The importance of self-management programmes in a comprehensive care approach for patients with atrial fibrillation

A theory that denies that thoughts can regulate actions does not lend itself readily to the explanation of complex human behavior. —Albert Bandura1 Today it is well accepted, that patients are active participants in their own health and treatment, and the term self-management is a common term within health education and promotion programmes. The literature describes various self-management programmes for patients with different diseases. The programmes are generally based on social cognitive theory, which Bandura describes as to involve knowledge of the specific disease, perceived self-efficacy, health goal setting, and strategies to retain or improve health outcomes.1 Many definitions of self-management exist and are not a straightforward concept. But, self-management, in this context, may be defined as ‘to be active in managing a disease’ which, for many patients with chronic illness, may be a lifetime task. Lorig et al.2 describe three self-management tasks for patients with a chronic disease; medical-, role-, and emotional management. Medical tasks involve medical management of the conditions, such as dealing with a special diet and remembering to take medication as prescribed. Role management involves changing, creating, or maintaining new behaviours or life roles. In the context of being affected with a heart disease, this may involve changing the routines to weekly perform exercises. As a chronic disease may reveal emotions, such as anger, fear, and depression, the emotional management is to learn to manage those emotions which may occur. Although, all the three tasks may not be involved in the same self-management programme. Many patients with AF describe that they live with an uncertainty as to when symptoms of AF will arise, the consequences the symptoms may have, and which non-pharmacological actions may prevent symptoms of AF. Moreover, patients experience struggling with continuously trying to understand and predict their symptoms, and feeling uninformed and unsupported by healthcare professionals.3 Patients with AF highlight the need for practical tools, as self-management strategies, to handle their situation.4 Also, if they have the ability and knowledge they use self-care to prevent the disease. Self-care in chronic illness is described to include self-care maintenance, self-care monitoring, and self-care management.5 Self-management programmes, as self-care, for patients with AF are suggested to include education about the disease (e.g. symptoms, treatments), management of symptoms as well as support to improve their ability to reduce or eliminate modifiable lifestyle factors with the aim to decrease symptoms and increase quality of life. Unhealthy lifestyle is considered to accelerate the development of AF, increase hospitalizations and mortality as well as affect the patient’s everyday living. The modifiable lifestyle factors, which include smoking, obesity, physical inactivity, high intake of alcohol, and psychological factors, such as depression and anxiety, could be incorporated, in a comprehensive care approach, in self-management programmes for self-care in patients with AF. Although the focus in Europe is on the European Society of Cardiology guidelines (ESC)6 other guidelines from Canada, Australia, the American Heart Association also highlight the importance of integrated care (in a comprehensive care approach) by a multidisciplinary team and self-management programmes to be implemented and evaluated. In those contexts nurses and allied health professionals play a prominent role in the management of patients with AF within the multidisciplinary team.7 But the challenge for clinicians is now that no exact recommendations are supported by strong research, and a recent review finds that there is a need for more research to determine which exact components should be included in the comprehensive care approach. To guide clinicians and to understand the interventions it is paramount to evaluate the interventions both quantitatively and qualitatively—unfortunately, only few interventional studies have been evaluated like that.8,9 We are calling for research, which designs, tests, and evaluates self-management programmes for patients with AF. There is a need to develop practical strategies to counteract symptoms, reduce risk, increase quality of life, and decrease negative lifestyle factors. To design and test an intervention including several components that may affect each other is complex and challenging. Craig suggests that designing complex intervention stats with identifying existing evidence, identifying and developing a theory as well as modelling the process and outcomes in different approaches.10 We propose that complex interventions such as self-management programmes in patients with AF can be led by nurses and should be feasible to evaluate in: Randomized interventional clinical trials to assess the appropriate content for such interventions. Randomized interventional clinical trials to test interventions of systematic and specific lifestyle and risk factor modification to improve treatment outcomes and quality of life. Qualitative studies to access topics and targets for these programmes as well as a part of the evaluation of the programmes. Nurses and allied health professionals have an important superior role and knowledge in guiding patients in a comprehensive care approach, as self-management programmes, and should be involved in those contexts. Conflict of interest: none declared. The opinions expressed in this article are not necessarily those of the Editors of the European Journal of Cardiovascular Nursing or of the European Society of Cardiology.