Recently, I reviewed the following treatment plan with an elder patient with heart failure and her family: double the carvedilol dose, continue to weigh daily and call if your weight increases by more than 3 lb in 1 day, stop taking the ibuprofen, decrease the salt in your diet, start walking to the mailbox each day, and return to the clinic in 2 weeks for a follow-up. When she returned for the follow-up visit, she had gained 6 pounds and had not stopped taking the ibuprofen but was immensely proud that she had walked to the mailbox twice since the last visit and had increased her carvedilol dose "most days." Did I get frustrated? Yes!! But, as often happens, I soon realized that all factors had not been considered when setting up her treatment plan, most of which contained key self-care components.

The responsibility for self-care that we place on patients with heart failure and their caregivers is phenomenal. Moser and Watkins1 define self-care as "[horizontal ellipsis]the process whereby individuals and/or their informal caregivers perform the daily activities that serve to maintain or restore health and well-being, prevent illness, and manage chronic illness." There is considerable literature available on the concept of self-care; indeed, if one searches the Google Web site2 for heart failure self-care, there are 125,000 sources displayed. Likewise, if one checks the National Library of Medicine's PubMed Web site3 for the same phrase, there are 288 articles listed. However, there are scant data available about the multitude of factors that affect decision making, a key precursor to self-care.1

Moser and Watkins have developed a conceptual model that addresses factors that influence decisions of patients with heart failure. This amazingly thorough model and the literature review provided as background offer tremendous benefits to clinicians, researchers, students, and patients.

This model can guide the myriad of clinicians who provide care to patients with heart failure through the key issues impacting patients' ability to make decisions about their self-care. Certainly, many of us have learned through experience (and research) that multiple issues affect patients' responses, but this model lays it out so clearly that one may even consider making it part of an assessment tool (formal or informal). An important point here is that, although this is a theoretical conceptual model, it is practically based enough for clinicians like me to relate to it and actually use it.

Perhaps, the most obvious benefit of the model may be for researchers. Laid out in this model are the key gaps in the literature where critical input is needed to further our understanding of factors affecting how patients with heart failure care for themselves. Important to note is the point made by Moser and Watkins for researchers to account for previous studies and move beyond answering the same questions repeatedly. From my perspective, that would also mean studying interventions and outcomes and not just describing relationships among variables.

This model is a gold mine for students, especially graduate students. Because it provides a great overview of the key issues involved in taking care of elder patients with heart failure, I can see advanced practice nurses copying (or downloading) this article again and again for graduate students working with them. In terms of research, this article is a graduate student's dream come true. It lays out a thorough listing of research needed in this area, with enough background review of the literature to get a project started.

Ultimately, our patients will derive the most benefit from this model. By attending to the factors noted in the model and keeping abreast of ongoing research on those aspects, I think we as clinicians will better understand how to develop more appropriate treatment plans that set patients up for success in their self-care efforts. For my patient, reviewing the model has made me appreciate how her mild cognitive deficit, her comorbidities (hypertension, arthritis, and obesity), her sensory impairment (poor vision), her previous experiences with healthcare providers, and her strong supportive family system affect her ability to take care of herself. Her daughter now helps with her medication dosing, daily weights, and telephone calls; we have prescribed an alternate pain regimen to replace ibuprofen; and she has begun a home physical therapy program.

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