Iranian Journal of Critical Care Nursing Summer 2010, Volume 3, Issue 2; 87-91
Self-care ability based on Orem’s theory in coronary artery disease
patients
Mohammad Hassani M. R.1 PhD, Farahani B.2 MSc, Zohour A. R.3 PhD, Panahi Azar Sh.* BSc
*
Internal-Surgery Department, Faculty of Nursing & Midwifery, Tehran Medical Branch, Islamic Azad University, Tehran, Iran;
Cardiovascular Department, Faculty of Medicine, Tehran Medical Branch, Islamic Azad University, Tehran, Iran;
2
Internal-Surgery Department, Faculty of Nursing & Midwifery, Tehran Medical Branch, Islamic Azad University, Tehran, Iran;
3
Statistics Department, Faculty of Nursing & Midwifery, Tehran Medical Branch, Islamic Azad University, Tehran, Iran
1
Abstract
Aims: According to Orem’s definition, self care includes those learned behaviors that individuals perform in order to
preserve or promote their life, health, well being and prevention or treatment of their disease. Self care can play an effective
role in the management of individuals with chronic diseases including coronary artery disease. The aim of this study was to
determine the self-care ability and the relationship between self-care ability and some variables in coronary artery disease
patients.
Methods: In this analytical-descriptive study, 307 individuals, aged 40 or older with coronary artery disease, referred to the
military-502 Hospital of Tehran between July and November in 2009 were selected by purposive sampling method. The
data was collected through an interview using "self-care ability practice" and the "basic conditioning factors" questionnaire.
Data were analyzed using SPSS 14 software and descriptive statistical methods and one-way ANOVA.
Results: The self-care ability mean was 59.13±12.62. Factors including sex, age, occupation, education and income level
didn't have a significant relationship with self care ability (p>0.05).
Conclusion: Self-care ability of coronary artery disease patients is in moderate level and self-care ability and health are not
affected by basic conditioning factors (socio-demographic).
Keywords: Coronary Artery Disease, Nursing, Orem’s Theory, Self-Care Ability
Introduction
Adherence to self-care behaviors in patients having
chronic diseases is of high importance and patients
can, by acquiring self-care skills, affect their comfort,
functional abilities and disease processes [1].
Coronary artery disease is the most common chronic,
progressive and life threatening disease [2] and the
most prevalent cause of adults’ hospitalization [3].
World Health Organization has acknowledged the fact
that modern epidemic of the new age is the coronary
artery disease [4]. From economical point of view,
exorbitant costs are annually spent on treatment,
prevention and rehabilitation of patients with coronary
artery disease [5]. More than 100 thousand coronary
artery patients are re-admitted in medical centers due
to the disease relapse [6].
In Iran, coronary artery disease is the main cause of
mortality, morbidity and disability, with high
treatment costs [7]. Although there is no specific
statistics regarding the prevalence of coronary artery
disease in Iran, according to studies conducted in Iran
the mortality due to coronary artery disease has
increased about 20-45% [8].
Recent research has shown that improving the quality
of treatment can reduce the mortality associated with
* Correspondence; Email: [email protected]
heart diseases. One of the major issues in promotion of
treatment quality is patients’ participation in their
treatment and care. Considering this issue is important
due to the fact that patients’ lack of knowledge of how
to take care of them with respect to diet therapy causes
negative health consequences for hospitalized patients
and lead to frequent hospitalization. Self-care
activities can push the patient toward maintaining
health and wellbeing, enhancing the individuals’
adaptation and reducing the patient's rate of morbidity
and disability and treatment costs [9]. Self-care
behaviors reduce the severe symptoms of the disease
and improve its clinical outcomes and reduce readmission [10]. Human needs for maintaining their
health, lack of health facilities and unavailability of
these facilities for everyone and rising treatment costs
are among the reasons which have led to paying more
attention to the concept of self-care [11].
Self-care in chronic illnesses implies the study and
control of disease symptoms, accepting diet therapy,
maintaining the healthy lifestyle, the control of disease
impact on daily performance and emotions and social
relations. The major principle of self-care is
participation and responsibility of patients. Since
chronic diseases have considerable effect on patients’
life, the control of many disease complications is
Received 2010/05/12; Accepted 2010/06/19
Self-care ability based on Orem’s theory in coronary artery disease patients ___________________________________________
possible by self-care behaviors [12]. Simultaneously
with the increase in the number of people with chronic
diseases, health service systems, in the long run, have
been suffering many problems in the field of care
services to these individuals. In other words, it can be
said that a chronic disease needs chronic care. In this
regard, many believe that in order to organize these
patients and facilitate the works, care must be done by
patients themselves [13].
Self-care ability is presented by Orem as one of the
nursing self-care theories including the person’s
ability to do self-care activities. In other words, it is an
ability that the person obtains to create a balance
between his abilities and the existing needs for care
that life processes create [14]. Self-care means a set of
information, willingness to self-care and patients’ self
care skill [15] that is measured using Kearney and
Fleischer’s self-care agency questionnaire.
Considering the increasing number of patients with
coronary artery disease, illness length and frequent
hospitalization and socio-emotional problems imposed
on patient and his family by the disease, and the
enormous financial burden imposed on Iran economics
by this disease and its complication; no research has
been conducted in Iran about the self-care ability of
coronary artery disease patients. This study was
conducted to determine the relationship between age,
sex, educational level, employment status and income
level and self-care ability of coronary artery disease
patients and creating educational models and planning
for promoting self-care behaviors.
Methods
This is a descriptive-analytical study performed on
coronary artery disease patients in one of heart
specialty hospitals of Tehran during a five-month
period from November to March2009. 307 patients
were selected based on purposive sampling.
Research inclusion criteria were the diagnosis of
coronary artery disease, having a history of at least
one hospitalization due to coronary artery disease, age
of above 40 years, complete consciousness at the time
of study, lack of critical and emergency situations,
lack of speech and hearing problems, absence of
mental, physical and psychological disabilities, no
history of psychedelic drugs’ use and willingness to
participate in the research. Patients whose care had
been done by others, patients whose disease had been
diagnosed for the first time and those who had the
history of cardiac surgery within the six months
leading to the study were not enrolled.
Data collection tools were the two following
questionnaires: the demographic questionnaire and
patients’ self-care ability questionnaire. The ESCI
questionnaire was developed in 1979 by Kearney and
Fleischer and consisted of 43 questions. Answer of
any question was considered based on the Likert fiveoption scale of "Always is true of me" (5 points) to "it
is not true of me at all" (1 score). For Some questions
that had negative orientation the scoring was inverse.
Content validity of the two parts of the questionnaire
was done by the confirmation of 10 esteemed faculty
members of the Islamic Azad University, Tehran
medical branch, and by applying their comments and
suggestions. In order to investigate the second part’s
face validity, a pilot study was done before sampling
and the questionnaires was given to coronary artery
disease patients eligible for participation in the study.
Results showed that the questionnaire is responsive in
different items and the items of instrument are
proportionate to patients' culture. In the next step, in
order to determine the reliability of the questionnaire’s
second part, (by test/retest approach) the questionnaire
was provided for the same 30 patients within 10 days.
The correlation between the results of the two stages
was 0.86 (these 39 patients were excluded). Internal
consistency of the questionnaire was approved by
Chronbach's alpha of 0.92. This tool has been used by
Akyol for determining the self-care ability of patients
with hypertension in Turkey, and its reliability and
validity have been confirmed in 1993 and 2004 by
Nahcivan for use in Turkish society.
Data was collected thorough interview. The researcher
referred to the hospital in work shifts and on different
days of the week and selected the patients who had the
required qualifications to participate in the research
and while providing the necessary explanations
regarding the research goals and how to answer the
questions and taking a verbal consent from them,
began the interview and completed the questionnaire.
Data was analyzed using SPSS 14 software and
descriptive and inferential statistical methods. In order
to find the relationship between self-care and the
variables of age, educational level, employment status
and income level, ANOVA (one-way analysis of
variance) was used and in order to determine its
relationship with the sex variable, independent t-test
was used.
Results
Mean age of subjects was 58.83±11.14 years and most
of them (195 patients) were male (63.5%). All subjects
were married. 127 patients (41.4%) suffered from
other chronic disease as well. 1-24 months had passed
from the coronary artery disease onset of 171 patients
(55.7%). This time period was 25-48 months for 86
____________________________________________________________________________________ Mohammad Hassani M. R. et al.
patients (28%), 49-72 months for 27 patients (8.8%)
and more than 72 months for 23 patients (7.5%).
The average of patients’ self-care ability was
59.13±12.62. 28 patients (9.1%) had the self-care
ability at the "good" level, 229 patients (74.6%) at the
"moderate" level and 50 patients (16.3%) at the "poor"
level. There was no significant correlation between
self-care ability and age, gender, education level,
employment status and income status (p>0.05; Table
1).
Table 1- Statistical indexes of self-care ability in the studied
population
Statistics→
Significance
Number Percent Mean SD
Variable↓
level
<49
66
21.5 62.43 12.74
50-59
105
34.2 58.83 13.16
p=0.14
Age (years)
F=1.80
60-69
103
33.6 62.16 11.46
70<
33
10.7 59.60 11.19
Male
195
63.5 60.58 12.17
p=0.67
Gender
t=-0.41
Female
112
36.5 61.20 12.74
Primary
128
41.7 61.40 13.29
Education
p=0.83
Educational Guidance
58
18.9 61.14 11.78
school
F=0.28
Level
Diploma
86
28
59.88 10.37
University
35
11.4 60.36 14.52
Unemployed
15
4.9
58.21 8.98
Worker
12
3.9
64.05 10.81
67
21.9 58.89 12.88
p=0.83
Employment Employee
F=0.28
Status
Free
43
14
58.91 9.81
Retired
98
34.9 61.61 13.15
Housewife
63
20.5 62.79 12.78
Less than the
213
69.4 61.46 11.62
costs
p=0.34
Equal to
Income
88
28.7 59.19 13.80
F=1.06
Costs
Status
More than
6
2
61.33 15.97
Costs
Discussion
9.1% of patients (28 patients) had good self-care
ability, 74.6% of patients (229 patients) had a
moderate and 16.3% (50 patients) had poor self-care
ability. In a study by Akyol conducted to evaluate the
self-care ability of hypertensive patients in Turkey,
self-care ability of subjects was intermediate.
According to the study of Unsars that also investigated
the self-care ability of diabetic hemodialysis patients
in Turkey, self-care ability of subjects has reported to
be at the average level [16]. In a study by Alvare with
the aim of determining the self-care ability of
hypertensive patients hospitalized in Bogota,
Colombia, 53% and 47% of subjects have been
reported to have poor and desirable self-care ability,
respectively [17].
In the present study, self-care ability of subjects
revealed no significant statistically correlation in
different age groups. According to Orem, the strengths
and self-care needs in a healthy person are different
according to the developmental level determined by
age. In the Unsars et al. a significant correlation was
not observed between the age and self-care ability of
dialysis patients. Akyol et al. also did not report any
significant correlation between age and self-care
ability of hypertensive patients. In this study, the
subjects’ self-care ability did not show any statistically
significant correlation with sex.
Coyle writes: "Gender as a basic conditional factor
can affect the self-care ability and needs. In addition,
gender is related to dependent care and dependent care
ability, according to various roles defined by culture."
[18]. Dashiff and Mccaleb, in their study reported a
significant correlation between gender and self care;
so that young females with diabetes type I have better
self-care ability than the male group [19]. In the
Unsars et al. study, male dialysis patients have also
better self-care ability. According to Akyol et al.
hypertensive men had higher self-care ability, but did
not report any statistically significant difference with
regard to the self care ability of both genders.
In this study, subjects’ self-care ability did not show
any statistically significant correlation in various
educational groups. As Coyle states, "Self-care power
and activity are learned behaviors that a person is
supposed to learn them from early childhood to
adulthood and formal education as a basic influential
factor, has a direct relationship with the levels of selfcare ability." Akyol et al. believe that "high education,
according to its relation with better job positions and
better income affects the self-care ability". Several
studies have reported a significant correlation between
education and self-care ability. Akyol et al. show
similar results in their study, regarding the relationship
of educational level and self-care ability. The results
of Baghaiy et al. study in Iran indicate a significant
relationship between educational level and self-care
ability [20].
In this study, subjects’ self-care ability in different
occupational groups did not show any statistically
significant relationship. Jirovec and Kasno believe that
job is directly related to the level of self-care ability,
because a better job status indicates higher levels of
education and income. According to Oksel et al., a
significant correlation has been reported for the selfcare ability and employment [21]. The results of the
Akyol et al. study are similar to the results of this
study and no significant relationship has been reported
between job and self-care ability.
Self-care ability based on Orem’s theory in coronary artery disease patients ___________________________________________
In this study, subjects’ self-care ability did not show
any statistically significant relationship with income
level. As Coyle writes, "Economic factors are a
reflection of individuals and families’ available
resources for providing self-care ability or dependent
care." In the study by Garcia with the aim of
determining the self-care ability of hypertensive
patients in Colombia, a significant correlation has
been reported between self-care ability and income
level [22]. In the study conducted by Artinian et al.,
the results are similar to this study and no significant
relationship has been reported between income level
and self-care behaviors of the subjects [23].
Nurses have the highest influence on self-care ability
level of coronary artery disease patients, considering
their wide role in the care of patients. Nurses can
evaluate the self-care of patients and diagnose the
shortcomings when encountering coronary artery
disease patients, in order to use the obtained data for
selecting complementary treatment methods. In
addition, the findings of this research can motivate
nurses to implement nursing activities based on the
theory of Orem, by involving patients in their selfcare, satisfying their educational needs, providing
constant educational programs and recognizing and
removing the obstacles of self-care behaviors’ proper
implementation. The results of this study can be used
by nursing managers to cause an improvement in the
nursing qualities, by holding some in-service training
and providing accurate and comprehensive
information regarding self-care behaviors according to
Orem model.
Conclusion
There is no relationship between some baseline factors
(the variables of age, sex, educational level, and
employment status and income level) and self-care
ability of coronary artery disease patients according to
Orem theory. Self-care ability of coronary artery
disease patients is in a moderate level. The
reinforcement of this ability in coronary artery disease
patients can considerably affect the disease control,
prevention of probable complications and reduction of
hospitalization and treatment costs and improvement
of individuals’ life quality.
Acknowledgement: Sincere cooperation of the
respected professors of nursing education department
of the Nursing and Midwifery College of Azad
University, Tehran medical branch and all patients
who had the necessary cooperation in performing this
study and the military-502 Hospital respected staff are
appreciated.
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