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Self-Care, Healthcare Reform and Their Implications to Nursing
ORIGINAL ARTICLE
Self-Care, Healthcare Reform and Their Implications to Nursing
by Lisa Keeping
H Abstract A move toward individual
ealthcare is moving toward individual freedom, self-responsibility and decreased reliance on experts. The capacity of individuals to take care of their own health is being increasingly emphasized. Although the concept of self-care has been around since the beginning of civilization,1 it has often not been consciously thought about or emphasized. In fact, the individual and the family have historically provided the bulk of healthcare for individuals,1,2,3 with ministering to the sick being an accepted part of the individual/ family role. Canada has one of the best healthcare systems in the world with universal access for its citizens, but the role that individuals have played in self-care and mitigating health outcomes has fluctuated over the years.4,5 With the advent of healthcare reform in the 1990s, the concept of self-care has become increasingly prominent in lay-person and healthcare provider language.6,7 In fact, the concept now plays a central role in health policy formulation and decision making. Moreover, there has been a corresponding increased emphasis on the active role that individuals can play in shaping health outcomes.
responsibility for health is
Origins of Self-Care
gaining momentum in
The effects of lifestyle on health and the individual’s capacity to affect health outcomes have been noted as far back as ancient Rome and Greece,4,5 the Middle Ages and the Renaissance.1,8 The earliest political underpinnings of self-care in Western civilization are found in the writings of 17th and 18th century English political and social theorists, and in the assumptions underlying classical liberalism, which asserts that individuals are selfsustaining, rational and motivated to maximize human potential.9 Classical liberalism extracts responsibility for individual outcomes from the context of societal forces and redirects responsibility toward the rational capacity of humans to determine their course in life.
Canada. Whether or not individual responsibility for self-care practices is in the best interest of the public is debated in this article. The origins of the self-care movement in the Canadian healthcare system, its benefits and pitfalls, are explored. The role that the nursing profession can play is also discussed.
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Self-care has been defined in a number of ways depending upon whether the disciplinary focus has been sociological, psychological, ecological, medical, nursing or health promotion.3,10 Owing to this diverse array of historic roots for self-care and its semantic confusion with self-help, medical self-care and self-treatment, there is no universally agreed-upon definition of the concept.11,12 Despite this, self-care consistently reflects individual behaviour that is voluntary, universal and self-limited, and which involves behaviourally and cognitively based experiences. In this article, self-care is defined as “a process whereby a lay person functions on his or her own behalf in health promotion and prevention and in disease detection and treatment at the level of the primary health resource in the healthcare system.”11
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Self-care has played a role in nursing since the time of Florence Nightingale. As early as 1859, Nightingale saw basic individual hygiene and environmental forces as instrumental determinants of individual and societal health.13 These values have been the guiding principles of public health nursing for years. Similarly, self-care is the basis of a nursing theory developed in the 1950s by Dorothea Orem,14,15 and has guided the many nursing curricula that have existed since that time.
The Self-Care Movement in Canadian Healthcare For self-care to be considered a movement, four criteria should exist: an ideology, a feeling of “we-ness” among the public involved, organization, and strategies and tactics for accomplishment of goals.16,17 The earliest and most modern interest in self-care in Canada can be linked with the feminist movement in the 1960s when issues of independence, autonomy and self-determination in health and illness for women emerged.3 Interest in self-care throughout the 1970s and ‘80s and the growth of selfhelp groups among the public3,12 were also influential. However, self-care as a movement did not technically begin until the 1990s with the occurrence of healthcare reform. Since that time, the public has rapidly become consumers of healthcare and have formed an ideology of developing self-care capacity to cope with rapid technological change and government cutbacks. Official plans enacted by government at federal and provincial levels to foster self-care abilities2,18 have demonstrated a role for government and healthcare professionals (HCPs) in helping to assure its attainment. Healthcare reform in the 1990s heightened public awareness through various political avenues, thus redirecting the emphasis on self-care activities and the role
individuals play in determining health outcomes.
Philosophical Assumptions and the Political Environment The first mention of self-care in Canada was in 1974 with the publication of the Lalonde Report,19 which emphasized the role of environmental forces and individual lifestyle in the well-being of individuals. Although other factors such as biology, environment and availability of health services were credited as contributors to health status, attention to the active role of individuals in modifying health outcomes was emphasized. During the late 1970s, environmental influences on health intensified and cumulated with the Alma Ata Declaration at the time the World Health Organization (WHO) developed the “Health-for-All Strategy—Primary Healthcare” (PHC).20 PHC is both a philosophy and a method of healthcare delivery that includes the five principles of accessibility, public participation, promotion of health and prevention of illness, intersectoral cooperation, and appropriate technologies. The principles represent the philosophical assumptions underlying the Canadian healthcare system today, and hence the philosophical grounding for self-care in Canada. Landmark documents such as The Ottawa Charter on Health Promotion21 and Achieving Health for All: A Framework for Health Promotion20 were also instrumental in laying the foundation for what has become the self-care movement in healthcare. Both documents discuss how health is created and attained by all members of society through the development of personal skills that enhance individuals’ capacities for coping with disability or disease. Another major health challenge
identified was enhancement of health through the reduction of social inequities. Achieving Health for All specifically identified self-care as a mechanism for achieving healthy individuals and communities. Starting in the late 1970s and through to the late 1980s, government focused on examining ways for delivering healthcare more cost effectively.22,23 Political upheaval has characterized the system since the early 1990s, as have collective efforts to reform and restructure Canada’s health system. Since that time, the federal government has refocused its involvement in healthcare on ensuring that the philosophy of PHC is maintained while, at the same time, transferring increased responsibility for healthcare funding to the provinces.24 Restructuring of the healthcare system has been, and continues to be, accomplished through reducing the size of the workforce, contracting out, offering part-time work, emphasizing greater productivity from the remaining employees, and moving from institutional to community-based patient care.25,26 These changes have represented times of unrest and upheaval within the Canadian system and have created an atmosphere conducive to a self-care movement in healthcare. A number of health-related documents pertaining to the health of Canadians have been compiled during the last 10 years. These also refer to the role of individuals in the maintenance of health.27 One such document, Strategies for Population Health,28 identified personal health practices and coping skills as contributory factors for determining population health. The Canadian Nurses Association (CNA) has also been active on a number of fronts developing and issuing policy statements for nurses on the safe and effective delivery of healthcare by nurses to the public.29,30
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One of the most notable contributions of the Canadian government to selfcare was launched by Health Canada in 1994 with the initiation of a selfcare project to study how nurses and doctors support self-care in practice.2 The Self-Care Project has been carried out in four stages, the fourth of which is currently underway. Results of this initiative demonstrate that nurses and physicians are actively engaged in promoting the self-care of patients through various means in their practice environments. Further to this, in 1999 a federally funded project sponsored by the CNA, College of Family Physicians of Canada, Association of Canadian Medical Colleges and Canadian Association of University Schools of Nursing was undertaken to assist HCPs support self-care in practice. This endeavour is reflected in a number of research projects currently being conducted with a view to promoting self-care in Canada.18,31
Societal Contributions Aside from the political agenda shaping the Canadian healthcare system, a number of concurrent changes in society have had a direct impact on healthcare. The 20th century has seen the emergence of a technological age in which patients, better educated than ever before, have improved access to information through computerized technology.7,32 As a result, patients have become consumers of healthcare. They are demanding to be better informed and to actively participate in self-care practice. Patients want to be partners in healthcare decisions. They no longer find the healthcare system’s paternalistic attitude acceptable or appropriate. The aim of consumerism has been to create a better balance of power between consumers and providers, indicating a move away from paternalism toward more
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democratic relationships.33,34,35 In addition, a well-educated public has produced consumers of healthcare who are concerned and involved with promoting healthy lifestyles for themselves and their families. In Canada, because of the increase in chronic diseases and an aging population,12,36 the biomedical model of curing disease has shifted to a philosophy of caring for individuals who have several health problems. Demographics reflect that people are living longer with a complexity of health issues that require individuals and families to play an increasingly active role in care. These changes, coupled with political factors and the emergence of healthcare reform, have resulted in a Canadian healthcare system of the 21st century that works in partnership with individuals and communities to ensure health for all.37
Self-Care in Healthcare: The Implications Arguably, the self-care movement in Canadian healthcare can be either a positive or a negative endeavour in terms of its implications for a healthcare system that, in the past, has received public support and international admiration.38 Debate focuses on the public embracing increased responsibility for healthcare versus a shift of responsibility for healthcare from government to individuals.
Personal Responsibility for Self-Care Although self-care practices have a widespread and long-standing history, little research has been conducted into particular self-care practices and their outcomes.1,2,12,18 It has been acknowledged, however, that selfcare is widely practised and universal, and involves actions that
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are often beneficial and seldom harmful to the individual. Even in instances where self-care behaviour can result in negative health outcomes, philosophers and researchers have argued that individuals have a moral right to freedom of will and choice when deciding on courses of health action.5,39 The concept of freedom to think, act and exert control over situations is a basic individual right that needs to be considered in the provision of health services. Advocates of the self-care movement will purport that “the health of individuals is being improved by the growth of the wellness movement, consumer empowerment, and the focus on personal responsibility.”7 If this is true, then better educated and informed consumers will mean that self-care has led to empowered individuals with increased self-care ability. If government’s focus is on the enhancement of health promotion for all individuals, then individual autonomy will become a reality, and society will benefit. In the past, and even today, a commonly accepted belief about healthcare was that HCPs should make decisions about disease management, and that patients/consumers should endorse recommendations without questioning the authority of the information.40,41 Advocates of increased personal responsibility for health see it as the acceptance of informed health consumers who are active participants in self-care capable of questioning matters relating to themselves. They believe that informed consumers are smart consumers capable of making decisions that fit their lifestyles and values. This ideology undermines an environment that has supported the paternalistic behaviours that have characterized healthcare relationships for years. Discussions of patient participation
in healthcare decisions that are supportive of self-care endorse the concept of empowered individuals who are able to make informed decisions on their own behalf.40,42 A move toward a greater emphasis on self-care behaviours in Canada in this instance is viewed as a step in the right direction toward establishing an egalitarian patient and institution/ community partnership. Meeting the needs of individuals and communities by working in partnership with HCPs has been encouraged within the context of PHC and the reform of Canada’s health system.37 Supporters of increased personal responsibility for health believe that altering personal behaviour has the greatest potential for reducing the long-term effects of chronic disease.5,23 The best way to achieve this is to have consumers assume an increasing personal responsibility for lifestyle behaviour. Since many causes of long-term morbidity are associated with modifiable lifestyle choices, producing knowledgeable consumers capable of making informed decisions makes sense. The benefits of such patient-participatory activity have been demonstrated in smoking cessation programs, stress reduction activities, fitness programs and other lifestyle modification endeavours.43,44 Several researchers have also found that patients’ involvement in healthcare decisions positively influences patient satisfaction, goal attainment and experiences with care.45,46 It appears that people who desire information and involvement in healthcare tend to assume an active role in information seeking and healthcare decision making. As a result, fully informed and active patients can positively influence recovery from illness and involvement in health-enhancement activities.
Shifting Responsibility for Healthcare from Government to Individuals Opponents of the argument for the public as an empowered partner in healthcare foresee a number of implications to the individual, community and larger society as a result of a self-care movement. They detect a hidden agenda of healthcare reform under the guise of improved self-care and proclaim empowerment a double-edged sword that disguises paternalistic health practices.6,7,13,42 A recent study in British Columbia found that although HCPs may talk the language of empowerment when interacting with people with chronic illness, they act according to the traditional biomedical model.40 Several researchers have described withdrawal of healthcare services as a means for government to meet the goal of budgetary restraint by shifting responsibility to the individual.47,48 In the government’s efforts to curtail escalating healthcare costs, the PHC principles of public participation and health promotion have been “sold” to the public under the ideology of self-care. Other researchers have questioned whether empowerment and self-care, which focus on enabling the individual, detract from the responsibility of the structures that perpetuate social inequities.7,13,39 Proponents of this way of thinking contend that going back to such liberal origins refocuses responsibility for societal inequities on the individual. Lowenberg13 has dubbed the rhetoric surrounding healthcare reform an ideology of choice. The shift from societal responsibility for healthcare back to the individual is seen as absolving the larger societal structures of government and industry from blame for their role in disease causation and inadequate provision of health services.
Victim blaming is a phenomenon that can potentially occur when government places a greater emphasis for health self-care on the individual. Victim blaming will likely become increasingly evident as individuals are blamed for failing to participate in self-care activities that HCPs have identified as being of benefit to them.5,13 The victim, or in this case the patient, is blamed when recommended behaviours are not endorsed for the betterment of the patient’s health. Generally, with this type of thinking, there is a failure to consider environmental forces that might have influenced behaviour choices.5,49 Victim blaming is especially problematic for those who are poor, as the environment in which they live limits their choices. When HCPs ignore the fact that individuals make decisions based on the information available to them, and that they are affected by the circumstances of their lives, then blaming becomes the avenue for explaining the inadequacies of a system incapable of helping these individuals. This way of thinking by HCPs re-introduces terms enshrined by paternalism such as compliance and adherence.40,41 Social inequities continue to be emphasized, since those who are socially disadvantaged, such as the poor, immigrants and other marginalized groups, do not possess the capabilities or means to take part in the self-care requirements expected of them. Moral condemnation for failure to perform self-care as expected permeates all levels of society. Lowenberg,13 in an analogy, likens the redirection of responsibility for care to the individual to “contemporary forms of social control that assists in applying the labels of guilt to those who visibly wear the scarlet letter A or in this case “I” for illness.” The move to a healthcare consumer who is well informed and who engages in self-care is ironically twisted in this move toward a more democratic
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patient-healthcare-provider relationship. Healthcare reform has seen the closure of hospital beds and nurse and physician shortages. This has had implications for the quality of care available to patients and families.50 A shortened hospital stay is justified in the best interest of patients, as the optimum location for a speedy recovery is at home with family and friends. The reality of what is happening, however, is that patients are often not prepared to provide the required level of self-care after an early discharge from hospital. Nursing shortages have meant that nurses do not have the time to provide patients with the essential skills and knowledge for the provision of adequate self-care at home. The CNA29 has acknowledged that the reduced number of nurses in acute and long-term care has affected the safety of clients and the quality of care delivered. In 1998, the CNA30 described the situation of home-care and communitycare services in Canada as a patchwork of programs delivered by both private and public agencies with little to offer in terms of consistency and comprehensiveness from one community to another. Although this was the situation three years ago, in many areas of Canada this situation still holds true today. As a result, community infrastructures are often not available to support early discharge for a population that may be poorly equipped to succeed in what has been requested of them. Thus, the cycle perpetuates itself, and patients are readmitted to hospital for complications for which the system has failed to prepare them. Alternatively, patients have been known to pay privately for services to convalesce at home. The CNA30 reports that consumer spending on private services has
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increased steadily in response to government’s decreased expenditure on healthcare. This accommodation by the public of inadequacies in the healthcare system has the potential to result in a two-tier system where only those who can afford to pay will attain the service that everyone deserves. This type of ideology embodies an idealized middle-class value system that requires a relatively privileged position in society.13,25 Another issue directly related to early discharge from hospital is concern about the burden of responsibility on primary caregivers in the home. Since women often perform the majority of caregiving in the home,51,52 this issue snowballs into one of gender inequality. Added to this, the human cost of caregiving to the individual and family is difficult to measure.
Nursing’s Position in the Debate Nurses need to take a stance on the issue of improved patient care under the self-care movement. Nurses deliver most of the direct patient care in the healthcare system, and can therefore see first-hand what is happening to the public’s self-care abilities.22 Questions that need to be critically considered include the following: • Are patients equipped with the knowledge and skills to care for themselves adequately when early discharge dictates that they must leave the hospital to recover in the comfort of their own home? • Have nursing staff levels allowed patients while in hospital to be provided with the care and knowledge required to care for themselves adequately at home? • Are community services available to meet patient and family needs? • Who is the primary caregiver in the home, and what is expected of him or her?
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Answers to these questions can help nurses decide whether or not the self-care movement is meeting with success in Canada. Nurses, who have a history of patient advocacy, are trusted by the public, and are therefore able to bring their concerns about the healthcare system to public awareness.53,54 To be effective in the advocacy role, nurses need to evaluate what the self-care movement and healthcare reform have brought to nursing practice and to their abilities to provide effective patient care. They need to take a stance that self-care is not effective care if the healthcare system does not provide the resources for it to happen. As consumers of healthcare services, the public needs to be informed about what the language of self-care fully entails. Cost-effective care does not ensure adequate selfcare. Services must be available when patients are discharged early from hospital, and nurses must make a stand when their practice environments are not conducive to ensuring that this happens. The profession will stand behind a self-care movement when system supports are available for nurses to effectively perform what is required and requested of them. Nurses need to be critical of the rhetoric surrounding empowerment and self-care and must determine how their practice environments are conducive to fostering their growth.
A Role for Nursing in the Self-Care Movement This is a time when nurses can affect what is happening to patients entrusted into their care. As advocates for patient empowerment and effective self-care abilities, nurses have recognized for quite some time that their practice at the institutional and community levels is often not effective in meeting patient’s
needs.30,50 The nursing profession has voiced discontent about what is happening within the healthcare system. It continues to do so. Nurses can move to the forefront of health promotion and lead the way for individuals and communities to be fully informed citizens capable of efficient self-care practices. In 1978, the Director-General of the WHO foresaw an important role for nursing in the implementation of PHC and challenged them to lead the way.55 He recognized that nurses are strategically placed, by virtue of their position and numbers, for espousing the principles of PHC. He did not, however, forecast the changing political environment of healthcare reform, and the challenges to patients and professionals that it would bring. One thing remains unchanged, however, and that is that nurses continue to be in strategic positions for helping to ensure that the self-care requirements expected of people are met successfully. Nurses’ advocacy role has never been stronger to help make this a reality. Remaining politically active and expressing concern for environmental circumstances that do not allow for patient safety and delivery of healthcare services continue to challenge nursing. Mobilizing individual and community resources must become a reality, along with the provision of financial support by government to address the inequalities that exist within Canada. Insisting that federal and provincial governments look further at workplace issues, and at the predicted worsening of nursing staff shortages in the future,56 is another agenda for nurses to pursue toward the goal of ensuring that patients achieve successful self-care. During interactions with patients, nurses must remain conscious of patient individuality and remember that there is more to achieving success-
ful self-care than just speaking the language. Researchers have demonstrated that changing the language is not sufficient to effect empowerment, as there must be a concomitant change in the power relationships of practitioner-patient interactions.42,57 Nurses must remember that social inequities still remain in Canadian society. These inequities affect how well individuals can or cannot fully accomplish what is considered appropriate for them. The determinants of health must be reflected in the wider context of the individual and society so that a fuller understanding of realizable patient outcomes can be obtained. Nursing curricula need to reflect the increasing emphasis on the self-care role and the implications of its successful attainment to Canadians. Creating an environment in which nurses learn from patients the factors that are important to them will help broaden the understanding of why people make the healthcare choices they do, and provide a more holistic view of the individual.58 Influencing students at the beginning of their career to embark on practices that foster patient self-care abilities will be one step toward accomplishing this goal. Students must realize that self-care does not happen because the system says it ought to. Staying in tune with how factors other than the individual affect health will result in enlightened nurses and publics.
this language always translates into practice is debatable. Whether or not the move toward self-care is of benefit to the health system also remains a source of concern and debate. Having an informed public capable of self-care is an attainable goal, but only if both individuals and society share the responsibility for the health outcomes of an entire population. We need to be conscious that selfcare does not occur solely at the level of the individual, but rather is shaped by a combination of individual contributions and the environments in which the individuals live.
References and Notes 1. Kemper DW, Lorig K, Mettler M. The effectiveness of medical self-care interventions: a focus on self-initiated responses to symptoms. Patient Education and Counseling 1993;21:29–39. 2. Health Canada. Supporting self-care: the contributions of nurses and physicians. (on-line) 1997 [cited February 19, 2002]. Available from: http://www.hc-sc.gc.ca/hppb/healthcare/ pubs/selfcare/maintoc.htm 3. Kickbush I. Self-care in health promotion. Social Science and Medicine 1989;29:125–130. 4. Hill L, Smith N. Self-care nursing: promotion of health. 2nd ed. Englewood Cliffs (NJ): Prentice Hall; 1990. 5. Minkler M. Personal responsibility for health? A review of the arguments and the evidence at century’s end. Health Education & Behaviour 1999;26(1):121–140. 6. Anderson JM. Home care management in chronic illness and the self-care movement: an analysis of ideologies and economic processes influencing policy decisions. Advances in Nursing Science 1990;12(2):71–83. 7. Anderson JM. Empowering patients: issues and strategies. Social Science & Medicine 1996;43(5):697–705. 8. Reiser SJ. Responsibility for health: a historical perspective. Journal of Medical Philosophy 1985;10(1):7–17. 9. Williams DM. Political theory and individualistic health promotion. Advances in Nursing Science 1989;12(1):14–25. 10. Carter PA. Self-care agency: the concept and how it is measured. Journal of Nursing Measurement 1998;6(2):195–207.
Conclusion The Canadian healthcare system has undergone massive reform and restructuring in the last decade, and the process is still not complete. The ideology of self-care that gained momentum in the 1990s has resulted in both the healthcare system and the public speaking the language of self-care at institutional and community levels of care. Whether or not
11. Levin LS, Katz AH, Holst E. Self-care: lay initiatives in health. 2nd ed. New York: Prodist; 1979. 12. Padula CA. Self-care and the elderly: review and implications. Public Health Nursing 1992;9(1):22–28. 13. Lowenberg JS. Health promotion and the “ideology of choice.” Public Health Nursing 1995;12(5):319–323. 14. Easton KL. Defining the concept of self-care. Rehabilitation Nursing 1993;18(6):384–387. 15. Orem D. Nursing: concepts of practice. St Louis: Mosby; 1991. 16. Schiller PL, Levin JS. Is self-care a social movement? Social Science & Medicine 1983;17:1343–1352. 17. Hawkins WE, Duncan DF, McDermott RJ. Can high technology make self-care a social movement? Family & Community Health 1986;9(2):37–45.
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18. Health Canada. Supporting self-care: perspectives of nurse and physician educators. (on-line) 1998 [cited February 19, 2002]. Available from: http://www.hc-sc.gc.ca/hppb/healthcare/ pubs/selfcare98/maintoc.htm
44. Stolley MR, Fitzgibbon ML. Effects of an obesity prevention program on the eating behaviour of African American mothers and daughters. Health Education & Behaviour 1997;24(2):152–164.
19. Lalonde M. A new perspective on the health of Canadians. Ottawa: Department of National Health and Welfare; 1974.
45. Barsevick AM, Johnson JE. Preference for involvement, information seeking and emotional responses for women undergoing colposcopy. Research in Nursing & Health 1990;13:1–7.
20. World Health Organization-Health and Welfare CanadaCPHA. Ottawa charter for health promotion. Canadian Journal of Public Health 1986;77(12):425–430. 21. Health and Welfare Canada. Achieving health for all: a framework for health promotion. Ottawa: Minister of Supply and Services Canada; 1986. 22. Blythe J, Baumann A, Giovannetti P. Nurses’ experiences of restructuring in three Ontario hospitals. Journal of Nursing Scholarship 2001;33(1):61–68. 23. Smith DR. Reducing healthcare costs through co-op care. Nursing Management 1994;26(6):44–47. 24. Storch JL, Meilicke CA. Political, social, and economic forces shaping the healthcare system. In: Hibberd JM, Kyle ME, editors. Nursing management in Canada. Toronto: W.B. Saunders; 1994. 25. Armstrong P, Armstrong H. Wasting away: the undermining of Canadian healthcare. Toronto: Oxford University Press; 1996. 26. Beardwood B, Walters V, Eyles J, French S. Complaints against nurses: a reflection of “the new managerialism” and consumerism in healthcare? Social Science & Medicine 1999;48:363–374. 27. Evans RG, Barer ML, Marmor TR, editors. Why are some people healthy and others not? The determinants of health of populations. New York: Aldine De Gruyter; 1994. 28. Advisory Committee on Population Health. Strategies for population health: investing in the health of Canadians. Ottawa: the Committee; 1994. 29. Canadian Nurses Association. Policy statement: necessary support for nursing care. Ottawa: the Association; 1996. 30. Canadian Nurses Association. Canadian nurses press federal government on home care. (on-line) 1998 [cited February 22, 2002.]. Available from: http://206.191.29.104/pages/press/homecare.html 31. Canadian Nurses Association. Supporting self-care: a shared initiative. Ottawa: the Association; 1999. 32. Sofarelli D, Brown D. The need for nursing leadership in uncertain times. Journal of Nursing Management 1988;6(4):201–207.
46. Mahler HI, Kulik JA. Preferences for health involvement, perceived control and surgical recovery: a prospective study. Social Science & Medicine 1990;31:743–751. 47. Robertson A, Minkler M. New health promotion movement: a critical examination. Health Education Quarterly 1994;21(3):295–312. 48. Salisberry PJ. Assuming responsibility for one’s health: an analysis of the key assumption in nursing’s agenda for healthcare reform. Nursing Outlook 1993;41:212–216. 49. Crawford R. You are dangerous to your health. International Journal of Health Services 1977;4:671. 50. Canadian Nurses Association. Quiet crisis in healthcare? nurses speak out. (on-line) 1998 [cited February 22, 2002]. Available from: http://206.191.29.104/pages/qcrisis/quietcrisis.html 51. Harrison MJ, Neufeld A. Women’s experiences of barriers to support while caregiving. Healthcare for Women International 1997;18(6):591–602. 52. Hoffman RL, Mitchell AM. Caregiver burden: historical development. Nursing Forum 1998;33(4):5–11. 53. Mallik M. Advocacy in nursing: a review of the literature. Journal of Advanced Nursing 1997;25:130–138. 54. Nelson ML. Advocacy in nursing. Nursing Outlook 1988;36:136–141. 55. Mahler H. Oral healthcare systems: an international collaborative study coordinated by the World Health Organization. Geneva: Quintessence Publishing; 1985. 56. Advisory Committee on Health Human Resources (ACCHR). The nursing strategy for Canada. (on-line) 2000 [cited February 22, 2002]. Available from: http://www.hcsc.gc.ca/english/pdf/nursing.pdf 57. Arksey H, Sloper P. Disputed diagnoses: the case of RSI and childhood cancer. Social Science & Medicine 1999;49:483–497. 58. Raatikainen R. Values and ethical principles in nursing. Journal of Advanced Nursing 1989;14:92–96.
33. Almond P. What is consumerism and has it had an impact on health visiting provision: a literature review. Journal of Advanced Nursing 2001;35(6):893–901. 34. Carter S, Mowad L. Is nursing ready for consumerism? Nursing Administration Quarterly 1988;12(3):74–78. 35. Price R. Consumerism in health—are we accountable and if so, how? Australian Nurses Journal 1981;10(9):50–52. 36. Knox JL. Demographic and epidemiological trends. In: Hibberd JM, Kyle ME, editors. Nursing management in Canada. Toronto: W.B. Saunders; 1994. 37. National Forum on Health. Canadian health action: building on the legacy. Final report of the National Forum on Health. Ottawa: the Forum; 1997. 38. Lewis S, Donaldson C, Mitton C, Currie G. The future of healthcare in Canada. British Medical Journal 2001;323:926–929. 39. Wilker D. Who should be blamed for being sick? Health Education Quarterly 1987;14(1):11–25. 40. Paterson B. Myth of empowerment in chronic illness. Journal of Advanced Nursing 2001;34(5):574–581. 41. Falk-Rafael AR. Advocacy and empowerment: dichotomous or synchronous concepts? Advances in Nursing Science 1995;18:25–32. 42. Opie A. “Nobody asked me for my view”: users’ empowerment by multidisciplinary health teams. Qualitative Health Research 1998;18:188–206. 43. Pelletier K. A review and analysis of the health and costeffective outcome studies of comprehensive health promotion and disease prevention programs at the worksite: 1991–1993 update. American Journal of Health Promotion 1993;8(1):50–61.
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Lisa Keeping, RN, PhD (c), is Assistant Professor of Nursing at St. Francis Xavier University, Antigonish, NS. She has been studying full-time at McGill University for the last two years and her research focus is with the psychosocial recovery of coronary artery bypass graft surgery patients and their partners after discharge from hospital. Lisa is the recipient of a three year fellowship from the Heart & Stroke Foundation of Canada.
Healthcare Management Forum Gestion des soins de santé
Self-Care, Healthcare Reform and Their Implications to Nursing
by Lisa Keeping
H Abstract A move toward individual
ealthcare is moving toward individual freedom, self-responsibility and decreased reliance on experts. The capacity of individuals to take care of their own health is being increasingly emphasized. Although the concept of self-care has been around since the beginning of civilization,1 it has often not been consciously thought about or emphasized. In fact, the individual and the family have historically provided the bulk of healthcare for individuals,1,2,3 with ministering to the sick being an accepted part of the individual/ family role. Canada has one of the best healthcare systems in the world with universal access for its citizens, but the role that individuals have played in self-care and mitigating health outcomes has fluctuated over the years.4,5 With the advent of healthcare reform in the 1990s, the concept of self-care has become increasingly prominent in lay-person and healthcare provider language.6,7 In fact, the concept now plays a central role in health policy formulation and decision making. Moreover, there has been a corresponding increased emphasis on the active role that individuals can play in shaping health outcomes.
responsibility for health is
Origins of Self-Care
gaining momentum in
The effects of lifestyle on health and the individual’s capacity to affect health outcomes have been noted as far back as ancient Rome and Greece,4,5 the Middle Ages and the Renaissance.1,8 The earliest political underpinnings of self-care in Western civilization are found in the writings of 17th and 18th century English political and social theorists, and in the assumptions underlying classical liberalism, which asserts that individuals are selfsustaining, rational and motivated to maximize human potential.9 Classical liberalism extracts responsibility for individual outcomes from the context of societal forces and redirects responsibility toward the rational capacity of humans to determine their course in life.
Canada. Whether or not individual responsibility for self-care practices is in the best interest of the public is debated in this article. The origins of the self-care movement in the Canadian healthcare system, its benefits and pitfalls, are explored. The role that the nursing profession can play is also discussed.
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Self-care has been defined in a number of ways depending upon whether the disciplinary focus has been sociological, psychological, ecological, medical, nursing or health promotion.3,10 Owing to this diverse array of historic roots for self-care and its semantic confusion with self-help, medical self-care and self-treatment, there is no universally agreed-upon definition of the concept.11,12 Despite this, self-care consistently reflects individual behaviour that is voluntary, universal and self-limited, and which involves behaviourally and cognitively based experiences. In this article, self-care is defined as “a process whereby a lay person functions on his or her own behalf in health promotion and prevention and in disease detection and treatment at the level of the primary health resource in the healthcare system.”11
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Self-care has played a role in nursing since the time of Florence Nightingale. As early as 1859, Nightingale saw basic individual hygiene and environmental forces as instrumental determinants of individual and societal health.13 These values have been the guiding principles of public health nursing for years. Similarly, self-care is the basis of a nursing theory developed in the 1950s by Dorothea Orem,14,15 and has guided the many nursing curricula that have existed since that time.
The Self-Care Movement in Canadian Healthcare For self-care to be considered a movement, four criteria should exist: an ideology, a feeling of “we-ness” among the public involved, organization, and strategies and tactics for accomplishment of goals.16,17 The earliest and most modern interest in self-care in Canada can be linked with the feminist movement in the 1960s when issues of independence, autonomy and self-determination in health and illness for women emerged.3 Interest in self-care throughout the 1970s and ‘80s and the growth of selfhelp groups among the public3,12 were also influential. However, self-care as a movement did not technically begin until the 1990s with the occurrence of healthcare reform. Since that time, the public has rapidly become consumers of healthcare and have formed an ideology of developing self-care capacity to cope with rapid technological change and government cutbacks. Official plans enacted by government at federal and provincial levels to foster self-care abilities2,18 have demonstrated a role for government and healthcare professionals (HCPs) in helping to assure its attainment. Healthcare reform in the 1990s heightened public awareness through various political avenues, thus redirecting the emphasis on self-care activities and the role
individuals play in determining health outcomes.
Philosophical Assumptions and the Political Environment The first mention of self-care in Canada was in 1974 with the publication of the Lalonde Report,19 which emphasized the role of environmental forces and individual lifestyle in the well-being of individuals. Although other factors such as biology, environment and availability of health services were credited as contributors to health status, attention to the active role of individuals in modifying health outcomes was emphasized. During the late 1970s, environmental influences on health intensified and cumulated with the Alma Ata Declaration at the time the World Health Organization (WHO) developed the “Health-for-All Strategy—Primary Healthcare” (PHC).20 PHC is both a philosophy and a method of healthcare delivery that includes the five principles of accessibility, public participation, promotion of health and prevention of illness, intersectoral cooperation, and appropriate technologies. The principles represent the philosophical assumptions underlying the Canadian healthcare system today, and hence the philosophical grounding for self-care in Canada. Landmark documents such as The Ottawa Charter on Health Promotion21 and Achieving Health for All: A Framework for Health Promotion20 were also instrumental in laying the foundation for what has become the self-care movement in healthcare. Both documents discuss how health is created and attained by all members of society through the development of personal skills that enhance individuals’ capacities for coping with disability or disease. Another major health challenge
identified was enhancement of health through the reduction of social inequities. Achieving Health for All specifically identified self-care as a mechanism for achieving healthy individuals and communities. Starting in the late 1970s and through to the late 1980s, government focused on examining ways for delivering healthcare more cost effectively.22,23 Political upheaval has characterized the system since the early 1990s, as have collective efforts to reform and restructure Canada’s health system. Since that time, the federal government has refocused its involvement in healthcare on ensuring that the philosophy of PHC is maintained while, at the same time, transferring increased responsibility for healthcare funding to the provinces.24 Restructuring of the healthcare system has been, and continues to be, accomplished through reducing the size of the workforce, contracting out, offering part-time work, emphasizing greater productivity from the remaining employees, and moving from institutional to community-based patient care.25,26 These changes have represented times of unrest and upheaval within the Canadian system and have created an atmosphere conducive to a self-care movement in healthcare. A number of health-related documents pertaining to the health of Canadians have been compiled during the last 10 years. These also refer to the role of individuals in the maintenance of health.27 One such document, Strategies for Population Health,28 identified personal health practices and coping skills as contributory factors for determining population health. The Canadian Nurses Association (CNA) has also been active on a number of fronts developing and issuing policy statements for nurses on the safe and effective delivery of healthcare by nurses to the public.29,30
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One of the most notable contributions of the Canadian government to selfcare was launched by Health Canada in 1994 with the initiation of a selfcare project to study how nurses and doctors support self-care in practice.2 The Self-Care Project has been carried out in four stages, the fourth of which is currently underway. Results of this initiative demonstrate that nurses and physicians are actively engaged in promoting the self-care of patients through various means in their practice environments. Further to this, in 1999 a federally funded project sponsored by the CNA, College of Family Physicians of Canada, Association of Canadian Medical Colleges and Canadian Association of University Schools of Nursing was undertaken to assist HCPs support self-care in practice. This endeavour is reflected in a number of research projects currently being conducted with a view to promoting self-care in Canada.18,31
Societal Contributions Aside from the political agenda shaping the Canadian healthcare system, a number of concurrent changes in society have had a direct impact on healthcare. The 20th century has seen the emergence of a technological age in which patients, better educated than ever before, have improved access to information through computerized technology.7,32 As a result, patients have become consumers of healthcare. They are demanding to be better informed and to actively participate in self-care practice. Patients want to be partners in healthcare decisions. They no longer find the healthcare system’s paternalistic attitude acceptable or appropriate. The aim of consumerism has been to create a better balance of power between consumers and providers, indicating a move away from paternalism toward more
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democratic relationships.33,34,35 In addition, a well-educated public has produced consumers of healthcare who are concerned and involved with promoting healthy lifestyles for themselves and their families. In Canada, because of the increase in chronic diseases and an aging population,12,36 the biomedical model of curing disease has shifted to a philosophy of caring for individuals who have several health problems. Demographics reflect that people are living longer with a complexity of health issues that require individuals and families to play an increasingly active role in care. These changes, coupled with political factors and the emergence of healthcare reform, have resulted in a Canadian healthcare system of the 21st century that works in partnership with individuals and communities to ensure health for all.37
Self-Care in Healthcare: The Implications Arguably, the self-care movement in Canadian healthcare can be either a positive or a negative endeavour in terms of its implications for a healthcare system that, in the past, has received public support and international admiration.38 Debate focuses on the public embracing increased responsibility for healthcare versus a shift of responsibility for healthcare from government to individuals.
Personal Responsibility for Self-Care Although self-care practices have a widespread and long-standing history, little research has been conducted into particular self-care practices and their outcomes.1,2,12,18 It has been acknowledged, however, that selfcare is widely practised and universal, and involves actions that
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are often beneficial and seldom harmful to the individual. Even in instances where self-care behaviour can result in negative health outcomes, philosophers and researchers have argued that individuals have a moral right to freedom of will and choice when deciding on courses of health action.5,39 The concept of freedom to think, act and exert control over situations is a basic individual right that needs to be considered in the provision of health services. Advocates of the self-care movement will purport that “the health of individuals is being improved by the growth of the wellness movement, consumer empowerment, and the focus on personal responsibility.”7 If this is true, then better educated and informed consumers will mean that self-care has led to empowered individuals with increased self-care ability. If government’s focus is on the enhancement of health promotion for all individuals, then individual autonomy will become a reality, and society will benefit. In the past, and even today, a commonly accepted belief about healthcare was that HCPs should make decisions about disease management, and that patients/consumers should endorse recommendations without questioning the authority of the information.40,41 Advocates of increased personal responsibility for health see it as the acceptance of informed health consumers who are active participants in self-care capable of questioning matters relating to themselves. They believe that informed consumers are smart consumers capable of making decisions that fit their lifestyles and values. This ideology undermines an environment that has supported the paternalistic behaviours that have characterized healthcare relationships for years. Discussions of patient participation
in healthcare decisions that are supportive of self-care endorse the concept of empowered individuals who are able to make informed decisions on their own behalf.40,42 A move toward a greater emphasis on self-care behaviours in Canada in this instance is viewed as a step in the right direction toward establishing an egalitarian patient and institution/ community partnership. Meeting the needs of individuals and communities by working in partnership with HCPs has been encouraged within the context of PHC and the reform of Canada’s health system.37 Supporters of increased personal responsibility for health believe that altering personal behaviour has the greatest potential for reducing the long-term effects of chronic disease.5,23 The best way to achieve this is to have consumers assume an increasing personal responsibility for lifestyle behaviour. Since many causes of long-term morbidity are associated with modifiable lifestyle choices, producing knowledgeable consumers capable of making informed decisions makes sense. The benefits of such patient-participatory activity have been demonstrated in smoking cessation programs, stress reduction activities, fitness programs and other lifestyle modification endeavours.43,44 Several researchers have also found that patients’ involvement in healthcare decisions positively influences patient satisfaction, goal attainment and experiences with care.45,46 It appears that people who desire information and involvement in healthcare tend to assume an active role in information seeking and healthcare decision making. As a result, fully informed and active patients can positively influence recovery from illness and involvement in health-enhancement activities.
Shifting Responsibility for Healthcare from Government to Individuals Opponents of the argument for the public as an empowered partner in healthcare foresee a number of implications to the individual, community and larger society as a result of a self-care movement. They detect a hidden agenda of healthcare reform under the guise of improved self-care and proclaim empowerment a double-edged sword that disguises paternalistic health practices.6,7,13,42 A recent study in British Columbia found that although HCPs may talk the language of empowerment when interacting with people with chronic illness, they act according to the traditional biomedical model.40 Several researchers have described withdrawal of healthcare services as a means for government to meet the goal of budgetary restraint by shifting responsibility to the individual.47,48 In the government’s efforts to curtail escalating healthcare costs, the PHC principles of public participation and health promotion have been “sold” to the public under the ideology of self-care. Other researchers have questioned whether empowerment and self-care, which focus on enabling the individual, detract from the responsibility of the structures that perpetuate social inequities.7,13,39 Proponents of this way of thinking contend that going back to such liberal origins refocuses responsibility for societal inequities on the individual. Lowenberg13 has dubbed the rhetoric surrounding healthcare reform an ideology of choice. The shift from societal responsibility for healthcare back to the individual is seen as absolving the larger societal structures of government and industry from blame for their role in disease causation and inadequate provision of health services.
Victim blaming is a phenomenon that can potentially occur when government places a greater emphasis for health self-care on the individual. Victim blaming will likely become increasingly evident as individuals are blamed for failing to participate in self-care activities that HCPs have identified as being of benefit to them.5,13 The victim, or in this case the patient, is blamed when recommended behaviours are not endorsed for the betterment of the patient’s health. Generally, with this type of thinking, there is a failure to consider environmental forces that might have influenced behaviour choices.5,49 Victim blaming is especially problematic for those who are poor, as the environment in which they live limits their choices. When HCPs ignore the fact that individuals make decisions based on the information available to them, and that they are affected by the circumstances of their lives, then blaming becomes the avenue for explaining the inadequacies of a system incapable of helping these individuals. This way of thinking by HCPs re-introduces terms enshrined by paternalism such as compliance and adherence.40,41 Social inequities continue to be emphasized, since those who are socially disadvantaged, such as the poor, immigrants and other marginalized groups, do not possess the capabilities or means to take part in the self-care requirements expected of them. Moral condemnation for failure to perform self-care as expected permeates all levels of society. Lowenberg,13 in an analogy, likens the redirection of responsibility for care to the individual to “contemporary forms of social control that assists in applying the labels of guilt to those who visibly wear the scarlet letter A or in this case “I” for illness.” The move to a healthcare consumer who is well informed and who engages in self-care is ironically twisted in this move toward a more democratic
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patient-healthcare-provider relationship. Healthcare reform has seen the closure of hospital beds and nurse and physician shortages. This has had implications for the quality of care available to patients and families.50 A shortened hospital stay is justified in the best interest of patients, as the optimum location for a speedy recovery is at home with family and friends. The reality of what is happening, however, is that patients are often not prepared to provide the required level of self-care after an early discharge from hospital. Nursing shortages have meant that nurses do not have the time to provide patients with the essential skills and knowledge for the provision of adequate self-care at home. The CNA29 has acknowledged that the reduced number of nurses in acute and long-term care has affected the safety of clients and the quality of care delivered. In 1998, the CNA30 described the situation of home-care and communitycare services in Canada as a patchwork of programs delivered by both private and public agencies with little to offer in terms of consistency and comprehensiveness from one community to another. Although this was the situation three years ago, in many areas of Canada this situation still holds true today. As a result, community infrastructures are often not available to support early discharge for a population that may be poorly equipped to succeed in what has been requested of them. Thus, the cycle perpetuates itself, and patients are readmitted to hospital for complications for which the system has failed to prepare them. Alternatively, patients have been known to pay privately for services to convalesce at home. The CNA30 reports that consumer spending on private services has
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increased steadily in response to government’s decreased expenditure on healthcare. This accommodation by the public of inadequacies in the healthcare system has the potential to result in a two-tier system where only those who can afford to pay will attain the service that everyone deserves. This type of ideology embodies an idealized middle-class value system that requires a relatively privileged position in society.13,25 Another issue directly related to early discharge from hospital is concern about the burden of responsibility on primary caregivers in the home. Since women often perform the majority of caregiving in the home,51,52 this issue snowballs into one of gender inequality. Added to this, the human cost of caregiving to the individual and family is difficult to measure.
Nursing’s Position in the Debate Nurses need to take a stance on the issue of improved patient care under the self-care movement. Nurses deliver most of the direct patient care in the healthcare system, and can therefore see first-hand what is happening to the public’s self-care abilities.22 Questions that need to be critically considered include the following: • Are patients equipped with the knowledge and skills to care for themselves adequately when early discharge dictates that they must leave the hospital to recover in the comfort of their own home? • Have nursing staff levels allowed patients while in hospital to be provided with the care and knowledge required to care for themselves adequately at home? • Are community services available to meet patient and family needs? • Who is the primary caregiver in the home, and what is expected of him or her?
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Answers to these questions can help nurses decide whether or not the self-care movement is meeting with success in Canada. Nurses, who have a history of patient advocacy, are trusted by the public, and are therefore able to bring their concerns about the healthcare system to public awareness.53,54 To be effective in the advocacy role, nurses need to evaluate what the self-care movement and healthcare reform have brought to nursing practice and to their abilities to provide effective patient care. They need to take a stance that self-care is not effective care if the healthcare system does not provide the resources for it to happen. As consumers of healthcare services, the public needs to be informed about what the language of self-care fully entails. Cost-effective care does not ensure adequate selfcare. Services must be available when patients are discharged early from hospital, and nurses must make a stand when their practice environments are not conducive to ensuring that this happens. The profession will stand behind a self-care movement when system supports are available for nurses to effectively perform what is required and requested of them. Nurses need to be critical of the rhetoric surrounding empowerment and self-care and must determine how their practice environments are conducive to fostering their growth.
A Role for Nursing in the Self-Care Movement This is a time when nurses can affect what is happening to patients entrusted into their care. As advocates for patient empowerment and effective self-care abilities, nurses have recognized for quite some time that their practice at the institutional and community levels is often not effective in meeting patient’s
needs.30,50 The nursing profession has voiced discontent about what is happening within the healthcare system. It continues to do so. Nurses can move to the forefront of health promotion and lead the way for individuals and communities to be fully informed citizens capable of efficient self-care practices. In 1978, the Director-General of the WHO foresaw an important role for nursing in the implementation of PHC and challenged them to lead the way.55 He recognized that nurses are strategically placed, by virtue of their position and numbers, for espousing the principles of PHC. He did not, however, forecast the changing political environment of healthcare reform, and the challenges to patients and professionals that it would bring. One thing remains unchanged, however, and that is that nurses continue to be in strategic positions for helping to ensure that the self-care requirements expected of people are met successfully. Nurses’ advocacy role has never been stronger to help make this a reality. Remaining politically active and expressing concern for environmental circumstances that do not allow for patient safety and delivery of healthcare services continue to challenge nursing. Mobilizing individual and community resources must become a reality, along with the provision of financial support by government to address the inequalities that exist within Canada. Insisting that federal and provincial governments look further at workplace issues, and at the predicted worsening of nursing staff shortages in the future,56 is another agenda for nurses to pursue toward the goal of ensuring that patients achieve successful self-care. During interactions with patients, nurses must remain conscious of patient individuality and remember that there is more to achieving success-
ful self-care than just speaking the language. Researchers have demonstrated that changing the language is not sufficient to effect empowerment, as there must be a concomitant change in the power relationships of practitioner-patient interactions.42,57 Nurses must remember that social inequities still remain in Canadian society. These inequities affect how well individuals can or cannot fully accomplish what is considered appropriate for them. The determinants of health must be reflected in the wider context of the individual and society so that a fuller understanding of realizable patient outcomes can be obtained. Nursing curricula need to reflect the increasing emphasis on the self-care role and the implications of its successful attainment to Canadians. Creating an environment in which nurses learn from patients the factors that are important to them will help broaden the understanding of why people make the healthcare choices they do, and provide a more holistic view of the individual.58 Influencing students at the beginning of their career to embark on practices that foster patient self-care abilities will be one step toward accomplishing this goal. Students must realize that self-care does not happen because the system says it ought to. Staying in tune with how factors other than the individual affect health will result in enlightened nurses and publics.
this language always translates into practice is debatable. Whether or not the move toward self-care is of benefit to the health system also remains a source of concern and debate. Having an informed public capable of self-care is an attainable goal, but only if both individuals and society share the responsibility for the health outcomes of an entire population. We need to be conscious that selfcare does not occur solely at the level of the individual, but rather is shaped by a combination of individual contributions and the environments in which the individuals live.
References and Notes 1. Kemper DW, Lorig K, Mettler M. The effectiveness of medical self-care interventions: a focus on self-initiated responses to symptoms. Patient Education and Counseling 1993;21:29–39. 2. Health Canada. Supporting self-care: the contributions of nurses and physicians. (on-line) 1997 [cited February 19, 2002]. Available from: http://www.hc-sc.gc.ca/hppb/healthcare/ pubs/selfcare/maintoc.htm 3. Kickbush I. Self-care in health promotion. Social Science and Medicine 1989;29:125–130. 4. Hill L, Smith N. Self-care nursing: promotion of health. 2nd ed. Englewood Cliffs (NJ): Prentice Hall; 1990. 5. Minkler M. Personal responsibility for health? A review of the arguments and the evidence at century’s end. Health Education & Behaviour 1999;26(1):121–140. 6. Anderson JM. Home care management in chronic illness and the self-care movement: an analysis of ideologies and economic processes influencing policy decisions. Advances in Nursing Science 1990;12(2):71–83. 7. Anderson JM. Empowering patients: issues and strategies. Social Science & Medicine 1996;43(5):697–705. 8. Reiser SJ. Responsibility for health: a historical perspective. Journal of Medical Philosophy 1985;10(1):7–17. 9. Williams DM. Political theory and individualistic health promotion. Advances in Nursing Science 1989;12(1):14–25. 10. Carter PA. Self-care agency: the concept and how it is measured. Journal of Nursing Measurement 1998;6(2):195–207.
Conclusion The Canadian healthcare system has undergone massive reform and restructuring in the last decade, and the process is still not complete. The ideology of self-care that gained momentum in the 1990s has resulted in both the healthcare system and the public speaking the language of self-care at institutional and community levels of care. Whether or not
11. Levin LS, Katz AH, Holst E. Self-care: lay initiatives in health. 2nd ed. New York: Prodist; 1979. 12. Padula CA. Self-care and the elderly: review and implications. Public Health Nursing 1992;9(1):22–28. 13. Lowenberg JS. Health promotion and the “ideology of choice.” Public Health Nursing 1995;12(5):319–323. 14. Easton KL. Defining the concept of self-care. Rehabilitation Nursing 1993;18(6):384–387. 15. Orem D. Nursing: concepts of practice. St Louis: Mosby; 1991. 16. Schiller PL, Levin JS. Is self-care a social movement? Social Science & Medicine 1983;17:1343–1352. 17. Hawkins WE, Duncan DF, McDermott RJ. Can high technology make self-care a social movement? Family & Community Health 1986;9(2):37–45.
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18. Health Canada. Supporting self-care: perspectives of nurse and physician educators. (on-line) 1998 [cited February 19, 2002]. Available from: http://www.hc-sc.gc.ca/hppb/healthcare/ pubs/selfcare98/maintoc.htm
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20. World Health Organization-Health and Welfare CanadaCPHA. Ottawa charter for health promotion. Canadian Journal of Public Health 1986;77(12):425–430. 21. Health and Welfare Canada. Achieving health for all: a framework for health promotion. Ottawa: Minister of Supply and Services Canada; 1986. 22. Blythe J, Baumann A, Giovannetti P. Nurses’ experiences of restructuring in three Ontario hospitals. Journal of Nursing Scholarship 2001;33(1):61–68. 23. Smith DR. Reducing healthcare costs through co-op care. Nursing Management 1994;26(6):44–47. 24. Storch JL, Meilicke CA. Political, social, and economic forces shaping the healthcare system. In: Hibberd JM, Kyle ME, editors. Nursing management in Canada. Toronto: W.B. Saunders; 1994. 25. Armstrong P, Armstrong H. Wasting away: the undermining of Canadian healthcare. Toronto: Oxford University Press; 1996. 26. Beardwood B, Walters V, Eyles J, French S. Complaints against nurses: a reflection of “the new managerialism” and consumerism in healthcare? Social Science & Medicine 1999;48:363–374. 27. Evans RG, Barer ML, Marmor TR, editors. Why are some people healthy and others not? The determinants of health of populations. New York: Aldine De Gruyter; 1994. 28. Advisory Committee on Population Health. Strategies for population health: investing in the health of Canadians. Ottawa: the Committee; 1994. 29. Canadian Nurses Association. Policy statement: necessary support for nursing care. Ottawa: the Association; 1996. 30. Canadian Nurses Association. Canadian nurses press federal government on home care. (on-line) 1998 [cited February 22, 2002.]. Available from: http://206.191.29.104/pages/press/homecare.html 31. Canadian Nurses Association. Supporting self-care: a shared initiative. Ottawa: the Association; 1999. 32. Sofarelli D, Brown D. The need for nursing leadership in uncertain times. Journal of Nursing Management 1988;6(4):201–207.
46. Mahler HI, Kulik JA. Preferences for health involvement, perceived control and surgical recovery: a prospective study. Social Science & Medicine 1990;31:743–751. 47. Robertson A, Minkler M. New health promotion movement: a critical examination. Health Education Quarterly 1994;21(3):295–312. 48. Salisberry PJ. Assuming responsibility for one’s health: an analysis of the key assumption in nursing’s agenda for healthcare reform. Nursing Outlook 1993;41:212–216. 49. Crawford R. You are dangerous to your health. International Journal of Health Services 1977;4:671. 50. Canadian Nurses Association. Quiet crisis in healthcare? nurses speak out. (on-line) 1998 [cited February 22, 2002]. Available from: http://206.191.29.104/pages/qcrisis/quietcrisis.html 51. Harrison MJ, Neufeld A. Women’s experiences of barriers to support while caregiving. Healthcare for Women International 1997;18(6):591–602. 52. Hoffman RL, Mitchell AM. Caregiver burden: historical development. Nursing Forum 1998;33(4):5–11. 53. Mallik M. Advocacy in nursing: a review of the literature. Journal of Advanced Nursing 1997;25:130–138. 54. Nelson ML. Advocacy in nursing. Nursing Outlook 1988;36:136–141. 55. Mahler H. Oral healthcare systems: an international collaborative study coordinated by the World Health Organization. Geneva: Quintessence Publishing; 1985. 56. Advisory Committee on Health Human Resources (ACCHR). The nursing strategy for Canada. (on-line) 2000 [cited February 22, 2002]. Available from: http://www.hcsc.gc.ca/english/pdf/nursing.pdf 57. Arksey H, Sloper P. Disputed diagnoses: the case of RSI and childhood cancer. Social Science & Medicine 1999;49:483–497. 58. Raatikainen R. Values and ethical principles in nursing. Journal of Advanced Nursing 1989;14:92–96.
33. Almond P. What is consumerism and has it had an impact on health visiting provision: a literature review. Journal of Advanced Nursing 2001;35(6):893–901. 34. Carter S, Mowad L. Is nursing ready for consumerism? Nursing Administration Quarterly 1988;12(3):74–78. 35. Price R. Consumerism in health—are we accountable and if so, how? Australian Nurses Journal 1981;10(9):50–52. 36. Knox JL. Demographic and epidemiological trends. In: Hibberd JM, Kyle ME, editors. Nursing management in Canada. Toronto: W.B. Saunders; 1994. 37. National Forum on Health. Canadian health action: building on the legacy. Final report of the National Forum on Health. Ottawa: the Forum; 1997. 38. Lewis S, Donaldson C, Mitton C, Currie G. The future of healthcare in Canada. British Medical Journal 2001;323:926–929. 39. Wilker D. Who should be blamed for being sick? Health Education Quarterly 1987;14(1):11–25. 40. Paterson B. Myth of empowerment in chronic illness. Journal of Advanced Nursing 2001;34(5):574–581. 41. Falk-Rafael AR. Advocacy and empowerment: dichotomous or synchronous concepts? Advances in Nursing Science 1995;18:25–32. 42. Opie A. “Nobody asked me for my view”: users’ empowerment by multidisciplinary health teams. Qualitative Health Research 1998;18:188–206. 43. Pelletier K. A review and analysis of the health and costeffective outcome studies of comprehensive health promotion and disease prevention programs at the worksite: 1991–1993 update. American Journal of Health Promotion 1993;8(1):50–61.
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Lisa Keeping, RN, PhD (c), is Assistant Professor of Nursing at St. Francis Xavier University, Antigonish, NS. She has been studying full-time at McGill University for the last two years and her research focus is with the psychosocial recovery of coronary artery bypass graft surgery patients and their partners after discharge from hospital. Lisa is the recipient of a three year fellowship from the Heart & Stroke Foundation of Canada.
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