Journal of Practical & Professional Nursing Category: Clinical Type: Research Article
Theory of Self-Care for People with Mental Disability in a Community
*Corresponding Author:Mayuko Yamashita
School Of Nursing, The Jikei University School Of Nursing, Tokyo, Japan
Email:firstname.lastname@example.org / email@example.com
Received Date: Apr 24, 2018 Accepted Date: May 30, 2018 Published Date: Jun 15, 2018
The death of inpatients in mental health hospitals has not shown marked improvement. The revolving-door phenomenon, by which a patient is hospitalized on and off in the short term, is designated as a chief cause. Unless treatment and self-management can be maintained continuously after remission by hospital treatment, acute exacerbation results in frequent hospitalization. Also, long-term outcome improvement cannot be expected. Because support is increasingly transferred to the community in the future, it will be important to provide support to enhance self-care capability necessary to live in a community for people with mental disabilities, rather than conventional support particularly addressing symptomatic improvement and functional recovery.
Earlier reports have described examination of self-care concepts such as conceptual analysis of self-management for patients with cancer , conceptual analysis of self-management for patients with cardiac arrest , and conceptual analysis of self-care for patients with schizophrenia , the concept of self-care for people with mental disabilities in a community has not been defined yet. One might infer that, because people with mental disabilities are said to have both diseases and disabilities, their mental symptoms should affect on their self-care resulting in various life disabilities [5,6]. Consequently, it is important to present clear concepts of self-care considering the disease characteristics of people with mental disabilities.
Furthermore, we think that we can present more multiple self-care factors by clarifying the recognition of supporters who help people with mental disabilities in a community. Then, we clarify the abilities and skills which are thought to be necessary for people with disabilities by home-care nurses and psychiatric social workers helping them in a community. By unifying individually extracted elements, this study was conducted to clarify the constituent elements of self-care for people with mental disabilities in a community. Because support services to help long-term inpatients leave the hospital are advanced based on the fundamental concept of the reforming vision in the future, we can obtain important suggestions in taking steps for concrete nursing support aimed at having support transferred and established in a community by clarifying the composing elements of self-care in a community.
Data collection method
We used the Japan Medical Abstract Society online (published in 1977), PubMed (published in 1946), and CINAHL (published in 1981). Because earlier studies did not distinguish clearly between self-care and self-management and because self-management is a part of self-care, we used “people with mental disabilities” and “self-care” or “self-managing or self-management” or “mental illness” or “mental disorder” or “psychiatric illness” or “psychiatric disorder” and “self-care” or “self-management” as keywords. Mental disorder is a state in which a patient is affected mainly by schizophrenia or a mood disorder, developing particular mental or behavioral symptoms and therefore suffering from functional disorders.
Additionally, we conducted a search in fields including mental hospitals and community because support for self-care in mental hospitals is implemented with a view to patients’ community life. The search duration was the publishing years of the databases for literature surveys to December 2016. From that search, 375 articles from the Japan Medical Abstract Society online, 90 from CINAHL and 26 from PubMed were identified. Confirming titles and abstracts from reports of the literature and judging their fitness for the theme of this study from the descriptive contents, we finally selected 42 reports of the literature as analytical targets.
At the second step, we conducted semi-structured interviews of supporters who helped people with mental disorders in communities to show what self-care they recognized as necessary for them to live in their community. We considered that if we define questionnaire items and do not structure them, then we could obtain some results beyond our expectations and any pre-set framework. Therefore, we chose to use a semi-structured interview. The reason we conducted semi-structured interviews is that the results obtained at the first step did not specifically elucidate self-care in community life. Therefore, we needed to elucidate the self-care recognized by specialists supporting people with mental disorders in the community.
We conducted 30-90 min semi-structured interviews of examinees who gave their consent to participation in our study. The interview included queries related to the abilities and skills that are considered necessary for people with mental disabilities from the viewpoint of specialists. We conducted interviews in a private room to secure privacy and recorded the interviews with an IC recorder with the consent of the interviewees.
At the third step, we combined the results obtained at the first and second steps and showed self-care required for people with mental disorders to live in their community.
At the second step, the analysis of supporters’ interview contents was conducted qualitatively and inductively according to the following procedure: (1) All interview contents recorded with an IC recorder were described word by word. (2) The parts describing abilities and skills necessary to live in a community were extracted and encoded using units by which a reader can understand the meaning and content. (3) The codes were categorized based on similarity. In addition, the categories were sub-categorized by raising the level of abstraction. To secure the reliability of the results, we conducted analyses while checking data interpretation as needed, supervised by a researcher with experience in qualitative studies from the analytical process.
At the third step, in terms of the constituent elements of self-care obtained by conceptual analysis and the categories obtained by interviews, we reconstructed them based on their respective similarities, commonalities, and differences to extract the final composition elements of self-care of people with mental disabilities living in a community.
|Elements||Element divisions||Concrete actions|
|Stability of mental and physical states||Management of mental condition||Monitoring of mental condition|
|Coping actions for symptoms|
|Actions for visiting hospitals|
|Health management||Monitoring of physical conditions|
|Actions for visiting the office in poor mental condition|
|Stress management||Monitoring of stress status|
|Maintenance of daily life||Diet management||Decision of menu|
|Buying cooking ingredients|
|Clearing a table|
|Using cooking instruments|
|Buying ready-made meals|
|Voluntarily eating food|
|Checking the expiration date|
|Sleeping management||To maintain satisfying sleeping|
|Rest||Consciousness of fatigue|
|Rest while suffering from fatigue|
|Bathing, changing clothes and applying cosmetics||Cosmetic behaviors including washing face, fixing hairs, shaving and brushing of teeth|
|Maintaining the body clean (by bathing)|
|Dressing in accordance with time, place and occasion|
|Cleaning and laundry||Cleaning the private room|
|Distinguishing between something clean and something not clean|
|Laundry considering the timing|
|Management of bedclothes|
|Decluttering||Putting belongings in order|
|Disposal of unnecessary items|
|Disposal of garbage||Waste sorting|
|Taking the trash out (at the designated place and date)|
|Shopping||Shopping things necessary to life|
|Use of public transportation||Using public facilities such as bank, post office, and city hall|
|Using public transportation such as train, bus, and tax|
|Use of social resources||Obtaining knowledge of accessible social resources|
|Appropriate use of social resources|
|Time management||Designing a life schedule|
|Life in accordance with schedule|
|Management of items||Management of valuables (seal, passbook and disability certificate)|
|Financial management||To use money systematically|
|To put money aside|
|To save money|
|Security management and risk management||To obey traffic rules|
|Safe use of fire|
|Use of phone|
|Anticrime measures (e.g. lock-up)|
|Ability to accept support||Self-recognition||To clarify what one can do and cannot do|
|Actions to request help||To issue SOS signals|
|To take counsel with someone|
|To accept support|
|Maintenance and development of human relations||Connectedness to others||To maintain appropriate family relationships|
|To maintain appropriate relationships with friends|
|To maintain appropriate relationships among people with mental disabilities|
|To maintain appropriate relationships with the opposite sex|
|To communicate with strangers appropriately|
|To maintain appropriate relationships with healthcare staff or welfare workers|
|To maintain appropriate relationships with people related to the workplace|
|To maintain appropriate relationships with neighborhood residents|
|To develop human relations|
|Communication skills||With a smile|
|Able to greet anyone|
|Able to say thanks|
|Able to listen to others|
|Able to become sympathetic to others’ world|
|Able to express will and feelings|
|Able to turn down offers|
|Able to communicate considering others and situations|
|Having the ability to solve problems|
|Will||To have a feeling of living in a community|
|To have the will to live|
|Motivation in life||Whereabouts||Having a place to spend time in character|
|Having a comfortable place|
|Having a favorite place to visit|
|Goal, dream and hope||Able to have goals|
|Able to have dreams|
|Able to have hopes|
|Able to have fun in life|
|Spending leisure time||Having hobbies or culture lessons|
|Able to spend time in character|
|Going out||Able to go out voluntarily|
|Obtaining, managing and using income||Obtaining income by working and helping|
|Able to enjoy something at one’s own expense|
|Able to buy something that one wants with one’s own money|
1) Stability of mental and physical states
These are the core behaviors of people with disabilities living in a community to stabilize mental and physical states. They consist of behaviors aimed at stability of mental and physical states: to do (management of mental symptoms) by “monitoring mental symptoms” and doing “coping behaviors for symptoms” and “hospital visit” and “drug compliance,” (health management) by “monitoring physical state,” “physical management,” and “visiting the office in poor mental condition,” and (stress management) by “monitoring stress condition” and “stress coping”.
2) Maintenance of daily life
These are concrete behaviors for people with mental disabilities to maintain their daily life. The behaviors for (maintenance of daily life) consist of (dietary management), (sleeping management), (rest), (bathing and cosmetic action), (cleaning and laundry), (decluttering), (disposal of garbage), (shopping), (use of public transportation), (use of social resources), (time management), (management of goods), (finance management), and (safety management and risk management).
3) Ability to accept support
The ability to accept support includes behaviors related to receiving supports from others when people with mental disabilities face various difficulties. They consist of (self-recognition) to assess their own circumstances and abilities and (behavior to request support) such as issuing SOS signals.
4) Maintenance and development of human relations
These include behaviors for people with mental disabilities to maintain and newly develop relationships with different people in a community. The maintenance and development of human relations consists of connectedness to others, including not only specialists but also different types of people and communication skill.
These are behaviors that empower people with mental disabilities to live in character in a community. They consist of self-resources such as self-determination, ability to solve problems, and appropriate self-assessment and will of people with mental disabilities for living in a community.
6) Motivation in life
These are behaviors for people with mental disabilities to have motivation in life and raise their QOL. Behaviors to have motivation in life consist of securing whereabouts, having goals, dreams and hopes, spending leisure time in character, and voluntarily going out and gaining, managing and using income.
In this study, after unifying the results of conceptual analysis of self-care of people with mental disabilities in a community and the results obtained by interviewing supporters about abilities and skills for them to live in a community, we categorized self-care of people with mental disabilities in a community into six constituent elements: stability of mental and physical states, maintenance of daily life, abilities to accept supports, maintenance and development of human relations, empowerment and motivation in life.
People with mental disabilities often show impairment of self-care abilities because of disease characteristics such as cognitive dysfunction that might include inability to sustain attention and deficits in executive function, positive symptoms such as hallucination and delusion, and negative symptoms such as abulia and autosynnoia. Consequently, nurses’ conscious and multifaceted or multiphase observations are presumed to be important. The methods are often entrusted to individual nurses in a clinical setting [9,10]. However, to realize the transfer to, and settlement in, community of people with mental disabilities, it is important to assess the actual situation of self-care adequately based on some indexes and to provide effective support to improve their self-care.
In psychiatric circles, self-care is often assessed using Orem and Underwood theory  as an index. This comprises six items that indicate self-care necessary for people to live. However, for this study, we extracted more items of self-care of the people with mental disabilities in a community. The items include the following: what is applied to Activities of Daily Living (ADL) that is fundamentally important to maintain a living such as diet, changing clothes, toilet, and bathing; what is applied to Instrumental Activities of Daily Living (IADL) to maintain higher-level living functions including using a telephone, domestic duties, and self-management such as drug compliance and financial management; what is applied to Social Functioning Abilities (SFA) including social participation, independent-minded creation of life, and aggressive use of accessible social resources; elements leading to motivation in life such as spending leisure time and having goals, dreams and hopes.
In other words, for people with mental disabilities to maintain their own life and healthy functions, sustainable personal growth, and happiness in community, it was demonstrated that they must acquire not only narrowly defined ADL but also behaviors to maintain independent living by self-management of safety, time, things, money, and life through their own cognitive decision-making and the independent-minded behaviors for self-fulfillment through communication with others and society to enhance their quality of life.
Because mental diseases often develop during adolescence as an important stage of life, patients are likely to have difficulty adjusting to social life without work experience . In addition, disease characteristics cause people with mental disabilities to experience many difficulties living in daily life .
Supporters have mainly been offering support to enhance ADL with the intention that people with disabilities who have difficulties living can transfer from a stay at the hospital to community and continue the life in community. However, behind the broader self-care elements extracted in this study, supporters’ consciousness has been shown to change and develop to the extent that they can aim not only to help people with mental disabilities to live independently as in the past but also to help them live in character and to improve their QOL by elevating IADL and SFA.
Bathing, changing clothes, and application of cosmetics among the self-care elements were also extracted from many reports of the literature and interviews. However, the elements of security management and risk management were only reported occasionally. The number of extracted items varied among elements. Furthermore, what was newly extracted from interviews though not extracted from reports of the literature included motivation in life and abilities to accept supports. In other words, the possibility exists that there is a difference in recognition of necessary self-care concepts among specialists.
As support for the transfer to and settlement in community become increasingly promoted, it will be necessary to consider support for improvement of IADL and SFA and for motivation in life as well as conventional support for ADL from diverse standpoints and to enhance and develop support for the improvement of self-care in healthcare facilities and community aiming to help them live in character.
With the composite elements of self-care in community visualized by concrete behaviors in this study, we can conveniently and clearly assess self-care capabilities for people with mental disabilities to live in a community as they like. We can also use them as indexes to examine necessary support for them. Additionally, they are useful as materials in examining the introduction of social resources for necessary self-care.
The place in which the subjects interviewed this time provide support is a suburb, somewhat distant from downtown and between an urban area and a rural one. Consequently, although we do not know whether the results apply to developing countries, they can be applied to areas located between an urban area and a rural area.
- Ministry of Health, Labor, and Welfare (2004) 2004 vision for Reforming Mental Health Care and Welfare. Ministry of Health, Labor, and Welfare, Government of Japan, Japan.
- Yoshida K, Kanda K (2010) A Concept Analysis of Self-Care of Cancer Patients. J Jpn. Acad Nurs Sci 30: 23-31.
- Chieko H (2003) Conceptual analysis of self-management of patients with cardiac arrest. Bulletin of Yamanashi College of Nursing 9: 103-114.
- Shiori U (1997) A concept analysis of “self care” among schizophrenic patients who are living in the community: application of hybrid model. The Japan Academy of Psychiatric and Mental Health Nursing 6: 26-33.
- Nozomu S, Mami K, Yuki M, et al. (2008) Care contents provided by psychiatric home nursing: from interviews with psychiatric home nurses. Japan Journal of Nursing Science 28: 41-51.
- Usami S, Nakayama Y, Nozue K, Fujii M, Ooi M (2014) The nursing care for psychiatric patients to prevent hospital readmission. The Japan Academy of Psychiatric and Mental Health Nursing 23: 70-80.
- Rodgers BL, Knafl KA (2000) Concept Development in Nursing: Foundations, Techniques, and Applications., Saunders, Ontario, USA. Pg No: 458.
- Nagai R, Tamura Y (2003) Medical friend’s nursing science dictionary (6thedn). Medical Friend Co. Ltd., Tokyo, Japan.
- Tomoko A, Katsumi H, Masako I (2006) Assessment for patients’ abilities using daily life capacities and life activities level assessment table in SAKATA Mitsuyoshi (Ed.), Seishin Kango Expert 4 (Second Version), Nakayama Shoten Co., Ltd. Tokyo, Japan.
- Mami K (2006) Viewpoints necessary for assessment in SAKATA Mitsuyoshi (ed.). Seishin Kango Expert 4 (Second Version), Nakayama Shoten Co., Ltd., Tokyo, Japan.
- Yuko M (1987) Self-care gainen to kango jissen: Dr. P.R. Underwood no shiten kara (Concept of self-care and nursing practice: from the viewpoint of Dr. P. R. Underwood (First Version), Herusu Shuppan, Co. Inc. Tokyo, Japan.
- Cabinet Office (2012) White paper for people with disabilities Heisei 23-year edition text, Cabinet Office, Government Office of Japan, Japan.
- Hiroshi D (1984) Restoration of life therapy. Clinical Psychiatry 26: 803-814.
Citation:Yamashita M (2018) Theory of Self-Care for People with Mental Disability in a Community. J Pract Prof Nurs 2: 003.
Copyright: © 2018 Mayuko Yamashita, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.