ORIGINAL ARTICLE

The effect of a supportive educational intervention developed based

on the Orem’s self-care theory on the self-care ability of patients with
myocardial infarction: a randomised controlled trial
Ali Mohammadpour, Narjes Rahmati Sharghi, Shahla Khosravan, Ali Alami and Majid Akhond

Aims and objectives. The aim of this study was to assess the effect of a supportive
educational intervention developed based on the Orem’s self-care theory on the What does this paper contribute
self-care ability of patients with myocardial infarction. to the wider global clinical
Background. Patients with cardiovascular disease suffer from the lack of knowledge community?
about the disease and consequently are not able to fulfil their own self-care needs. • The supportive educational inter-
Design. This was a randomised controlled trial conducted in 2012. vention developed based on the
Methods. We recruited a random sample of 66 patients with myocardial infarc- Orem’s self-care theory can
improve patients’ self-care abil-
tion who had been recently discharged from coronary care unit. The study setting
ity.
was two university hospitals located in Khorasan, Iran. Patients were randomly • Cardiac patients need self-care
allocated to either the experimental or the control groups. Patients in the experi- support. The supportive educa-
mental group received education, support, and counselling while patients in the tional intervention developed
control group received no intervention. We employed a demographic question- based on the Orem’s self-care
naire and the Myocardial Infarction Self-Care Ability Questionnaire for data theory can help health care pro-
fessionals identify and fulfil
collection and SPSS version 16.00 for data analysis.
patients’ self-care needs.
Findings. After the study, patients in the experimental group had higher levels of
self-care knowledge, motivation and skills compared to the prestudy readings and
the control group.
Conclusion. The supportive educational intervention developed based on the
Orem’s self-care theory can improve nonhospitalised patients’ self-care ability and
positively affect public health outcomes. Consequently, using the developed pro-
gramme for providing follow-up care to nonhospitalised patients is recommended.
Relevance to clinical practice. Having the ability to develop caring systems based
on the nursing theories is a prerequisite to standard nursing practice. Identifying
patients’ educational needs is a fundamental prerequisite to patient education.
Our findings revealed that the supportive educational intervention developed
based on the Orem’s self-care theory can help health care providers identify and
fulfil patients’ self-care needs.

Authors: Ali Mohammadpour, BSN, MSN, PhD in nursing, Asso-
ciated Professor, Department of Nursing, Social Determinants of
Health Research Center, Gonabad University of Medical
Sciences, Gonabad, Iran. Narjes Rahmati Sharghi, BSN, Student
in Master of Nursing Education, Student Research Committee,
Gonabad University of Medical Sciences, Gonabad, Iran; Shahla
Khosravan, BSN, MSN, PhD in nursing, Associated Professor,
Department of Community and Mental Health Nursing, Faculty
of Nursing and Midwifery, Social Determinants of Health
Research Centre, Gonabad University of Medical Sciences, Gona-
bad, Iran; Ali Alami, MD, PhD, Assistant Professor, Department
of Health School of Public Health; Social Determinants of
Health Research Center, Gonabad University of Medical
Sciences, Gonabad, Iran; Majid Akhond, BSN, Student in Master
of Intensive Care Nursing, Mashhad University of Medical
Sciences, Mashhad, Iran
Correspondence: Narjes Rahmati Sharghi, Student in Master of
Nursing Education, Student Research Committee, Gonabad University
of Medical Sciences, Gonabad, Iran. Telephone: +98 09173000878
E-mail: narjes.rahmati.sharghi@gmail.com

© 2015 John Wiley & Sons Ltd

Journal of Clinical Nursing, doi: 10.1111/jocn.12775 1
A Mohammadpur et al.
Key words: clinical trial, Orem’s self-care theory, patient education, self-care
ability
Accepted for publication: 8 December 2014
Introduction
Cardiovascular disease (CVD) is the first leading cause of
death worldwide (Costa et al. 2012, Thygesen et al. 2012).
In our country, Iran, 205 cases per 100,000 people die
from CVD yearly (Beyranvand et al. 2011). CVD dramati-
cally affects patients’ lives (Woods et al. 2004). Taherian
et al. (2007) reported that patients with CVD experience
many problems such as job loss and ineffective role perfor-
mance (Taherian et al. 2007).
Follow-up care and rehabilitation are the main compo-
nents of standard nursing care provided to patients with
CVD (Brunner & Suddarths 2011). However, in Iran, there
is no follow-up care available to patients with CVD and
hence, most of these patients convalesce at home. Conse-
quently, self-care is a matter of great importance for these
patients. Rafieifar et al. (2005) also noted that conventional
self-care is the most important approach to primary care
(Rafieifar et al. 2005).
Despite the great importance of self-care, patients usually
receive little, if any, detailed health information from health
care providers. In other words, they are provided only with
short pieces of general information limited to areas such as
medications and permitted level of physical activity. Conse-
quently, patients, particularly during the first six month
after hospital discharge, suffer from health misinformation
and misconceptions as well as lack of knowledge about the
aetiology, risk factors and the management of CVD. The
consequences of such unawareness are adverse emotional
reactions such as stress and anxiety (Jaarsma et al. 1994).
Accordingly, patients with CVD are not able to fulfil their
own self-care needs and hence, are frequently re-admitted
to hospital to receive primary care services. Frequent hospi-
talisations place a heavy financial burden on patients and
their families and increase the risk of cardiovascular com-
plications, nosocomial infections, as well as emotional and
physical health problems (Heydari et al. 2011).
Background
Many strategies have been developed for supporting
patients with chronic diseases after hospital discharge. The
Orem’s self-care deficit theory is one of these strategies
(George 2011). It is a simple, easy-to-apply, widely used
2 Journal of Clinical Nursing
theory of self-care (Arlene & Marjorie 1996, Mohamma-
dhassani et al. 2010). Olivella-Fernandez et al. (2012)
noted that Orem’s theory has made a significant contribu-
tion to care provision and knowledge development in nurs-
ing. They also reported that this theory could help nurses
improve patients’ self-care ability. The main focus of the
theory is on individual’s health-maintenance and self-care
abilities. According to this theory, most people have the
potential for self-care. Similarly, individuals’ self-care
knowledge, motivation and skills help them develop their
self-care abilities. According to Orem, when self-care needs
exceed self-care ability—for example in case of chronic dis-
eases such as CVD—, people experience health deviation
and require care. Accordingly, they need to fulfil their self-
care needs either individually or by asking for others’ help
(Memarian 2011, Meleis 2012). When using this theory, a
nurse assesses clients’ self-care knowledge, motivation and
skills and determines their self-care needs. Then, the nurse
selects one of the nursing systems proposed by Orem—
wholly compensatory system, partially compensatory sys-
tem or supportive-educative system—to fulfil the clients’
self-care needs (Meleis 2012). The supportive-educative sys-
tem helps individuals reduce their self-care deficit, improve
their self-care ability, and fulfil their universal, developmen-
tal and health deviation self-care needs. In this system, a
nurse acts mainly as a regulator, educator, supporter and
counsellor (Meleisebrahim 2007).
Previous studies demonstrated that patient education
could improve patients’ self-care ability (Daryabygi & Jalili
2003, Shojaefard et al. 2008, MangolianShahrbabaki et al.
2012). The findings of a review study also revealed that
educational interventions could significantly modify self-
care behaviours in patients with heart failure (Barnason
et al. 2011). Moreover, many studies have examined and
indicated the effectiveness of Orem’s self-care theory in
improving patient outcomes (Daryabygi & Jalili 2003, Naj-
afi et al. 2008, Shojaefard et al. 2008, Hamidizadeh et al.
2009, Barnason et al. 2011, MangolianShahrbabaki et al.
2012). However, to the best of our knowledge, none of the
previous studies has investigated the effects of the Orem’s
self-care theory on all the dimensions of patients’ self-care
ability and all kinds of patients’ self-care requisites. Conse-
quently, we conducted this study aiming at examining the
effect of a supportive educational intervention developed
© 2015 John Wiley & Sons Ltd
Original article Effect of supportive educational self-care MI

based on the Orem’s self-care theory on self-care ability of ability, we developed the 47-item MI Self-Care Ability
patients with myocardial infarction. Questionnaire (MISCAQ). The MISCAQ consisted of three
dimensions including self-care knowledge (13 items), self-
care motivation (12 items) and self-care skills (22 items).
Methods The MISCAQ items included patients’ self-care knowledge,
motivation, and skills in areas such as the symptoms of MI,
Design cardiac drugs and their side effects, healthy diet for patients
with MI, permitted level of sexual activity and heart disease
This was a randomised controlled trial conducted in 2012.
risk factors (such as obesity, hypertension, and emotional
and mental stress). The MISCAQ consisted of both multi-
Participants ple-choice and Likert-type questions. The possible ranges
for the scores of the knowledge, motivation and skills
The study setting was four coronary care units affiliated to
dimensions of MISCAQ were 0–52, 0–48, and 0–88,
two university hospitals located in Southern Khorasan, Iran.
respectively. The items of MISCAQ were generated based
The study population consisted of all patients with myocar-
on an extensive literature review and the researchers’ clini-
dial infarction (MI) who had been recently discharged from
cal and teaching experiences. Moreover, we invited nine
the study setting. The inclusion criteria were having an age
nurse educators, four cardiac care nurses and two cardiolo-
of less than 70 years, having a history of previous hospitali-
gists to confirm the content validity of the questionnaire.
sation, having a definite diagnosis of MI—as established by
We included their comments in the final version of the MI-
a cardiologist and documented in patients’ medical records
SCAQ. The reliability of the MISCAQ was assessed using
—, and having no history of speech and hearing impair-
the test–retest method. Accordingly, we asked 20 patients
ments and physical and mental disabilities. We referred to
with MI to respond to the questionnaire. Two weeks later,
the medical records units of the study setting and listed the
we asked the patients to complete the questionnaire for the
names of all patients with MI who had been discharged
second time. The inter-class correlation coefficient between
during the two years preceding the study. The list included
test and retest readings was 0758.
80 patients meeting the study inclusion criteria. Then, we
recruited a random sample of 66 names from the list. Intervention
Thereafter, we phoned the recruited patients, provided
Initially, we performed a pretest to assess the patients’ self-
them with information about the aim and process of the
care ability and to identify their educational needs in terms
study, and invited them to the study. All the invited
of MI self-care. Then, based on the identified educational
patients agreed to participate in the study.
needs, we provided the patients in the experimental group
We used the results of Mehri et al. study (2008) and
with information regarding the functions of cardiovascular
the following formula for calculating the sample size,
þ ðZ1 bÞÞ2 system, aetiology and risk factors for MI, management of
n ¼ 2ððZ1 a=2Þ
ðl1l2Þ=S . Accordingly, with a confidence level
MI risk factors, and the importance of adherence to treat-
of 95% and a power of 80%, the sample size was deter-
ment and dietary regimens. Educations were provided in
mined to be 31 patients in each group. We employed the
three 45-minute sessions. Moreover, during the first
coin-tossing method to randomly assign the patients to
45 days after the educations, we made frequent phone calls
either the control or the experimental groups. We asked
to the patients in the experimental group and provided
the patients to refer to the study setting to receive the
them with the required counselling services in terms of MI
study intervention.
self-care. The patients were also able to make phone calls
to or visit the researchers to receive further education. On
Instruments
the other hand, the patients in the control group received
The study instrument consisted of a demographic question- no intervention.
naire and the MI Self-Care Ability Questionnaire. The Finally, we performed a post-test to re-assess the patients’
demographic questionnaire consisted of questions regarding self-care ability.
patients’ age, gender, educational status, weight, height, his-
tory of previous MI, family history of MI, and systolic and
Data analysis
diastolic blood pressures.
To assess the patients’ universal, developmental and We employed the Statistical Package for Social Sciences ver-
health deviation self-care requisites as well as their self-care sion 16.0 (SPSS version 16.0; SPSS Inc., Chicago, IL, USA)

© 2015 John Wiley & Sons Ltd

Journal of Clinical Nursing 3
A Mohammadpur et al.

to analyze the study data. We described the study data
using indices such as mean and standard deviation. More-
over, we employed the independent- and paired-samples
t-tests to compare the study groups in terms of self-care
ability. The level of significance was set at below 005.
Ethical considerations
A university-affiliated Ethics Committee and the Clinical
Trials Appraisal Center affiliated to the Iranian Ministry of
Health approved the study. We explained the aim and the
process of the study to the participants and ensured them
that both participation in and withdrawal from the study
were voluntary. We also guaranteed the confidentiality of
the study participants’ information. Finally, we obtained a
verbal informed consent from each participant.
Results
In total, 66 patients—33 patients in each group—partici-
pated in the study. Table 1 shows the study participants’
Table 1 Patients’ characteristics
characteristics. The results of the independent-samples t
and the Fisher’s exact tests revealed that before the inter-
vention, there was no statistically significant difference
between the study groups in terms of characteristics such as
age, gender, education, body mass index, mean arterial
blood pressure, number of MIs, and family history of MI
(Table 1).
On the other hand, the results of the paired-samples t-test
showed that in the control group, the levels of self-care
knowledge, motivation and skills did not change signifi-
cantly after the intervention (p-value >005; Table 2). How-
ever, the results of this test revealed that in the
experimental group, the levels of self-care knowledge, moti-
vation and skills increased significantly after the interven-
tion (p-value <00001; Table 2).
Moreover, the results of the independent-samples t test
showed that before intervention, the study groups did not
differ significantly in terms of self-care knowledge, motiva-
tion and skills (p-value >005; Table 2). However, the
results of this test revealed that the postintervention self-
care knowledge, motivation and skills in the experimen-
tal group were significantly higher than the control group
(p-value ≤00001; Table 2).

Variables Cont. group Exp. group p-Value

Discussion
Age (years) 530  117 524  85 0802*
BMI 257  42 264  41 0531* The aim of this study was to assess the effect of a sup-
Education 58  49 65  48 0550* portive educational intervention developed based on the
MAP (mmHg) 972  182 981  153 0837*
Orem’s self-care theory on self-care ability of patients with
Gender (M/F) n 27/6 27/6 100†
Number of MI (1/2<) n 27/6 29/4 0.733†
MI. The study findings demonstrated that our participants’
FH of MI (Y/N) n 12/2 17/1 0321† had low levels of self-care ability. This finding indicates
that patients with MI are at risk for ineffective self-man-
Cont., Control; Exp., Experimental; BMI, Body Mass Index; MAP,
agement. Consequently, self-care education and counselling
Mean Arterial Pressure; M, Male; F, Female; MI, Myocardial
Infarction; FH, Family History; Y, Yes; N, No; n, number. in these patients are of grave importance. Orem also noted
*The results of the independent sample t-test. that patients who have low levels of self-care knowle-
†
The results of the Fisher’s exact test. dge, motivation and skills experience self-care deficit and

Table 2 The difference between the groups and between the pre- and postintervention readings of self-care knowledge, motivation and skills
(the results of the Independent- and paired-samples t-test)

Control group Experimental group

Variables Time point Mean  SD p-Value* Mean  SD p-Value* p-Value†

Knowledge Before 14  05 0447 14  05 <0001 0808

After 15  05 20  (00) <0001
Motivation Before 16  04 0572 17  04 0001 0446
After 16  04 20  (00) <0001
Skill Before 15  05 100 13  04 <0001 0221
After 15  05 20  (00) <0001

*The results of the paired-samples t test.

†
The results of the independent samples t-test.

© 2015 John Wiley & Sons Ltd

4 Journal of Clinical Nursing
Original article
hence, require education and counselling (cited Meleis
2012).
The study results revealed that before the intervention,
the study groups did not differ significantly in terms of vari-
ables such as age, gender, education, body mass index,
mean arterial blood pressure, number of MIs, family history
of MI, as well as self-care knowledge, motivation and skills.
However, after the intervention, the levels of self-care
knowledge, motivation and skills in the experimental group
were significantly higher than the control group. This find-
ing implies that the supportive educational intervention
developed based on the Orem’s self-care theory was effec-
tive in increasing the patients’ self-care ability in the experi-
mental group. Information provision helps improve
patients’ knowledge and understanding, which are in turn
the core components of self-care (Driscoll et al. 2009). Bar-
nason et al. (2011) reported that cognitive-behavioural
interventions significantly improve self-care knowledge as
well as self-care maintenance and self-care management
behaviours in patients with heart failure (Barnason et al.
2011). Rostami et al. (2009) also reported that older
patients’ quality of life improved significantly after the
implementation of a care plan developed based on the
Orem’s self-care theory (Rostami et al. 2009). Moreover,
Orem defined human being as a self-care agent (George
2011) who assumes responsibility for self-care and develops
his self-care ability through learning, experiencing and com-
municating with others (Naroei & Khani 2010). She
believed that the purpose of nursing practice is to support
individuals and to help them develop their self-care ability
(Shahsavari et al. 2010).
On the other hand, we found that in the experimental
group, the levels of self-care knowledge, motivation and
skills improved significantly after the study. However, these
variables did not change significantly in the control group.
Generally, education improves patients’ self-care ability (Sa-
hebalzamani et al. 2012). Armer et al. (2009) found that the
supportive-educative intervention developed based on the
Orem’s self-care theory, decreased the risk of lymphatic
nodes edema in patients undergoing mastectomy (Armer
et al. 2009). Shojaefard et al. (2008) also reported that
patient education improved self-care ability in patients with
heart failure (Shojaefard et al. 2008). Bolourchifard et al.
(2009) and MangolianShahrbabaki et al. (2012) also found
that education had a positive effect on the level of self-care
knowledge, attitude and practice in patients with diabetic
foot ulcers and heart failure (Bolourchifard et al. 2009,
MangolianShahrbabaki et al. 2012). All these findings sup-
port the effectiveness of Orem’s self-care theory in improv-
ing patient outcomes.
© 2015 John Wiley & Sons Ltd
Journal of Clinical Nursing
Effect of supportive educational self-care MI
Conclusion
Patients with myocardial infarction are highly in need for
receiving self-care education, support and counselling.
Hence, nurses and other health care providers have to
actively intervene in improving their self-care ability. The
supportive educational intervention developed based on the
Orem’s self-care theory can improve patients’ self-care abil-
ity. Consequently, the introduction of the Orem’s self-care
theory into the baccalaureate nursing curriculum and
continuing education programmes is recommended to
bridge theory-practice gap, promote nurses and nursing
students’ clinical practice, and improve patient outcomes.
Relevance to clinical practice
Having the ability to develop caring systems based on the
nursing theories is a prerequisite to standard nursing prac-
tice. Patient education is an important component of nurs-
ing care. On the other hand, identifying patients’
educational needs is a fundamental prerequisite to patient
education. Our findings suggest that the supportive educa-
tional intervention developed based on the Orem’s self-care
theory can help healthcare providers identify and fulfil
patients’ self-care needs.
Limitations
The study was conducted patients who had been dis-
charged from coronary care units affiliated to two local
universities. Consequently, the study findings were limited
in generalisability. Moreover, study intervention, data col-
lection and data analysis were not blinded.
Recommendations
Investigating the effects of supportive educational interven-
tions developed based on the Orem’s self-care theory on
patient outcomes in other patient populations and settings
is recommended.
Acknowledgements
We gratefully thank the Research Administration of Gona-
bad University of Medical Sciences, Gonabad, Iran, for
funding the study. Moreover, nurses, head-nurses and
nurse-managers affiliated to the study settings who sup-
ported us during the study as well as the patients and their
family members who agreed to participate in the study
deserve our sincere gratitude.
5
A Mohammadpur et al.
Disclosure
The authors have confirmed that all authors meet the
ICMJE criteria for authorship credit (www.icmje.org/ethi
cal_1author.html), as follows: (1) substantial contributions
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