Contributor: Maria João Dias Ferreira

I’m part of the nursing team at a Heart Failure Outpatient Clinic (HFOC), where we apply a multidisciplinary approach to patients with Heart Failure (HF). This model encompasses two strands of nursing care: a scheduled nursing consultation, where various topics are covered in teaching sessions for self-care and self-management of HF signs and symptoms, and a treatment session, usually unscheduled and urgent, aimed at restoring well-being to a level where it is safe to manage these patients on an outpatient basis, and therefore avoiding possible re-admissions and harmful consequences.

The negative impact that HF has on patient’s quality of life requires nurses to provide new forms of care that prevent and control the progression of the disease. At the HFOC, the nursing consultation is the preferred setting for achieving and maintaining therapeutic regimen compliance and improving self-care. During the nursing consultation, we apply the validated Portuguese version of the European Heart Failure Self-care Behaviour Scale (EHFScBS) (Pereira, 2013), which not only allows the assessment of knowledge for self-care but also provides a structured interview guide to improve adherence to the therapeutic regimen. The criteria contemplated in this tool allows nurses to understand whether the patient has a knowledge deficit and which specific area of their self-care the nurse should focus on during the teaching sessions.

But how did this script come about? How do we progress in the hierarchy of contemporary nursing knowledge from practical guidelines to the conceptual models on which they are based?

In the early 21st century, the first EHFScBS was developed, validated, and published in Sweden (Jaarsma, Strömberg, Martensson & Dracupa, 2002), demonstrating that this tool is valid and reliable. Practical tool for measuring the self-reported self-care behaviour of patients with HF even often being proposed to evaluate the outcome of HF management programs that focus on changing patients’ self-care practices.

With the use of this “small” script, we can understand that the nursing process during the HF consultation emphasizes patient change and transformation, with the nurse acting as a collaborator in decisions, positively influencing the patient’s health and well-being, improving self-accountability for change and favouring their autonomy.

Based on the work developed by Fawcett regarding the Nursing Metaparadigm focused on the levels of structured knowledge (Fawcett, 1984), we can fit this methodology of care centered on self-care in the Transformation Paradigm, thereby creating the foundation of the levels of knowledge structure. This paradigm sees phenomena as unique but in interaction with everything around them. Changes occur through stages of organization and disorganization, but always towards higher levels of organization (Newman, 1992). (See Figure 1).

Following the publication of the tool, the authors of the EHFScBS contributed to several years of research in HF self-care, enabling them to develop the Mid-Range Theory of Self-Care in Chronic Illness in 2012 (Riegel, Jaarsma & Strömberg, 2012). In this set of guidelines for nursing practice, the authors describe the process of maintaining health through health-promoting practices during chronic disease management. The main concepts include maintenance, self-monitoring, and self-care management by the patient and family. The authors also describe factors that influence self-care, including experience, ability, motivation, culture, confidence, lifestyle habits, functional and cognitive status, and the support provided by other individuals and access to care. In their middle-range theory development, the authors refer to Orem’s Grand Nursing Theory influence and how it was the conceptual model that guided and structured it (Riegel, Jaarsma & Strömberg, 2012).

Gradually moving up the hierarchy of the nursing metaparadigm (Fawcett, 1984), we can broaden the horizon of nursing knowledge and include the practice of self-care promotion in Virginia Henderson’s Need Theory (Henderson, 1964). This philosophy aims to reduce deficits and self-care needs, helping the patient adapt and achieve independence in their daily activities. Henderson’s fourteen basic needs include physical, psychological, social, and spiritual components, ranging from correct breathing to finding meaning in life, emphasizing holistic patient care and not just the illness itself. This holistic approach continues to influence nursing practice today, highlighting the importance of patient-centred care and the promotion of autonomy.

At the apex of the Nursing Metaparadigm (Fawcett, 1984) are the Central Concepts: person, environment, health, and nursing care. Returning to the initial context of this article, we can consider the following central concepts: Person: adult with an HF self-care knowledge deficit; Environment: Heart Failure Outpatient Clinic; Health: HF self-care deficit; Nursing Care: HF self-care promotion through teaching sessions.

As time progresses, technology evolves, and as information is further accessible, nurses have created task-oriented care routines, often without considering the magnitude of what they can do or whether the problems solved are the correct ones.

The way in which nursing thought is organized, valuing the theories that have brought us this far, has shown me the dimension of nursing practice, defined limits to my scope of practice, and hopefully improved it, delivering genuine nursing care with and for the patient and their family, always considering their community and environmental context.
Communicating, executing, thinking as a group and empowering nursing research, amplifies nursing at the centre of care, adding value, and giving the group the visibility it deserves in the world.

References

Fawcett, J. (1984). The metaparadigm of nursing: present status and future  refinements. Image – The Journal of Nursing Schoolarship, 16(3), pp. 84-89. https://sigmapubs.onlinelibrary.wiley.com/doi/10.1111/j.1547-5069.1984.tb01393.x

Henderson, V. (Agosto de 1964). The Nature of Nursing. American Journal of Nursing, 64(8), pp. 62-68. Obtido em 03 de Dezembro de 2023

Jaarsma, T., Stromberg, A., Martensson, J., & Dracupa, K. (02 de Maio de 2002). Development and testing of the European Heart Failure Self-CareBehaviour Scale. The European Journal of Heart Failure, pp. 363-370. Obtido em 03 de Dezembro de 2023, de https://onlinelibrary.wiley.com/doi/epdf/10.1016/S1388-9842%2802%2900253-2

Newman, M. (Janeiro de 1992). Prevailing paradigm in nursing. Nursing Outlook, 40(1), pp. 10-13. Obtido em 03 de Dezembro de 2023, de https://pubmed.ncbi.nlm.nih.gov/1570217/

Ordem dos Enfermeiros. (2011). CIPE® Versão 2 – CLASSIFICAÇÃO INTERNACIONAL PARA A PRÁTICA DE ENFERMAGEM. Genébra: Ordem dos Enfermeiros. Obtido em 03 de Dezembro de 2023, de https://www.ordemenfermeiros.pt/media/27837/ordem-enfermeiros-cipe.pdf

Pereira, F. Á. (2013). Dissertação de Mestrado apresentada ao Instituto de CIências Biomédicas de Abel Salazar da Universidade do Porto em Ciências de Enfermagem. O Autocuidado na Insuficiência Cardíaca: tradução, adaptação e aplicação da European Heart Failure Self-Care Scale para o contexto português, p. 95. Obtido em 02 de Dezembro de 2023, de https://repositorio-aberto.up.pt/bitstream/10216/70811/2/30857.pdf

Queirós, P., Vidinha, T., & Filho, A. (Nov-Dez de 2014). Autocuidado: o contributo teórico de Orem para a disciplina e profissão de Enfermagem. Revista Enfermagem Referência, IV(3), pp. 157-164. Obtido em 05 de Dezembro de 2023, de http://dx.doi.org/10.12707/RIV14081

Riegel, B., Jaarsma, T., & Strömberg, A. (Jul-Set de 2012). A middle-range theory of self-care of chronic illness. Advances in Nursing Science, 35(3), pp. 194-204. doi:10.1097/ANS.0b013e318261b1ba

About Maria João Dias Ferreira

I am a registered nurse for 19 years and a cardiology nurse for 17 years, working with heart failure patients for the last 9 years. I have a Masters Degree in Health Management and since September 2023, I have been attending the Master Nursing Course at the Faculty of Health Sciences and Nursing / School of Nursing (Lisbon). This post was created in the nursing theories curricular unit, with the pedagogical supervision of Professor Zaida Charepe (PhD, Associate Professor).
My research interests include improving self-care planning, communication and finding better nursing outcomes for the patients. I am currently part of a nursing team at a Heart Failure Outpatient Clinic, a multidisciplinary model to approach adults, improving self-care and self-management of their heart failure.