• unlimited access with print and download
    $ 37 00
  • read full document, no print or download, expires after 72 hours
    $ 4 99
More info
Unlimited access including download and printing, plus availability for reading and annotating in your in your Udini library.
  • Access to this article in your Udini library for 72 hours from purchase.
  • The article will not be available for download or print.
  • Upgrade to the full version of this document at a reduced price.
  • Your trial access payment is credited when purchasing the full version.
Buy
Continue searching

Spirituality and self care: Expanding self-care deficit nursing theory

Dissertation
Author: Mary Louise White
Abstract:
The purpose of this study was to extend the theory of self-care deficit nursing by including specific constructs of religion, spirituality, and spiritual self-care practices within the structure suggested by Orem's self-care deficit nursing theory. Based on an extensive literature review, practice experience, and a discovery theory-building approach, a new mid-range theory called White's theory of spirituality and spiritual self-care (WTSSSC) was developed. To begin to test this mid-range theory, empirical indices of many of the main concepts were identified from prior studies and one new instrument (the Spiritual Self-Care Practice Scale) was developed. Hypothesized relationships among the main concepts of the mid-range theory were examined and tested in a sample of 142 urban African American outpatients who had been previously diagnosed with heart failure. The results of this study provided support that White's midrange theory of spirituality and spiritual self-care (WTSSSC) is a viable extension of Orem's self-care deficit nursing theory (SCDNT). The relations between QOL and spirituality, spiritual self-care practices, chronic illness self-care for heart failure, and physical and mental health were statistically significant and in the expected directions. The midrange theory can be used to incorporate spirituality and spirituality self-care practices which can mitigate the effects of chronic disease related to overall QOL for African Americans who have been diagnosed with heart failure. Results of this study have provided additional support for the use of spiritual self-care practices to assist in managing chronic illness, specifically heart failure. Nurses who work with patients diagnosed with heart failure should provide instruction on self-care practices specifically for heart failure (weight and diet management, medication compliance, sleep, etc.) and then encourage the use of spiritual self-care practices to enhance the well-being and QOL for these individuals. Nursing education needs to include spirituality and the importance of spiritual self-care practices as part of teaching Orem's theory of self-care to enhance patient health and QOL. This education could be presented in nursing education classes in colleges and universities; professional development programs; and presentations at state, regional, national and international conferences. Further research is needed to continue development of the WTSSSC.

TABLE OF CONTENTS

Dedication ....................................................................................................................................... ii Acknowledgments.......................................................................................................................... iii List of Tables ................................................................................................................................. xi List of Figures .............................................................................................................................. xiii CHAPTER 1: BACKGROUND, SPECIFIC AIMS, AND SIGNIFICANCE ..........................1 Introduction ..........................................................................................................................1 Self-Care ..............................................................................................................................1 Historical Perspectives on Self-Care .......................................................................4 Chronic Illness .....................................................................................................................6 Heart Failure ........................................................................................................................6 Depression............................................................................................................................9 Spirituality..........................................................................................................................10 Quality of Life....................................................................................................................12 Purpose of the Study ..........................................................................................................12 Hypotheses .........................................................................................................................13 Significance of the Study ...................................................................................................14 CHAPTER 2: REVIEW OF THE LITERATURE...................................................................15 Introduction ........................................................................................................................15 Self-Care ............................................................................................................................15 Self-Care and Chronic Illness ................................................................................19 Heart Failure ......................................................................................................................21 Pathophysiology .....................................................................................................21 Causes of Heart Failure ..........................................................................................22

vi

Right-Sided Versus Left-Sided Heart Failure ........................................................23 Racial Differences in Heart Failure .......................................................................23 Stages of Heart Failure...........................................................................................25 Functional Capacity ...............................................................................................26 Treatment of Heart Failure.....................................................................................28 Self-Care and Heart Failure ...................................................................................28 Spirituality..........................................................................................................................32 Defining Spirituality ..............................................................................................32 African American Spirituality................................................................................33 Spirituality in Health Care .....................................................................................34 Spirituality in Chronic Illness ................................................................................35 Spirituality in Heart Failure ...................................................................................36 Spirituality in African Americans with Heart Failure ............................................37 Depression..........................................................................................................................38 Depression in Chronic Illness ................................................................................39 Depression and Heart Failure .................................................................................39 Depression in African Americans with Heart Failure ............................................40 Quality of Life....................................................................................................................41 Quality of Life and African Americans .................................................................43 Quality of Life and Chronic Illness .......................................................................43 Quality of Life and Heart Failure ...........................................................................44 Quality of Life among African Americans with Heart Failure ..............................45 Summary ............................................................................................................................46 CHAPTER 3: THEORETICAL AND CONCEPTUAL FRAMEWORK .............................47

vii

Introduction ........................................................................................................................47 Spirituality and Spiritual Self-Care: Expanding Self-Care Deficit Nursing Theory .........47 Defining Spirituality ..........................................................................................................48 Spiritual Beliefs and Practices ...........................................................................................50 Defining Self-Care .............................................................................................................52 Self-Care Deficit Nursing Theory ......................................................................................53 Self-Care, Health, and Well-Being ....................................................................................54 Self-Care Requisites...........................................................................................................55 Basic Conditioning Factors ................................................................................................56 Self-Care Agency ...............................................................................................................58 Self-Care Operations ..............................................................................................59 Power Components ................................................................................................60 Foundational Capabilities and Dispositions...........................................................61 Spiritual Self-Care .............................................................................................................62 Theory Building Strategy ...................................................................................................62 Mid-Range Theory Building ..............................................................................................63 Theoretical Substruction ....................................................................................................63 Philosophical Assumptions ................................................................................................65 Ontology ................................................................................................................65 Epistemology .........................................................................................................66 Worldview..............................................................................................................66 Conceptual and Theoretical Assumptions .........................................................................66 Conceptual Assumptions .......................................................................................67 Theoretical Assumptions .......................................................................................67

viii

Conceptual and Theoretical Propositions ..........................................................................68 Conceptual Propositions ........................................................................................68 Theoretical Propositions ........................................................................................68 Theory Testing ...................................................................................................................69 Significance to Nursing......................................................................................................70 CHAPTER 4: METHODOLOGY .............................................................................................73 Introduction ........................................................................................................................73 Purpose of the Study ..........................................................................................................73 Research Design.................................................................................................................73 Participants .........................................................................................................................74 Sample....................................................................................................................74 Instruments .........................................................................................................................75 Demographic Survey .............................................................................................76 Spiritual Involvement and Beliefs Scale – Revised ...............................................76 Spiritual Self-Care Practice Scale ..........................................................................80 Revised Heart Failure Self-Care Behavior Scale ...................................................83 Short-Form (SF-12) Health Survey .......................................................................84 Patient Health Questionnaire – 9 ...........................................................................86 Zung Self-Rating Depression Scale .......................................................................88 World Health Organization Quality of Life – Bref ................................................89 Variables ............................................................................................................................92 Data Collection Procedures ................................................................................................93 Data Analysis .....................................................................................................................95 CHAPTER 5: RESULTS OF DATA ANALYSIS ....................................................................98

ix

Description of the Sample ..................................................................................................98 Scaled Variables...............................................................................................................106 Research Hypotheses .......................................................................................................111 Hypothesis One ....................................................................................................111 Hypothesis Two ...................................................................................................114 Hypothesis Three .................................................................................................122 Hypothesis Four ...................................................................................................124 Hypothesis Five ...................................................................................................132 Hypothesis Six .....................................................................................................134 Summary ..........................................................................................................................138 CHAPTER 6: DISCUSSION, IMPLICATIONS, AND RECOMMENDATIONS .............139 Basic Conditioning Factors ..............................................................................................139 Demographics ......................................................................................................140 Age and education....................................................................................140 Social support...........................................................................................141 Health state...............................................................................................142 Support systems .......................................................................................143 Religion ....................................................................................................143 Basic Conditioning Factors and Self-care Agency ..........................................................144 Therapeutic Self-care Demand ........................................................................................145 American Heart Association heart failure stages .................................................145 Self-care Agency ..............................................................................................................146 Spirituality............................................................................................................147 Self-care ...........................................................................................................................147

x

Chronic Illness Self-care ......................................................................................147 Spiritual Self-care ................................................................................................151 Health and Well-being .....................................................................................................155 Health ...................................................................................................................155 Quality of Life......................................................................................................156 Conclusions ......................................................................................................................157 Limitations .......................................................................................................................157 Implications for Nursing Practice ....................................................................................159 Recommendations for Nursing Education .......................................................................160 Recommendations for Nursing Theory ............................................................................161 Recommendations for Further Research ..........................................................................161 Appendix A: Instruments .............................................................................................................164 Appendix B: Research Information Sheet ...................................................................................179 Appendix C: Human Investigation Committee............................................................................181 References ....................................................................................................................................182 Abstract ........................................................................................................................................210 Autobiographical Statement.........................................................................................................212

xi

LIST OF TABLES Table 1 Orem’s Power Components and Spiritual Influences ..................................................60 Table 2 Theoretical Association to Instruments Used in Study ................................................75 Table 3 Factor Structure of the SIBS-R ....................................................................................78 Table 4 Factor Analysis – Spiritual Self-care Practices Scale ..................................................81 Table 5 WHOQOL-BREF Domains .........................................................................................90 Table 6 Scoring Protocol for WHOQOL-BREF .......................................................................91 Table 7 Variables in the Study ..................................................................................................93 Table 8 Descriptive Statistics – Age and Length of Time Since Diagnosis of Heart Failure ...99 Table 9 Frequency Distributions – Demographic Characteristics of the Sample (N = 142) ..100 Table 10 Frequency Distributions – Heart Failure Characteristics (N = 142) ..........................102 Table 11 Frequency Distributions – Self-reported Physical and Emotional/Mental Health (N = 142) ........................................................................................................103 Table 12 Frequency Distributions – Religion as a Child and Religion at Time of the Study (N = 142) .........................................................................................................104 Table 13 Frequency Distributions – Attendance at Religious Services as a Child and At time of the Study (N = 142) ..................................................................................105 Table 14 Frequency Distributions – People to whom Patients Diagnosed with Heart Failure Turn in Times of Need (N = 142) ..................................................................106 Table 15 Description of Scaled Variables (N = 142) ................................................................107 Table 16 Mediation Analysis – Mediating Role of Heart Failure Self-care on the Relationship between Spirituality and Quality of Life (N = 142) .............................113 Table 17 Mediation Analysis – Mediating Role of Heart Failure Self-care on the Relationship between Spirituality and Physical Health (N = 142) ............................115 Table 18 Mediation Analysis – Mediating Role of Heart Failure Self-care on the Relationship between Spirituality and Mental Health (N = 142) ..............................117

xii

Table 19 Mediation Analysis – Mediating Role of Heart Failure Self-care on the Relationship between Spirituality and Depression as Measured by the PHQ-9 (N = 142) .......................................................................................................119

Table 20 Mediation Analysis – Mediating Role of Heart Failure Self-care on the Relationship between Spirituality and Depression as Measured by the Zung SDS (N = 142) ..................................................................................................121

Table 21 Mediation Analysis – Mediating Role of Spiritual Self-care on the Relationship Between Spirituality and QOL (N = 142) ..................................................................123

Table 22 Mediation Analysis – Mediating Role of Spiritual Self-care on the Relationship Between Spirituality and Physical Health (N = 142) .................................................125

Table 23 Mediation Analysis – Mediating Role of Spiritual Self-care on the Relationship Between Spirituality and Mental Health (N = 142) ...................................................127

Table 24 Mediation Analysis – Mediating Role of Spiritual Self-care on the Relationship Between Spirituality and Mental Health (Depression as Measured By the PHQ09; N = 142) ...........................................................................................129

Table 25 Mediation Analysis – Mediating Role of Spiritual Self-care on the Relationship Between Spirituality and Mental Health (Depression as Measured By the Zung; N = 142) ...............................................................................................131

Table 26 Pearson Product Moment Correlations – Spirituality, Spirituality Self-care Chronic Illness Self-care for Heart Failure, Physical and Mental Health, and Quality of Life (N = 142) ...........................................................................................133

Table 27 Pearson Product Moment Correlations and Point-Biserial Correlations – Quality Of Life and Demographic Variables (N = 142) .........................................................135

Table 28 Stepwise Multiple Linear Regression Analysis – Quality of Life and Basic Conditioning Factors ........................................................................................137

xiii

LIST OF FIGURES Figure 1 SCDNT with Spirituality and Related Constructs .......................................................54 Figure 2 Concept Map ................................................................................................................72 Figure 3 White’s Theory of Spirituality and Spiritual Self-Care ...............................................72 Figure 4 Statistical Analysis .......................................................................................................96 Figure 5: Mediation Model – Spirituality and Quality of Life Mediated by Heart Failure Self-Care Practices .....................................................................................................114 Figure 6 Mediation Model – Spirituality and Physical Health Mediated by Heart Failure Self-Care Practices .....................................................................................................116

Figure 7 Mediation Model – Spirituality and Mental Health Mediated by Heart Failure Self-Care Practices .....................................................................................................118

Figure 8 Mediation Model – Spirituality and Mental Health (Depression as Measured By PHQ-9) Mediated by Heart Failure Self-Care Practices ......................................120

Figure 9 Mediation Model – Spirituality and Mental Health (Depression as Measured By Zung) Mediated by Heart Failure Self-Care Practices .........................................122

Figure 10 Mediation Model – Spirituality and Quality of Life Mediated by Spiritual Self-Care Practices .....................................................................................................124

Figure 11 Mediation Model – Spirituality and Physical Health Mediated by Spiritual Self-Care Practices .....................................................................................................126

Figure 12 Mediation Model – Spirituality and Mental Health Mediated by Spiritual Self-Care Practices .....................................................................................................128

Figure 13 Mediation Model – Spirituality and Mental Health (Depression as Measured By PHQ-9) Mediated by Spiritual Self-Care Practices..............................................130

Figure 14 Mediation Model – Spirituality and Mental Health (Depression as Measured By Zung) Mediated by Spiritual Self-Care Practices ................................................132

Figure 15 Hypothesis 6...............................................................................................................140

Figure 16 Hypothesis 1...............................................................................................................148

Figure 17 Hypothesis 2...............................................................................................................150

Figure 18 Hypothesis 3...............................................................................................................152

xiv

Figure 19 Hypothesis 4...............................................................................................................154

Figure 20 Hypothesis 5...............................................................................................................156

1

CHAPTER 1

BACKGROUND, SPECIFIC AIMS, AND SIGNIFICANCE

Introduction

Interest in the relationship between spirituality and health-related quality of life (QOL) has been a major focus of study for the last few years. Researchers in the fields of theology, sociology, psychology, and medicine have examined spirituality, with these research studies providing substantial contributions to the continuing discussions of this construct (Como, 2007). Nursing, traditionally, has been concerned with the human spirit as a focal point of the human condition across the lifespan. Nurses need to be cognizant of the relationship between spirituality and patients’ ability to cope with chronic illness. Spirituality is an important element in the lives of many African Americans, who also are living with chronic illness. Spirituality and self-care for chronic illness has not been studied extensively in this population. The present research study examines the concept of spirituality within a self-care perspective that contributes to the QOL of African American men and women diagnosed with heart failure (HF). Self-Care Self-care is a complex and multidimensional concept that is widely researched and examined in health care. The World Health Organization (WHO; 1983) defined self-care as “the activities individuals, families, and communities undertake with the intention of enhancing health, preventing disease, limiting illness, and restoring health” (p. 181). Self-care also is defined as a “naturalistic decision making process involving the choice of behaviors that maintain physiologic stability (self-care maintenance) and the response to symptoms when they occur (self-care management)” (Riegel et al., 2004, p. 351). Self-care is situation- and culture- specific; involves the capacity to act and to make choices; is influenced by knowledge, skills,

2

values, motivation, locus of control and efficacy; and focuses on aspects of healthcare under individual control (Gantz, 1990). In 1959, Orem developed concepts associated with self-care requirements (Orem, 2003c). She originally described two types of self-care requirements: (a) requirements that are universal to all human beings and (b) requirements that occur relative to health deviations (e.g., chronic illness). Self-care requirements are “an essential or desired input to an individual or the individual’s environment in order to maintain or optimize human functioning” (p. 104). For example, a self-care requirement is that a person adjusts the amount of food eaten relative to the needs and activity of the individual taking external conditions into consideration. According to Orem, meeting self-care requirements requires action on the part of the individual to achieve the goal of optimizing or maintaining health. In a 1969 discussion of self-care, Orem (2003a) indicated that in order to determine the extent to which a person is able to accomplish self-care in a therapeutic manner, nurses must assess the individual’s physical limitations to design ways to compensate and the ability of the patient to overcome the limitations. Orem initially described four types of nursing systems: (a) wholly compensatory, (b) partially compensatory (supportive), (c) supportive educative, and (d) compensatory educative, with the degree of compensation related to the extent of the individual’s limitations. In 1978, Orem (2003b) further narrowed the four self-care nursing systems to three. She described three of these nursing systems as:  Wholly compensatory: self-care agency is not interactive or is negatively interactive with self-care demand. It may be interactive with nursing agency. Nursing agency is interactive with the self-care demand in generating a system of action that meets the demand and at the same time is operative to protect and preserve the person’s self-care agency. (p. 115)  Partially compensatory: Both self-care agency and nursing agency variables are interactive with self-care demand, and nursing agency will be directed to assist the person to withhold use of or further develop self-care agency. (p. 115)

3

 Supportive educative system: Nursing agency is interactive with self-care agency and self-care agency is interactive with self-care demand. (p. 115)

While Orem discussed nurses’ actions in helping increase patients’ self-care agency, Barofsky (1978) provided practical aspects of what activities individuals had to be able to perform to operate in this capacity. Self-care practices of individuals are influenced by a complex interaction of biological and psychosocial factors. The seminal work of Barofsky (1978) divided self-care activities into four types: 1. Regulatory self-care, which can include day-to-day activities such as eating sleeping, and bathing, 2. Preventative self-care, which can include exercise, dieting, and brushing teeth, 3. Reactive self-care, which is responding to symptoms without a physician’s intervention, and 4. Restorative self-care, which can include both a behavior change and compliance with a professionally prescribed treatment regimen. To meet the demands of self-care, Orem (2001) further delineated three requisites: (a) universal requisites, which are created by life processes and needed by all humans for the maintenance of the integrity of human structure and function, including water, air, food, social interaction, rest, and protection; (b) developmental self-care requisites, which include maturational needs adjusted to developmental stage (e.g., pregnancy, adolescence), and situational needs that stem from life events which left alone would impede human development; and (c) health-deviation self-care requisites, which are associated with genetic and constitutional defects, human structural and functional deviations, and medical treatments. Incorporating aspects of Barofsky’s (1978) self-care activities and Orem’s (2001) self- care requisites, a practical definition of self-care is “the practice of activities that individuals initiate and perform on their own behalf in maintaining health, life, and well-being” (Orem,

4

2001, p. 43). The words, health, life, and well-being, within this definition provide a rationale for nurses to participate in and encourage the self-care process of individuals. Nurses have the knowledge and understanding to promote health through teaching the disease process and suggesting activities and behaviors that can improve outcomes, ultimately leading to a longer, healthier life and enhanced overall well-being. Historical Perspectives on Self-Care Self-care, as a function of society, has been practiced since ancient times. Primitive cultures developed healing rituals involving consumption of foods thought to be beneficial long before physicians began encouraging a balanced diet. Women assisted one another during childbirth and passed their knowledge to the next generation without having a written birth plan to guide the process (Feldhusen, 2000). Traditions and rituals regarding self-care have evolved over time and are still in practice in modified forms in modern societies. For example, many Jewish people living in Europe in the Middle Ages avoided the Bubonic Plague through ritualistic hand washing and preparation of food. These self-care rituals protected the culture from annihilation that swept Europe at that time (Freeman & Abrams, 1999). Self-care practices are endorsed both in popular and research literature that provide ways to improve oneself both mentally and physically. In addition, support groups (e.g., Alcoholics Anonymous and Weight Watchers TM ) have been established to help individuals engage in self-care to improve their overall health. As a phenomenon, self-care has been widely researched and examined. Medicine, psychology, health education, sociology, public health, business administration, the insurance industry, and nursing have developed uses for self-care practices. Self-care has even been described as a social movement, sparking ongoing debate about political processes (Schiller & Levin, 1983). Such debates have resulted in corporations providing workers with monetary

5

reimbursements for engaging in healthier life-style behaviors, such as joining a gym, or participating in an organized sports league. Research has led to the development of theories and models of self-care behavior in psychology and nursing. Bandura published Social Foundations of Thought and Action: A Social Cognitive Theory in 1986. This book expresses Social Cognitive Theory (SCT), which is a model that explains the nature of behavioral change within the context of larger social structures. The nature of human agency, or the ability to control life events, is explained as a reciprocal relationship between behavior, interpersonal factors (cognitive, affective, biologic), and external factors (Bandura, 1986). Pender’s Health Promotion Model, originally published in 1987, is a nursing framework that serves as “a guide for exploration of the complex biopsychosocial processes that motivate individuals to engage in health behaviors, directed toward the enhancement of health” (Pender, 1996, p. 51). This nursing framework has been used in over 100 research studies to date (Pender, Murdaugh, & Parsons, 2005). Nursing has embraced the idea of self-care since the 1950s (Denyes, Orem, & Bekel, 2001) when Orem began formulating her theory regarding nursing and self-care. Orem first used the idea of self-care in 1956 in her definition of nursing. In 1959, the concept of self-care was published as part of a guide for developing a curriculum for practical nurses. A decade’s worth of work with other colleagues resulted in a formal articulation of her ideas in 1971 in a book entitled Nursing: Concepts of Practice. The second edition of her book, published in 1980, further refined and extended the theory of self-care. Orem’s (2001) Self-Care Deficit Nursing Theory (SCDNT) is: . . . descriptively explanatory of the relationship between the action capabilities of individuals and their demands for self-care or the care demands of children or adults who are their dependents. Deficit thus stands for the relationship between the action that individuals should take (the action demanded) and the action

6

capabilities of individuals for self-care or dependent-care. Deficit in this context should be interpreted as a relationship, not as a human disorder. (p. 149).

More than 400 nursing research reports that have made reference to Orem’s theory have been cited in the CINAHL database to date. Many of these papers featured self-care within the perspective of a chronic illness. Chronic Illness Self-care in the context of chronic illness is particularly challenging given the need for lifelong commitment to undertaking activities to maintain life and improve health. More than 50% of Americans say they have one or more chronic illnesses (Easton, 2009). Commonly studied chronic illnesses include diabetes, heart disease (including HF), hypertension, chronic obstructive pulmonary disease (COPD), and end-stage renal disease (ESRD). Chronic illness is defined as “the medical condition or health problem with symptoms or limitations that require long-term management” (Frietas & Mendes, 2007, p. 592). Frietas and Mendes further explain that chronic illness involves permanence and a deviation from normalcy, affecting aspects of everyday life, including physical, psychological, and social abilities. Chronic illness self-care activities include but are not limited to: following up with medical care, self-monitoring (e.g., glucose checks for diabetes, blood pressure monitoring for hypertension), taking medications properly, adhering to diet and exercise regimens, and smoking cessation (Katon & Ciechanowski, 2002). Activities associated with self-care also include seeking information regarding the chronic illness either through media sources or friends, self-advocacy, and working with medical professionals or family members (Loeb, 2006). Heart Failure

Heart failure (HF) is a widely studied chronic illnesses and is a common diagnosis for hospitalized adults 65 years and older (Schnell, Naimark, & McClement, 2006.) HF is defined as “a progressive and debilitating clinical syndrome characterized by an inability of the heart to

7

deliver enough oxygen and nutrients to meet the body’s metabolic needs” (Rockwell & Riegel, 2001, p. 18). This chronic illness results in the characteristic pathophysiologic changes of vasoconstriction and fluid retention and is characterized by ventricular dysfunction, reduced exercise tolerance, diminished QOL, and shortened life expectancy (House-Fancher & Foell, 2007). Symptoms of HF commonly include shortness of breath, swelling, and fatigue (Riegel & Carlson, 2002). Statistics regarding HF are readily available. For example, in 2005 the prevalence for HF in adults age 20 and over was 5,300,000, with about half of the incidence involving women (American Heart Association [AHA], 2008). African Americans have a higher incidence of HF, develop HF at an earlier age, and experience higher rates of mortality related to HF than Caucasians. The health disparities for African American men and women with HF are clearly demonstrated in statistics reflecting excess morbidity and mortality. In the U.S., approximately 4.2% of the African American women, compared to 1.8% of Caucasian women, are living with HF (AHA 2009a, c, d). Total mention death rate for heart failure (HF listed on a death certificate as either the cause of death or a contributing factor) is highest for African American men (81.9 per 100,000 deaths) followed by Caucasian men (62.1 per 100,000). The African American female death rate for HF (58.7) is 15 points higher than for Caucasian women (43.2; AHA, 2009a, c, d). The estimated financial cost of HF in the United States in 2008 was $34.8 billion. While the financial cost of HF is high, so is the human cost. Saunders (2009) identified social isolation, physical exhaustion, sleep deprivation, and anxiety among caregivers of HF patients. Patients experience social and psychological decline as their disease progresses (Murray, Kendall, Grant, Boyd, Barclay, & Sheikh, 2007). Between 14% and 37% of HF patients experience depression (Bekelman et al., 2007) and between 45% and 82% of HF patients

8

experience insomnia (Skotzko, 2009), which can lead to daytime fatigue and decreased activity. Twenty-two percent of HF caregivers also showed symptoms of depression (as measured by the Geriatric Depression Scale; Barnes et al., 2006). In 2005, there were more than 1,000,000 hospital discharges for individuals with HF, an increase of 171% since 1979 (American Hospital Association, 2008). As more people are being discharged from hospitals with HF, an urgent need exists for the health care system and HF patients in particular, to prevent future admissions. Engaging in self-care behaviors can prevent future readmissions for HF patients as well as reducing symptoms of HF. Self-care among people with HF includes both maintenance and management activities. Maintenance activities refer to healthy lifestyle choices, such as exercising and smoking cessation (Moser & Watkins, 2008), and treatment adherence behaviors such as daily weighing, restricting sodium intake, and taking daily medications (Riegel, Vaughan Dickson, Goldberg, & Deatrick, 2007). Self-care management activities require “cognitive process[es] and actions that include recognizing symptoms of worsening HF and performing self-care strategies [when these symptoms are recognized] such as cutting down on salt intake or taking an extra diuretic” (Moser & Watkins, 2008, p. 206). A major component of the self-care process involves decision making. Riegel, Carlson, and Glaser (2000) conceptualized stages in the decision making process as (a) recognizing a change; (b) evaluating the change; (c) implementing a treatment strategy; and (d) evaluating the treatment strategy. While not necessarily linear, these stages of decision making are an integral part of performing self-care. Depression has been widely studied in the HF population, with estimates of depression ranging from 30% to 50%. (Koenig, Vandermeer, Chambers, Burr-Crutchfield, & Johnson, 2006; Friedmann, et al, 2006; Sherwood et al., 2007). Depressive symptoms in HF individuals have been associated with physical limitations resulting from the HF, the intrusiveness of the

9

disease on the individual’s life, maladaptive coping, and decreased HF self-efficacy (Paukert, LeMaire, & Cully, 2009). Depression The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association [APA], 2000) conceptually defines depression as a period in which there is either depressed mood or loss of interest or pleasure and at least four other symptoms, such as problems with sleep, eating, energy, concentration, and self-image that reflect a change in functioning that lasts for two weeks or longer. Commonly, people experience depressive symptoms that can be characterized as loss of interest, feelings of worthlessness, withdrawal from social interactions, and loss of hope. Somatic symptoms, such as weight loss, insomnia, loss of energy, and decreased concentration are also experienced when depressed (Koenig, 2007). Eller and colleagues (2005) describe depressive symptoms that also include feelings of overwhelming sadness, a sense of futility, fear and worry regarding life and death, lack of motivation, confusion, and suicidal ideation. Reports on the prevalence of depression presented in published studies indicate that depression affects approximately 18.8 million Americans each year. Analysis suggests that 15% of the population can be expected to experience functional depression at some time during their lifetime (American Psychiatric Association, Media Relations Guide for Psychiatric Physicians, 2008). Major Depressive Disorder (MDD) is the leading cause of disability in the U. S. among people from 15 to 44 years of age (WHO, 2004). MDD is the fourth leading cause of disability worldwide based on disability-adjusted life-years (DALYs; Ustun, Ayuso-Mateos, Chatterji, Mathers, & Murray, 2004). By 2020, MDD is projected to be the second leading cause of global disability based on DALYs and the foremost cause of disease burden in developed nations (Murray & Lopez, 1996). Depression often co-exists with other chronic illnesses, such as: heart

10

disease (including HF), stroke, cancer, HIV/AIDS, diabetes, and Parkinson’s disease (National Institute of Mental Health, [NIMH] 2007.) Depression is thought to be more common among women than men, possibly resulting from biological, life cycle, hormonal, and psychosocial factors unique to women (NIMH, 2008.) Among African Americans, lifetime MDD is observed to occur in 10.4% of the population. Over a 12-month period, persistent MDD occurs in 56.5% of the African American population as compared to 38.6% of the Caucasian population (Williams et al., 2007). African- American females are diagnosed with MDD at approximately twice the rate of their male peers. In African American women with HF, the increase in the prevalence of depression can lead to even less involvement in daily activities of self-care, and can result in additional health setbacks to an already vulnerable population. Spirituality People engaging in self-care activities have to be concerned with the physical body, as well as human emotional and spiritual aspects. Themes common in the spirituality literature involve relations to other people; awareness of a higher being; and recognition of the broader world. Phrases used to characterize spirituality include: accepting others, even when they do things that are wrong (McCauley, Tarpley, Haaz, & Barlett, 2008); being able to interact with people (Cooper, Brown, Vu, Ford, & Powe, 2001); and seeking forgiveness (Blumenthal et al., 2007). Acknowledgement of and relationship with a higher being, (e.g. God, Allah, Waheguru, Vishnu or Shiva) (Musgrave, Allen, & Allen, 2002) is exemplified by these types of statements: feeling God’s presence (Mofidi et al., 2007); a higher power cares for me (Simoni & Ortiz, 2003); and God can heal people of their injuries and diseases (Gonnerman, Lutz, Yehieli, & Meisinger, 2008). Spirituality related to the greater world are evidenced by descriptions such as: connectedness to self, others, nature and the world (Dessio et al., 2004); touched by the beauty of

Full document contains 228 pages
Abstract: The purpose of this study was to extend the theory of self-care deficit nursing by including specific constructs of religion, spirituality, and spiritual self-care practices within the structure suggested by Orem's self-care deficit nursing theory. Based on an extensive literature review, practice experience, and a discovery theory-building approach, a new mid-range theory called White's theory of spirituality and spiritual self-care (WTSSSC) was developed. To begin to test this mid-range theory, empirical indices of many of the main concepts were identified from prior studies and one new instrument (the Spiritual Self-Care Practice Scale) was developed. Hypothesized relationships among the main concepts of the mid-range theory were examined and tested in a sample of 142 urban African American outpatients who had been previously diagnosed with heart failure. The results of this study provided support that White's midrange theory of spirituality and spiritual self-care (WTSSSC) is a viable extension of Orem's self-care deficit nursing theory (SCDNT). The relations between QOL and spirituality, spiritual self-care practices, chronic illness self-care for heart failure, and physical and mental health were statistically significant and in the expected directions. The midrange theory can be used to incorporate spirituality and spirituality self-care practices which can mitigate the effects of chronic disease related to overall QOL for African Americans who have been diagnosed with heart failure. Results of this study have provided additional support for the use of spiritual self-care practices to assist in managing chronic illness, specifically heart failure. Nurses who work with patients diagnosed with heart failure should provide instruction on self-care practices specifically for heart failure (weight and diet management, medication compliance, sleep, etc.) and then encourage the use of spiritual self-care practices to enhance the well-being and QOL for these individuals. Nursing education needs to include spirituality and the importance of spiritual self-care practices as part of teaching Orem's theory of self-care to enhance patient health and QOL. This education could be presented in nursing education classes in colleges and universities; professional development programs; and presentations at state, regional, national and international conferences. Further research is needed to continue development of the WTSSSC.