on and evaluating a
course of action in response to symptoms.45,47,72 The
following is an example of the thought process of an
HF patient who is trying to interpret symptoms of short-
ness of breath:
I think it is really asthma, but it acts somewhat (pointing
to heart)IBut that’s not my trouble. Cause my heart
never acted like this when I had the asthma. It wasn’t this
feeling you can’t catch your breathIit’s short, the
shortnessII could always do something for my asthma.

This don’t clear up. It clears up someIwhen I had
asthma I could get up and dress and go to churchII had
the asthma attack, but they would kind of go away. But
this doesn’t. I’m relieved some, but it’s never like with
asthmaINo it’s not like asthma all together, but it’s
something like a bad asthma attack.47(p168)
Self-care Strategies Are Often Based on Past
Experiences
Self-care strategies improved over time with HF pa-
tients learning and building from previous experiences
to guide their ongoing self-care strategies and decisions.
Some self-care routines were embedded in action-based
strategies that were practiced over time. For example,
patients would use memory aids or refine daily routines
to determine the best way to help with remembering
complex medication schedules.26,63,70,71,75
I have a basket of prescriptions and I set the basket
down, and I start with one and go around it and take
themIused this method for years, and it just seems to
work and that’s why I continue it.75(p8)
Self-care decisions could also reflect emotional re-
actions to previous HF experiences. This patient de-
scribed the reason for occasionally missing his diuretic
dose:
I don’t take my Lasix when I am going out somewhere, I
can’t always get to a bathroom quick enoughI. I had an
accident when I was out a few months ago and I was so
embarrassed I could have died.’’37(pp14Y15)
Some patients avoided taking action by seeking help
from HCPs for signs of worsening symptoms for fear
of rehospitalization and often delayed calling until
they needed emergency assistance.43,44,74 On the other
hand, other patients sought early advice for worsening
symptoms to avoid the fear they described with acute
decompensation.43 Finally, some patients reported a
balancing act of attitudes where they pondered be-
tween both positive and negative self-care choices that
were based on lessons learned from previous experi-
ences.32,67 The following is an example from Hoyt:
Dorothy had experienced what she described as the
‘‘catch 22.’’ She did not want to call an ambulance and
risk that by the time they would arrive at her home, her
symptoms would have resolved. She was afraid, based on
past experiences, that she would call too soon, and so
tended to wait until a crisis to ask for help. Reflecting on
an acute emergency requiring ‘‘911’’, or what Dorothy de-
scribed as getting in ‘‘big trouble’’, allowed her to recognize
her own cues and decrease risk of recurrence.43(pp108Y112)
During the process of learning, some patients often
used a variety of strategies to manage and determine
the effects of their medications, such as home-based
lay clinical trials.38,47 This often involved meticulous
note-taking, analysis, and ‘‘juggling’’ of both medica-
tions and daily activities and contributed to informal
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Review of Patient Heart Failure Self-care Strategies 131
knowledge as patients made connections between medi-
cations and symptoms they experienced.38,47,58 How-
ever, not all patients felt comfortable sharing this
information with their healthcare team members be-
cause they may not feel the HCPs would agree with
their judgments. The following is an example from
Glassman:
One patient described her strategy to improve her
tolerance to a medication based on a past experience of
symptomatic hypotension that prevented her from going
to work. She stopped the medication for a few days,
reintroduced the medication at 2 the prescribed dose and
then slowly titrated the medication depending on how
she felt getting out of bed in the morning. At the same
time, she did not report this to her physician and actually
‘‘lied to him about the dose’’ she was taking, as she was
too embarrassed to disclose her own approach to
titrating the medication.38(p109)
Patients with HF expressed difficulty with trans-
lating self-care knowledge into understanding how
to engage in these activities and behaviors.39,46,62,80
These patient ‘‘lay clinical trials’’ may have reflected an
expert approach to managing their HF for some HF
patients, whereas others may have blindly experimented
with self-care tasks as an attempt to try and understand
‘‘how’’ to self-care.76 For example, some patients thought
that increasing fluid intake when they were ‘‘getting
sick’’ or when they had eaten something salty would
help ‘‘flush out’’ the system and improve symptoms,
but in fact, this action could make their symptoms
worse.20(p181) In another study, women who were trying
to lose weight by eating low-calorie meals as a positive
healthy choice were unaware of the high sodium con-
tent in these food choices and could make their HF
symptoms worse.37
I thought I was doing the right thing trying to lose
weight, had no idea I was making my heart problem
worse.37(p13)
Discussion
This meta-synthesis shows that most patients with HF
do want to engage in self-care and go to great lengths
to find ways to practice self-care behaviors. It is appar-
ent that they may also have difficulty executing these
self-care behaviors on their own and require effective
guidance and support from HCPs or and/or caregivers.
Three key messages arise from these findings and are
discussed below.
Patients Engage in Perception and
Action-Based Strategies
The effect of HF on an individual’s life can be pro-
found,81 and patients often mobilize resources to over-
come these life-changing experiences in an effort to
132 Journal of Cardiovascular Nursing x March/April 2015
achieve control, maintain independence, and improve
their quality of life. In this context, patients define self-
care not only by the actual performance of tasks but
also by the emotional reactions and strategies necessary
for learning how to adapt to living with HF. Results
from our meta-synthesis suggest that ‘self-care need,’ as
defined by HF patients, represents a broader view of
‘‘caring for oneself to help adapt to living with HF’’ and
extends to include coping strategies beyond the empir-
ical action-based definition of self-care. Although the
empirical literature does appreciate the potential impact
of emotions and coping on self-care,7 findings from our
meta-synthesis highlight the comprehensive approach
that HCPs need to assume when helping patients im-
prove their quality of life through self-care strategies.
For example, patients may defer seeking healthcare for
fear of hospitalization, even though they recognize the
early symptoms of decompensation. Without exploring
the fear underlying the decision, education outlining the
tasks for symptom monitoring and management that
includes contact with HCPs may not be adopted by such
patients. Furthermore, HCPs may need to take a step
back and explore the emotional reactions that HF pa-
tients experience before proceeding with interventions
specifically targeting self-care activities. Helping patients
come to terms with and accepting HF can then facilitate
uptake of self-care strategies.
Learning Self-care Is a Process in Which
Cumulative Experience is Paramount
Most patients do want to learn how to engage in self-
care in an effort to decrease uncertainty, regain a sense
of control, and improve their quality of life; however,
they are unsure as how best to accomplish these goals.80
While developing these action strategies to help self-
manage their HF, their ideas and knowledge from pre-
vious experiences may not always be helpful, and in
fact, may make their symptoms worse. At the same
time, patients may be reluctant or embarrassed to share
their action strategies with their healthcare team mem-
bers. Therefore, HCPs need to encourage and promote
discussions, and coach patients to initiate self-care strat-
egies with an agenda that builds trust and encourages
learning. Rather than focusing on the possible problems
that arose from their self-care decisions, HCPs need to
harness these situations as opportunities for learning
and growth and highlight the positive learning that
comes from such attempts. Arguably, more can be learned
from situations in which HF self-care was not successfully
undertaken. For example, consultations and/or hospi-
talization provide a useful opportunity to assess what
seems to work or not work within patients’ actual self-
care practice. As adults, experiential learning is often
more effective than abstract thinking,82 and under-
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
standing the patients’ experiences with HF self-care builds
an excellent foundation for individualizing learning
opportunities. Home-based lay clinical trials need to
be regarded as attempts to overcome difficulty with the
current HF self-care regimen rather than as overt non-
compliance. Exploring the actions and perceptions of
such self-care clinical trials with HF patients creates an
opportunity for adapting self-care activities to pa-
tients’ current situations and helps patients learn more
about the why and how of their HF self-care. Fur-
thermore, focusing on the positive learning rather than
maladaptive decision making within a clinical trial will
contribute to building patient self-confidence and effi-
cacy, which is necessary for self-care.15,83
Strategies to Optimize Self-care Must Be
Adapted to the Daily Routine and
Environment
As we continue to develop group and individual inter-
ventions for promoting self-care in HF patients, it is
critical that individualized instruction include help-
ing patients understand the how and why of self-care
within their personal life situation. Healthcare practi-
tioners need to provide a safe environment for patients
to explore real or potential situations when integrating
self-care into their daily life will be difficult. Creative
problem solving, behavioral strategies, and mutual goal
setting are necessary to help patients overcome chal-
lenges for integrating self-care into their daily routine
and sustaining such action strategies over time.80,84,85
Strategies to optimize self-care also extend to indi-
vidualizing patients’ symptom experience and man-
agement. For example, if individuals know that ‘‘when
their ring gets tight’’ they need an extra diuretic, teach-
ing them to check for pedal edema is not helpful if they
do not experience pedal edema with an HF exacerba-
tion. Often, the early symptoms of HF are subtle and
may be difficult for a person to identify, and therefore,
HCPs need to be ‘‘detectives’’ and help patients deci-
pher their unique and early symptoms of HF exacer-
bation from other symptoms they may have attributed
to HF. Sometimes, the process of raising awareness
through reflection is an unfamiliar skill for patients,86
and they may need some guidance with identifying the
physical symptoms, environmental features, and emo-
tional feelings of their situation. Through reflective
listening techniques,87 HCPs can raise patient aware-
ness of the objective and subjective features that predom-
inated in the patient’s experience of HF symptoms and
management strategies. Once these individual patterns
of symptom deterioration are identified, HCPs can devise
individualized algorithms or similar decision aids with
patients, and caregivers when available, to help them
navigate key stages in decision-making processes around

What’s New and Important
h Patients define self-care not only by the actual
performance of tasks but also by the emotional
reactions and strategies necessary for learning how to
adapt to living with HF.
h Self-care is a process of learning, and self-care activities
are often intentional, planned, and built on previous
experiences.
h Individualized approaches that emphasize how to
self-care must be adopted for patients to develop the
necessary HF self-care skills.
self-care of HF, especially in relation to timely help-
seeking from the appropriate sources. Importantly, these
approaches prioritize the patients’ experiences and strat-
egies as opposed to reiterating self-care tasks and recom-
mendations. As such, discussions around self-care and
management of HF are more likely to elicit and be
congruent with patients’ personal values.
Limitations
As with all reviews, the findings of this meta-synthesis
are constrained by the scope and quality of the in-
cluded studies. Although a number of studies in this
review are based on naturalistic decision-making theory,
many studies lacked a theoretical approach to under-
standing these multifactorial and complex behaviors.
This is an important weakness because health behav-
iors, including those associated with HF self-care, can
be conceptualized in a variety of ways depending on
underlying assumptions about the nature and determi-
nants of this behavior. If HF self-care is viewed in more
complex terms as being both an outcome and a natu-
ralistic process, that is then a process influenced by
personal and contextual factors. Theoretical and meth-
odological approaches to understanding this conceptu-
alization of self-care are needed which can encompass
and unpack this complexity.
Conclusions
In summary, patient engagement in self-care is at the
foundation for living with a chronic condition such as
HF. Healthcare providers need to appreciate that pa-
tients regard self-care as an adaptation to living with
a chronic condition that they undertake to maintain
independence and quality of life. Healthcare providers
need to recognize that self-care requires a process of
learning from experience, and embrace an individual-
ized approach for helping HF patients develop the nec-
essary self-care skills while emphasizing the how and
not just the what. We also need to provide a safe and
nonjudgmental environment for patients to discuss their
attempts when learning how to self-care while high-
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Review of Patient Heart Failure Self-care Strategies 133
lighting the value of learning from all their experiences.
Finally, the supportive role of caregivers as a necessary
strategy for patient self-care support cannot be un-
derstated. The additional insight into the nature and
complexity of HF self-care needs gained from this
meta-synthesis of literature exploring the strategies that
patients use to engage in self-care should help clinicians
develop more effective support to patients and care-
givers as they strive to improve clinical outcomes in
this high risk population.
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