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In 2019 we were fortunate to publish a ‘concept analysis in self-management’ in BMJ Open (Van de Velde, 2019). Later on we received a reply from Riegel and colleagues. We wish to thank these authors of the International Centre for Self-Care Research for writing this appealing comment on our article. This is a nice way of exchanging knowledge and insight in the concept of self-management and therefore we appreciate this greatly.
We like to respond to this reply in a extensive way since we think that this could be of great value for all researchers as example how scientific communication (as supported by BMJOpen) might strengthen health care and health care research.
Our intention was indeed to clarify the concept of self-management since this concept presently has been put forward as an important key-factor in new ways of defining health, e.g.: “the ability to adapt and self-manage in the face of social, physical, and emotional challenges” (Huber, 2014). Before this definition can be considered viable, the key concept should be clarified and untangled leading to a general consensus on the concept. Consequently, this concept analysis has been performed because of the demographic and epidemiological transition which is accompanied by new attitudes towards health and health care delivery in which self-management became a pivotal concept. Coming from this understanding, our main intention was not to clarify differences between juxtaposing con...
Our intention was indeed to clarify the concept of self-management since this concept presently has been put forward as an important key-factor in new ways of defining health, e.g.: “the ability to adapt and self-manage in the face of social, physical, and emotional challenges” (Huber, 2014). Before this definition can be considered viable, the key concept should be clarified and untangled leading to a general consensus on the concept. Consequently, this concept analysis has been performed because of the demographic and epidemiological transition which is accompanied by new attitudes towards health and health care delivery in which self-management became a pivotal concept. Coming from this understanding, our main intention was not to clarify differences between juxtaposing concepts such as self-care, and for instance disease management or illness management. We believe that other scientific methods may be more suitable for that, what will be discussed below. For that specific reason, and to avoid semantic discussions, we excluded the term self-care in our search strategy. Notwithstanding, we do agree that there is indeed often confusion about the difference between self-care and self-management as has been shown in the literature and in practice (Richard and Shea, 2011). Moreover, both concepts are also used interchangeably (BMA, 2019).
However, we have been debating this issue in length with the research group. We therefore have put our rationale in this response why we did not include articles about self-care in our search strategy.
First of all, and perhaps the most important one, the first step in the concept analysis according to Walker and Avant (2014) is to narrow the analysis to one single concept. So, if we would have included also self-care we would have created a methodological bias; this possibly would have increased the ambiguity, instead of providing clarity. In excluding self-care as literature, we specifically aimed to narrow our search by selecting articles with the term self-management in the title or in the keywords of the article. When doing so, we excluded all the other juxtaposing concepts, not only self-care but also disease management or illness management. After that, articles were included if solely the theoretical or conceptual foundations of self-management was discussed to be sure we were not biased. We could have added this in the discussion but we did not to do so since this is a prerequisite in the method of concept analysis according to Walker and Avant.
Besides this argument, there are also arguments in the literature that self-management and self-care are two different concepts. Depending on the point of reference and the theoretical viewpoint, self-care can be seen as the overarching concept, in which self-management is only one subcomponent, such as described in the theoretical paper by Richard and Shea (2011) and in nursing research (Cecebi, 2008). On the other hand, self-management can be seen as the overarching concept in which self-care is one of the subcomponents, such as in occupational therapy research. For instance, in occupational therapy, self-care (such as dressing oneself and taking care of one’s own health) is seen as one of the three main activity domains of daily living next to productivity (such as having and maintaining a job) and leisure (such as playing and being engaged in sports for fun). Each of these three domains are related to living and managing life in general. This is closely linked to the International Classification of Functioning, Disabililty and Health, in which self-care is only one of the nine domains, next to e.g. domestic Iife (such as household tasks) and major life areas (such as education and working) (WHO, 2001). Also these domains should be managed but are not defined as self-care. This point of view on self-management is also in line for instance with the geriatric literature. Many examples are out there to support the idea of self-care as a synonym for basic activities of daily living as measured by the Katz index (Katz et al, 1967) for instance and are part of the triade of basic (dressing, washing oneself,…), instrumental (housekeeping, laundry,…) and advanced activities (leisure, hobbies, but also education,…) (Reuben et al, 1989).
From these three perspectives described above, self-management is related to managing life in all its aspects (despite of the illness) and could be overarching the concept of self-care in which the focus is more on only managing the illness (in life).
In conclusion, we could stat that the starting point of view determines how the two concepts are interrelated and intertwined or whether both are fundamentally different. This might explain the different conceptualisation of our research group compared to the definition from the International Center for Self-Care Research. Although they state that there are quite a lot of similarities between both proposed definitions, we think that – though similarities are apparent -also differences are apparent.
If we put them next to each other:
‘self-care is a process of maintaining health through health promoting practices and managing illness’ (Riegel et al, 2019).
‘Self-management is the intrinsically controlled ability of an active, responsible, informed and autonomous individual to live (with the medical, role and emotional consequences of his chronic condition(s)), in partnership with his social network and the healthcare provider(s)’ (Van de Velde et al, 2019).
In the definition of self-care, the focus is on managing illness and consequently this starts primarily from a biomedical perspective, while in the definition of self-management the focus is on managing life, despite the fact that there is a chronic condition and that might be more bio-psycho-social oriented. That means that there is a fundamental difference in viewpoint.
Therefore, we unfortunately are not sure whether we agree with the statement that our research would have been stronger when we had also included publications related to self-care as suggested by Riegel and colleagues (2019), because we would not only have mixed two concepts, but we also would have muddled two philosophical foundations. We therefore believe that a concept analysis of self-care would be different from a concept analysis of self-management. Untangling these two concepts is necessary, specifically because a lack of differentiation between the two could have a chilling effect on interdisciplinary discourse, it could impede research and could possibly reduce health care professionals’ effectiveness. Therefore, a clear concept delineation would benefit health care professionals, policymakers, teachers and students for health care delivery in general, but also for research purposes.
Our concept analysis, the reply and this comment, shows that research is always loaded with values and perhaps short-sighted perspectives, yet we all use sound research methods. It shows at the same time the urgent need to collaborate and move beyond the boundaries of the own profession. We therefore appreciate this comment as an open invitation.
British Medical association (BMA), Self-care: question & answer. Patient Liaison Group resources and self-care
Cebeci F, Senol S (2008). Discharge training and counselling increase self-care ability and reduce post discharge problems in CABG patients, J. Clin. Nurs. 17: 412-420.
Huber M, Knottnerus JA, Green L, et al. How should we define health? BMJ 2011;343:d4163.
Katz, S., Ford, A. B., Moskowitz, R. W., Jackson, B. A. and Jaffe, M. W. Studies of illness in the aged. The index of ADL: a standardized measure of biological
and psychosocial function. JAMA. 1963;185, 914–919.
Richard A, Shea K. Delineation of Self-care and Associated Concepts, J. Nur. Scholarship. 2011;43: 255-264.
Riegel B, Jaarsma T, Lee CS, Stromberg A. Integrating Symptoms Into the Middle-Range Theory of Self-Care of Chronic Illness. ANS Adv Nurs Sci. 2019;42(3):206-215.
Reuben, D. B. and Solomon, D. H. Assessment in geriatrics. Of caveats and names. Journal of the American Geriatrics Society. 1989; 37, 570–572.
Van de Velde D, De Zutter F, Satink T, et al. Delineating the concept of self-management in chronic conditions: a concept analysis. BMJ Open. 2019;9(7):e027775.
Walker L, Avant K. Strategies for theory construction in nursing. 5th edn. Edinburgh: Pearson, 2014
World Health Organization. International Classification of Functioning, Disability and Health. Geneva, WHO, 2001.
We read with interest the paper by Van de Velde et al delineating the concept of self-management in chronic conditions.1 We agree that there is a lack of consensus on the meaning of self-management, ambiguity regarding the concept, and an urgent need for uniformity with regard to terminology. One major area of ambiguity is the relationship between self-management and self-care. These terms are often thought of as synonyms, used interchangeably, or considered as integrated concepts (e.g. self-care as an overarching or umbrella term, with self-management as onecomponent of self-care).2 This is why, until 2018, major search engines combined the terms. When one searched for “self-management”, literature on “self-care” was provided as well. Since Van de Velde and co-workers aimed to delineate the concept of self-management and develop a definition for its use in healthcare, we expected a more thorough review of related concepts in their concept analysis. Thus, we were surprised to find that several important publications on self-care were excluded.
We believe that the concept analysis by van de Velde et al would have been stronger if they also had included publications related to self-care. In 2012, after many years studying self-care in heart failure, we developed the Middle-Range Theory of Self-Care of Chronic Illness,3 which was updated this year.4 In this theory we defined self-care as the process of “maintaining health through health promoting practices and managi...
We believe that the concept analysis by van de Velde et al would have been stronger if they also had included publications related to self-care. In 2012, after many years studying self-care in heart failure, we developed the Middle-Range Theory of Self-Care of Chronic Illness,3 which was updated this year.4 In this theory we defined self-care as the process of “maintaining health through health promoting practices and managing illnesses” (p. 195),3 a definition quite similar to the definition provided for self-management. Since publication, investigators around the globe have used our theory to study how individuals maintain their health, monitor and manage their illnesses. But even before the official publication of the Middle-Range Theory of Self-Care of Chronic Illness, there was a wealth of publications studying self-care that might have been included in the present concept analysis.
We agree with the authors that self-management, or self-care, is important for the sustainability of our healthcare systems into the future. Discussions aimed at reaching consensus on shared terminology can only benefit society and the development of the science. So, we thank you for your efforts to examine “self-management” and hope that you will do the same for “self-care”. Such an effort to compare and contrast the two common terms would be a major contribution to our shared goal of consensus.
1. Van de Velde D, De Zutter F, Satink T, et al. Delineating the concept of self-management in chronic conditions: a concept analysis. BMJ Open. 2019;9(7):e027775.
2. Godfrey CM, Harrison MB, Lysaght R, Lamb M, Graham ID, Oakley P. Care of self - care by other - care of other: the meaning of self-care from research, practice, policy and industry perspectives. Int J Evid Based Healthc. 2011;9(1):3-24.
3. Riegel B, Jaarsma T, Stromberg A. A middle-range theory of self-care of chronic illness. ANS Adv Nurs Sci. 2012;35(3):194-204.
4. Riegel B, Jaarsma T, Lee CS, Stromberg A. Integrating Symptoms Into the Middle-Range Theory of Self-Care of Chronic Illness. ANS Adv Nurs Sci. 2019;42(3):206-215.