Self-Management in Chronic Illnesses: A Concept Analysis
Dianne Rinehardt
Chamberlain College of Nursing
NR501: Theoretical Basis for Advanced Nursing Practice
November 2015

Self-management in Chronic Illness: A Concept Analysis Globally, the human species is experiencing longer life-spans. As the number of persons with extended lifespans increases, so does the prevalence of those living with chronic illnesses. With the inception of the Patient Protection and Affordable Care Act (ACA) in 2010, there has been a paradigm shift in the focus of healthcare from treatment to prevention. The origin of this paradigm shift occurred when traditional provider-directed/patient compliant approach failed to produce the outcomes that were expected (Udlis, 2011). Transforming healthcare from a treatment modality to one of prevention assumes that each person will be actively engaged in the prevention of chronic illnesses. Dorothea Orem’s self-care and self-care deficit nursing theory is based on the premise that people are naturally inclined towards self-care and that nursing should be focused on identifying and correcting any self-care deficits. Orem defined self-care as, “care that is performed by oneself for oneself when one has reached a state of maturity that is enabling for consistent, controlled, effective, and purposeful action” (Orem, Taylor & Renpenning, 2001, p 149). Orem’s self-care and self-care deficit theory is directly applicable to the concept of self-management. The process begins with identification of the deficit in knowledge that the person has in the self-management of their own care. Once the deficit has been identified, the person then is educated on the specific condition, care associated with that condition and self-management techniques that can be adopted. The concept analysis outlined by Walker and Avant (2005) was used add clarity to the meaning of self-management in chronic illnesses. The eight steps to concept analysis that were followed are: selecting a concept, determining the aim or purpose of the concept, identifying the uses of the concept, determining the defining attributes, identifying a model case, identifying a borderline, related, contrary, invented or illegitimate cases, identifying antecedents and consequences, and defining empirical referents (McEwen & Wills, 2014, p 58).
Aim
The baseline premise of self-management is that the person is directly involved in the management of their illness. However, there is more involved in this concept than just the person. Self-management involves effective strategies that are a result of the collaboration of the patient in concert with a number of medical professional, care providers (family), society and technology (Knight & Shea, 2011). The purpose of this paper is to explore the concept of self-management and, within that exploration, identify the defining attributes, cases, antecedents, consequences, and empirical referents.
Literature review A literature search was performed using EBSCO and CINAHL databases in addition to the Center for Medicare and Medicaid Services (CMS) website. Key terms used in the search were Orem, self-management, chronic illness, self-care deficit, and/or informatics. The search was limited to literature written in the past 5 years. Rothenberger (2011) explored the concept of self-management as it applies to patients diagnosed with pre-diabetes. According to Rothenberger’s research, there was a significant increase in the discussion and publication of results related to pre-diabetes and self-management after 2002. While focused primarily on persons diagnosed with pre-diabetes, many of the applications of the concepts identified within this article can be applied universally across chronic illnesses. Rothenberger’s discussion of the defining attributes, cases, antecedents and consequences are easily mirrored in the self-management of any chronic illness. The primary goal of self-management is improved health outcome. Rothenberger stated that there has been extensive research that supports self-management as an effective strategy to slow or prevent the onset of type 2 diabetes; however, there was no support to the statement within the article. This article, however, appropriately identified and supported where the current healthcare system fails to identify chronic illness in an early stage and even when identified, fails to properly educate the person in the requisite lifestyle modifications. “Engagement in long-term lifestyle modification, goal-setting, self-monitoring and ongoing support are all features of a coordinated system of care for chronic illness” (Rothenberger, 2011, p 83). Udlis (2011) identified similar antecedents to self-management as Rothenberger, but not identically. For Udlis, the antecedents to self-management were: information, self-efficacy, support, intention and mutual investment knowledge (Udlis, 2011, p 132). Information passed on to the patient in the form of education is critical to self-management. Without information about the chronic illness and how lifestyle modifications will benefit the patient, self-management would be doomed to failure. The information presented by Udlis was properly supported and cited and applicable to those engaged in the propagation of the self-management modality. Knight & Shea (2014) proposed a unique application of informatics to assist in the goal of the self-management modality. Historically, patients had to rely on memory or writing implements or information passed by medical professionals in their efforts to self-manage their conditions. This article presented a unique way of accomplishing self-management through the application of technological resources. Informatics may ultimately pave the new road into fulfilling the current goal of increasing patient self-management through computer or other technological resources. The information presented in this article is currently futuristic and may direct the methods used in the near future to assist in creating a medically self-managing populace.
Uses
The use of this concept would extend the knowledge base within the nursing profession to deliver education and training along with necessary equipment to empower the patient to self-manage. As stated by Udlis (2011), the need for information is a “fundamental pre-cursor to self-management” (Udlis, 2014, p 132).
In self-management, patients will retain better health and reduce the expense of the treatment of chronic illnesses. Feeling involved and empowered in the decision-making, self-managed patients will be more compliant with treatment recommendations and, as a result, will lead healthier lives (Rothenberger, 2011).
Defining attributes
The defining attributes of self-management of chronic illnesses would include: information, engagement in lifestyle modifications, the setting of realistic, individualized goals, self-monitoring, and ongoing support of medical professionals. Information (knowledge) is necessary for self-management because the patient must have an understanding of the condition and an ability to perform the required tasks (Udlis, 2011). Self-monitoring involves being self-aware and observing one’s own lifestyle. Realistic and individualized goal setting is a critical attribute in self-management. Knight & Shea (2014) take this a step further when incorporating health empowerment technology (HET) in concert with collaborating nurses. HET encourages self-management because they incorporate the individual’s needs, promotes understanding between the patient and healthcare team, and establishes mutually agreed upon goals.
Model cases
Within a concept analysis, model cases that contain all the attributes of the concept are important to consider (Walker & Avant, 2005). The following are two cases that one would consider model cases for this concept.
Mr. R is a 51 year old male with a past history of hypertension, hyperparathyroidism, and chronic pain due to injuries sustained to his neck, back, hips and knees as a result of combat experience. Mr. R’s non-treated blood pressure was 186/108 and with treatment, 135/95. Mr. R had excess weight around his midsection and was advised to lose 20 lbs. Mr. R is a type “A” personality and had a high degree of stress due to his military role. Mr. R was given a blood pressure cuff to monitor his blood pressure daily. Mr. R was advised by a nutritionist to begin a Mediterranean diet. He was advised to get therapy to deal with his stress levels. Additionally, Mr. R ultimately had surgery for his hyperparathyroidism and was given a referral for physical therapy and pain management to deal with chronic pain. Mr. R’s wife participated in his care. Mr. R monitored his weight regularly and lost 25 lbs in 6 months. Additionally, Mr. R was able to identify stress triggers and reduce them. Post-surgery for hyperparathyroidism, Mr. R reported a significant improvement in his energy level and reduction in pain. After his retirement, Mr. R noticed that his blood pressures were down in the 116/80 range and was removed from medication. Mr. R completed physical therapy and is scheduled for pain management to address his chronic pain. This model case contains the necessary attributes of self-management of chronic illness. Both Mr. R and his wife acquired knowledge of the medical condition and treatment, were engaged in lifestyle modifications, and there was regular support and follow-up with medical professionals.
Mr. T is a 79 year old male with a history of congestive heart failure (CHF) that was diagnosed when Mr. T was 54 years old. Mr. T had an initial ejection fraction (EF) of 15% which required the implantation of an ICD (implanted cardiac device). Both Mr. and Mrs. T were educated on the diagnosis and the lifestyle modifications that would be required to achieve a best health outcome for Mr. T. Prior to this medical event, Mr. T was and otherwise healthy 54 year old male with no indication of cardiac disease. Mr. T is 5’10” tall and weighed 168 lbs. at the time of diagnosis. Mr. T had a history of smoking and heavy alcohol consumption. Additionally, Mr. T enjoyed a diet that contained many items not conducive to good cardiac health. Both Mr. and Mrs. T were very engaged in learning about the condition and the necessary lifestyle modifications and were eager to implement them. Although Mr. T agreed to cease all tobacco usage, he decided that complete cessation of alcohol consumption would not be a goal he could comply with. Between the T’s and the healthcare team, it was agreed that Mr. T would limit his alcohol consumption. Mr. T scheduled regular follow-up examinations with his cardiologist to monitor his health progress through reading of the implanted device and records of his self-monitoring saved on a thumb drive. As a result of the education given to Mr. T, his self-management and technological advancements, Mr. T has survived CHF for 25 years. In 2008, Warner reported of the persons with the diagnosis of CHF, only 50% will survive 5 years and of those with advanced forms of the disease 90% will expire within 1 year. This model case exemplifies the improved outcomes with self-management with additional benefits from HET as espoused by Knight and Shea (2011).
Alternative cases
A contrary case would be Mrs. S who is a 53 year old female with a history of cardiomyopathy and hypotension. Mrs. S was diagnosed when a familial history of cardiomyopathy became evident and she brought it to her physician’s attention. Mrs. S was advised to monitor her blood pressure due to hypotension while taking the medications for cardiomyopathy that would reduce blood pressure. She was advised to quit smoking. Mrs. S was given Chantix to assist in that effort and attended a class designed to help in her efforts to quit smoking. During an annual physical exam, it was revealed that Mrs. S was not taking her medication as directed and continued to smoke. This case contains attributes that are contrary to the self-management of chronic illness. Regardless of information and guidance provided to this patient, she has an inability or unwillingness to work towards appropriate goals.
In a related case, Mr. H was diagnosed with type 1 diabetes at the age of 24 years. There was a familial history of this type of diabetes occurring in young adulthood. Mr. H was instructed on how to take his glucose level 3 times per day before meals. He was given the sliding scale to administer a specific insulin level based on his current glucose reading. He was given instructions on what may and may not be consumed as a part of a new diabetic diet and advised to continue exercising. Mr. H’s weight of 130 lbs. was appropriate for his height of 5’8” and so there was no advice to lose weight. He was asked to return to the clinic in 6 months. Mr. H reported that his glucose was being monitored and that he hated the diet but would do it because he had no other choice. He advised the physician that he continued to play tennis 3 days per week. Mr. H demonstrated compliance with physician instructions, not self-management. He continues to exercise, but he enjoyed the activity prior to diagnosis. He resents the diet that he has been restricted to. Mr. H was not educated properly to understand the benefits of self-management and is not truly self-aware of his condition.
Antecedents and consequences
An antecedent for the self-management of chronic illness is that the patient has been given information regarding the health risk and benefits for change in lifestyle (Udlis, 2011). Without adequate information, self-management is doomed to failure.
A consequence of self-managed behavior includes progress towards the goals set by the collaboration through self-monitoring of that progress (Rothenberger, 2011). With the ultimate goal of self-management being better health outcomes, the only valid method of determining the achievement of that outcome is through monitoring of that progress.
Empirical referents
Self-management of chronic illnesses has many empirical referents. Goal setting can be reported by the patient. The measurement is the patient’s ability to state the lifestyle modification goals. Consequences of self-management can be measured through attainment of goals set, such as: reduction in weight, reduction in blood pressure, or reduction in pain levels as reported by the patient. “Ongoing monitoring of empirical referents can ensure that all attributes of self-monitoring are present (Rothenberger, 2011, p. 83).
Conclusion
Although self-management is mentioned regularly as a concept in chronic illness treatment, a specific definition of the concept remains elusive. Concept analysis consistent with Odem’s self-care and self-care deficit theory provides a basic level of understanding of the concept of self-management that encourages further exploration and research. As society further engages in the technologies of the 21st century and refocus of healthcare to a prevention model, the concept of self-management will assist in attaining the goal of improved health outcomes.

References
Knight, E. P., & Shea, K. (2014). A Patient-Focused Framework Integrating Self-Management and Informatics. Journal Of Nursing Scholarship, 46(2), 91-97 7p. doi:10.1111/jnu.12059
Orem, D. E., Taylor, S. G., & Renpenning, K. M. (2001). Nursing: Concepts of practice (6th ed.). St. Louis, MO: Mosby.
Parker, M. E. & Smith, M. C. (2010). Nursing theories and nursing practice (3rd ed.). Philadelphia, PA: F. A. Davis Company.
Patient Protection and Affordability Act. (2010, March 23). Retrieved November 8, 2015, from http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf
Rothenberger, C. D. (2011). Chronic Illness Self-Management in prediabetes: a concept analysis. Journal Of Nursing & Healthcare Of Chronic Illnesses, 3(2), 77-86 10p. doi:10.1111/j.1752-9824.2011.01092.x
Udlis, K. A. (2011). Self-management in chronic illness: concept and dimensional analysis. Journal Of Nursing & Healthcare Of Chronic Illnesses, 3(2), 130-139 10p. doi:10.1111/j.1752-9824.2011.01085.x
Walker L. O. & Avant K. C. (2005). Strategies for theory construction in nursing, 4th ed. Pearson Educational Inc., Upper Saddle River, NJ.
Warner, J. (2008). Heart Failure Patients Too Optimistic. Retrieved November 25, 2015, from http://www.webmd.com/heart-disease/heart-failure/news/20080603/heart-failure-patients-too-optimistic