Self-care Demands Research Articles

Compare and Contrast of Grand Theories: Orem’s Self-Care Deficit Theory and Roy’s Adaptation Model

Nursing theories are developed to provide a connecting frame work which focus on nursing practice. Dorothy Orem’s Self-Care Deficit Theory and Sister Callista Roy’s Adaptation Model are grand theories; both developed these to enhance nursing practice and education. Orem Model emphasizes on the individuals demands of self care which the nurse can accomplish through certain actions to promote health and well being. However, the adaptation model gives an effective frame work for addressing the adaptive needs of individuals, families and groups. Orem’s theory is applicable in certain settings such as acute care units, ambulatory clinics, community, senior citizen homes, hospice, and rehabilitation centre. Whereas, Roy’s model is practical in many areas of nursing practice to enhance practical nursing for individuals of all ages in health and illness, it is also more relevant to assessment and intervention during the changes which occur with aging. In conclusion, both the models are well defined to promote better patient care, to enhance the image of nursing profession, and to improve communication among nurses.

Patient-level Medication Regimen Complexity in Older Adults With Depression

PurposePolypharmacy and medication adherence are well known challenges facing older adults. Medication regimen complexity increases the demands of self-care in the home. Some medication regimens may be more complex than others, especially when dosage form, frequency of dosing, and additional usage directions are included in complexity along with the number of medications In older adults with depression, it is unknown what features of their medications most influence their medication regimen complexity. MethodsA sample cohort of 100 adults ≥65 years old with a diagnosis of depression was randomly selected from electronic medical records (EMR) in ambulatory clinics at the University of Colorado (CU) and University of San Diego (SD). Demographic, medical history, and medication-related information was extracted from the EMR. Complexity was determined using the Medication Regimen Complexity Index (MRCI). IRB approval was obtained. FindingsThe cohort mean age was 74.3 years (SD) and 79.7 years (CU). The mean unweighted Charlson comorbidity index for 1.0 (SD) and 1.8 (CU). The mean number of medications was 7.1 and 8.0, with 1.1 and 1.2 depression meds, 5.4 and 4.3 non-depression prescription meds, and 0.6 and 2.4 OTC meds for the SD and CU cohorts, respectively. 66% of SD adults and 70% of CU adults took six or more meds. Individual MRCI scores were on average 17.62 (SD) and 19.36 (CU). Dosing frequency contributed to 57-58% of the MRCI score, with patients facing an average of 7–8 unique dosing frequencies in their regimen. In both cohorts, there was an average of 3 additional directions added to the regimens to clarify dosing. ImplicationsAs expected, in our older adult cohorts with depression the majority of patients took multiple medications. Using a standardized instrument, we characterized the regimen complexity and found that it was increasingly complex due to numerous dosing forms, frequencies and additional directions for use. Patient-level medication regimen complexity should go beyond depression medication to encompass the patient’s entire regimen for opportunities to reduce complexity and improve ease of self-care.

Stroke, multimorbidity and polypharmacy in a nationally representative sample of 1,424,378 patients in Scotland: implications for treatment burden.

BackgroundThe prevalence of multimorbidity (the presence of two or more long-term conditions) is rising internationally. Multimorbidity affects patients by increasing their burden of symptoms, but is also likely to increase the self-care demands, or treatment burden, that they experience. Treatment burden refers to the effort expended in operationalising treatments, navigating healthcare systems and managing relations with healthcare providers. This is an important problem for people with chronic illness such as stroke. Polypharmacy is an important marker of both multimorbidity and burden of treatment. In this study, we examined the prevalence of multimorbidity and polypharmacy in a large, nationally representative population of primary care patients with and without stroke, adjusting for age, sex and deprivation.MethodsA cross-sectional study of 1,424,378 participants aged 18 years and over, from 314 primary care practices in Scotland that were known to be demographically representative of the Scottish adult population. Data included information on the presence of stroke and another 39 long-term conditions, plus prescriptions for regular medications.ResultsIn total, 35,690 people (2.5%) had a diagnosis of stroke. Of the 39 comorbidities examined, 35 were significantly more common in people with stroke. Of the people with a stroke, the proportion that had one or more additional morbidities present (94.2%) was almost twice that in the control group (48%) (odds ratio (OR) adjusted for age, sex and socioeconomic deprivation 5.18; 95% confidence interval (CI) 4.95 to 5.43). In the stroke group, 12.6% had a record of 11 or more repeat prescriptions compared with only 1.5% of the control group (OR adjusted for age, sex, deprivation and morbidity count 15.84; 95% CI 14.86 to 16.88). Limitations include the use of data collected for clinical rather than research purposes, a lack of consensus in the literature on the definition of certain long-term conditions, and the absence of statistical weighting in the measurement of multimorbidity, although the latter was deemed suitable for descriptive analyses.ConclusionsMultimorbidity and polypharmacy were strikingly more common in those with a diagnosis of stroke compared with those without. This has important implications for clinical guidelines and the design of health services.Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-014-0151-0) contains supplementary material, which is available to authorized users.

Patient-Level Medication Regimen Complexity in Patients With HIV.

Patients with HIV often have multiple medications besides antiretrovirals (ARV). Medication regimen complexity-formulations, dosing frequencies, and additional directions-expands pill burden by considering self-care demands. Studies show an inverse association between ARV adherence and medication complexity for ARVs only. Patient-level medication regimen complexity beyond ARV complexity is unknown. To measure and characterize Patient-level Medication Regimen Complexity Index (pMRCI) and Antiretroviral Medication Regimen Complexity Index (ARCI) for patients in 2 HIV clinics. We hypothesized that an all-medication complexity metric will exceed disease-state-defined complexity metrics; for ARVs only, the pMRCI score will be smaller than the ARCI score by capturing fewer features of regimens. Associations between complexity and adherence were not assessed. Electronic records supplied a retrospective, random sample of adult patients with HIV; medication lists were used to code the pMRCI (n=200). A random subsample (n=66) was coded using ARCI for ARV regimens only. Medication counts ranged from 1 to 27; pMRCI scores ranged from 2 to 67.5. ARVs contributed roughly 25% to the pMRCI; other prescriptions contributed about 66%. Dosing frequency made the largest contribution of all components (62%) to the pMRCI. For ARVs, pMRCI and ARCI scores did not differ statistically. Unique dosing frequencies raised complexity and may provide opportunities for intervention. Other prescriptions drove pMRCI scores, suggesting that HIV management programs should review all medications. A patient-level approach added value to understanding the role of medications in patient complexity; future work can assess association of pMRCI with adherence and patient outcomes.

Stroke, multimorbidity and polypharmacy in a nationally representative sample of 1,424,378 patients in Scotland: implications for treatment burden

The prevalence of multimorbidity (the presence of two or more long-term conditions) is rising internationally. Multimorbidity affects patients by increasing their burden of symptoms, but is also likely to increase the self-care demands, or treatment burden, that they experience. Treatment burden refers to the effort expended in operationalising treatments, navigating healthcare systems and managing relations with healthcare providers. This is an important problem for people with chronic illness such as stroke. Polypharmacy is an important marker of both multimorbidity and burden of treatment. In this study, we examined the prevalence of multimorbidity and polypharmacy in a large, nationally representative population of primary care patients with and without stroke, adjusting for age, sex and deprivation. A cross-sectional study of 1,424,378 participants aged 18 years and over, from 314 primary care practices in Scotland that were known to be demographically representative of the Scottish adult population. Data included information on the presence of stroke and another 39 long-term conditions, plus prescriptions for regular medications. In total, 35,690 people (2.5%) had a diagnosis of stroke. Of the 39 comorbidities examined, 35 were significantly more common in people with stroke. Of the people with a stroke, the proportion that had one or more additional morbidities present (94.2%) was almost twice that in the control group (48%) (odds ratio (OR) adjusted for age, sex and socioeconomic deprivation 5.18; 95% confidence interval (CI) 4.95 to 5.43). In the stroke group, 12.6% had a record of 11 or more repeat prescriptions compared with only 1.5% of the control group (OR adjusted for age, sex, deprivation and morbidity count 15.84; 95% CI 14.86 to 16.88). Limitations include the use of data collected for clinical rather than research purposes, a lack of consensus in the literature on the definition of certain long-term conditions, and the absence of statistical weighting in the measurement of multimorbidity, although the latter was deemed suitable for descriptive analyses. Multimorbidity and polypharmacy were strikingly more common in those with a diagnosis of stroke compared with those without. This has important implications for clinical guidelines and the design of health services.

Self care in patients with chronic heart failure. Pilot study - self care includes problems

The goal of this pilot study was to define the scope of therapeutic self-care demand in heart failure (HF) patients according to the concepts of self-care postulated by D.E. Orem and to determine the level of problems experienced and self-care in these patients. A questionnaire consisting of 7 areas with closed format questions was developed according to the definition. The level of patient problems and level of self-care actions were mapped in each area. The questionnaire was distributed at the hospital outpatient clinic. The study group consisted of 47 heart failure patients (14 women) with following characteristics: average age 68 years, average BMI 29.4, resynchronization therapy 21%, hypertension 69.8%, diabetes mellitus 25.6%, coronary artery disease 46.5%, dilated cardiomyopathy 46.5%, obesity 46.5%, smoking history 39.5% (present and past smoking together), other cardiac disease 16.28%, condition after myocardial infarction 27.8% (NYHA II 41%, NYHA III 56.8%, NYHA IV 2.2%). The greatest problems were in the area of physical activity, sleep and fatigue, the least were in the area of chest pain and blood circulation. The greatest self-care agency was shown in the area of managing problems with physical activities and sleep, the lowest in the area of liquid intake and output. In the patients' subjective opinion, fatigue and sleep problems had the greatest impact on the quality of life. There were no substantial differences in either area based on gender. The data can serve as a foundation for modifying the extent and structure of patient education for more comprehensive and more effective out‑patient treatment of HF.

The Kennedy Krieger Independence Scales-Spina Bifida Version: a measure of executive components of self-management.

Successful implementation of functional self-care skills depends upon adequate executive functioning; however, many scales assessing adaptive skills do not address the inherent executive burden of these tasks. This omission is especially relevant for individuals with spina bifida, for whom medical self-care tasks impose a significant burden requiring initiation and prospective memory. The Kennedy Krieger Independence Scales-Spina Bifida Version (KKIS-SB) is a caregiver-reported measure designed to address this gap; it assesses skills for managing both typical and spina bifida-related daily self-care demands, with a focus on the timely and independent initiation of adaptive skills. Parents of 100 youth and young adults with spina bifida completed the KKIS-SB. Exploratory factor analysis and Pearson's correlations were used to assess the factor structure, reliability, and construct validity of the KKIS-SB. The scale demonstrates excellent internal consistency (Cronbach's alpha = .891). Exploratory factor analysis yielded four factors, explaining 65.1% of the total variance. Two primary subscales were created, initiation of routines and prospective memory, which provide meaningful clinical information regarding management of a variety of typical (e.g., get up on time, complete daily hygiene routines on time) and spina bifida-specific self-care tasks (e.g., begin self-catheterization on time, perform self-examination for pressure sores). Based upon internal consistency estimates and correlations with measures of similar constructs, initial data suggest good preliminary reliability and validity of the KKIS-SB.

The Influence of Social Environmental Factors on Rehospitalization Among Patients Receiving Home Health Care Services

Guided by Orem's theory, this study examined the influence of social environmental factors on rehospitalization among home health care patients. Living arrangement, frequency of caregiving, and type of primary informal care were found to be related to functional ability. Measurable differences in clinical status and functional ability were related to the duration that patients received home health care services until rehospitalization, with the likelihood of rehospitalization increasing proportionately to the magnitude of the differences. Social environmental factors contributed to rehospitalization (self-care deficit) through functional ability (self-care agency) by altering the balance between self-care demand (clinical status) and self-care agency.

Cumulative complexity: a functional, patient-centered model of patient complexity can improve research and practice

ObjectiveTo design a functional, patient-centered model of patient complexity with practical applicability to analytic design and clinical practice. Existing literature on patient complexity has mainly identified its components descriptively and in isolation, lacking clarity as to their combined functions in disrupting care or to how complexity changes over time. Study Design and SettingThe authors developed a cumulative complexity model, which integrates existing literature and emphasizes how clinical and social factors accumulate and interact to complicate patient care. A narrative literature review is used to explicate the model. ResultsThe model emphasizes a core, patient-level mechanism whereby complicating factors impact care and outcomes: the balance between patient workload of demands and patient capacity to address demands. Workload encompasses the demands on the patient's time and energy, including demands of treatment, self-care, and life in general. Capacity concerns ability to handle work (e.g., functional morbidity, financial/social resources, literacy). Workload-capacity imbalances comprise the mechanism driving patient complexity. Treatment and illness burdens serve as feedback loops, linking negative outcomes to further imbalances, such that complexity may accumulate over time. ConclusionWith its components largely supported by existing literature, the model has implications for analytic design, clinical epidemiology, and clinical practice.

Voices From the Shadows

Breast cancer survivors with lymphedema face a lifetime of stressful physical and emotional symptoms and challenging self-care demands. An in-depth understanding of the perceptions and feelings surrounding life with lymphedema is critical to developing effective supportive care approaches. The objective of the study was to explore perceptions and feelings related to lymphedema in breast cancer survivors. The expressive writings of 39 individuals were evaluated for this descriptive qualitative study. Data were analyzed using conventional content analysis. Qualitative analyses produced 4 major themes: (1) marginalization and minimization, (2) multiplying losses, (3) yearning to return to normal, and (4) uplifting resources. Subthemes for each major theme were also identified. The lymphedema experiences of breast cancer survivors reveal perceptions of marginalization from healthcare providers who are not well informed about lymphedema management and minimizing its impact. Multiple distressing losses confront these patients on a daily basis, including body image disturbances, loss of functionality and control over time, permanent uncertainty, and adverse effects on relationships. The daily challenges of lymphedema often result in cumulative frustration and resentment that contribute to failure to perform self-care. Normalcy has been lost, never to return. These women find solace, encouragement, and hope to meet the challenges of lymphedema through support from others and their spiritual beliefs. Healthcare providers need greater awareness of the physical and psychosocial effects of lymphedema in breast cancer survivors. Nurses have unique opportunities to serve as advocates for reducing perceived marginalization and promoting effective self-care and other activities that promote psychological well-being and reduce physical deterioration.

Nursing process as a strategy in the development of competence for self-care

OBJECTIVE: To investigate the contribution of clinical care and education of nursing in a hospital context, in the development of competence for self-care for people with chronic renal failure. METHODS: A case study conducted with a patient during hospitalization in Fortaleza, through the nursing process proposed by Orem determining deficiencies and enabling self-care demands satisfaction from him. RESULTS: The requisites of therapeutic self-care d.emands of health deviation sef-care requisites enabled the identification of three nursing diagnoses based on the North American Nursing Diagnosis Association - NANDA for which interventions were defined based on NIC and results according to NOC. CONCLUSION: In the hospital context, clinical and educational nursing care based on the nursing process proposed by Orem contributes as a facilitator for the development of competence for self-care in people with chronic disease.

Overwhelmed Patients

OBJECTIVEPatients with diabetes may experience high burden of treatment (BOT), including treatment-related effects and self-care demands. We examined whether patients with type 2 diabetes and their clinicians discuss BOT, the characteristics of their discussions, and their attempts to address BOT during visits.RESEARCH DESIGN AND METHODSTwo coders independently reviewed videos of 46 primary care visits obtained during a practice-based trial and identified utterances concerning BOT, classifying them by topic and by whether BOT was addressed (i.e., whether statements emerged aimed at alleviating BOT).RESULTSOf the 46 visits, 43 (93.5%) contained BOT discussions. Both coders identified 83 discussions: 12 involving monitoring, 28 treatment administration, 19 access, and 24 treatment effects. BOT was unambiguously addressed only 30% of the time.CONCLUSIONSBOT discussions usually arise during visits but rarely beget problem-solving efforts. These discussions represent missed opportunities for reducing treatment-related disruptions in the lives of patients with diabetes, which may affect adherence and well-being.

An emic view of caring for self: Grandmothers who care for children of mothers with substance use disorders

In the US more than 3.4 million children live with a mother who has a substance abuse disorder (SUD) and at some time in their life will be cared for by a grandmother. Most studies have focused on the economic, physical and emotional burdens of the conflated role of mother/grandmother. This study explores how 11 grandmothers cared for themselves while caring for the children of mothers with SUDs. The domain of inquiry was the self-care practices of grandmothers from an emic (generic) view. An assumption of the study was that the grandmothers represent a unique sub culture of women with particular beliefs, values and practices. An ethnographic approach was used to collect data from observations, in-depth interviews, and participant observation in various community settings. Patterns and themes revealed relational aspects of caring for self focused on the emic beliefs of self-care. The themes of being obligated and dedicated; distancing oneself as a reasoned action; and accepting the magnitude of the problem clearly identified the ability of grandmothers to take actions and make decisions about how to care for themselves. Leininger’s three modes of care are represented in a schema of the emic view of caring for self. The schema is an illustration of the dynamic capacity of grandmothers to know and meet their own self-care demands and needs in order to care for their grandchildren. The need for increased awareness to change public policy and legislation related to the complex issues of caregiving by grandparents is addressed.

Abstract P194: Depression Screening in Heart Failure: Preliminary Clinical Trial Results

Purpose: To explore factors contributing to depression identified by patients and mental health nurse specialists. Background: Heart failure incidence approaches 10 per 1,000 Americans after age 65 years. Nearly half of all patients with heart failure experience depression, an independent risk factor for increased cardiovascular morbidity and mortality. Methods: Patients with heart failure ( n = 175; mean age = 63.1 years, SD = 13; range age 25-over 89 years) were screened for depression, using the PHQ-9 and CESD. Mental health clinical nurse specialist referrals were made based on a combination of questionnaire scores (i.e., moderate to severe depression) and patient narratives, including expressed feelings of depression, loneliness, sadness, or suicidal thoughts. Content analysis research methods were used to categorize patient and mental health nurse specialist consultation narratives and identify factors contributing to depression. Results: Using the PHQ-9 and CESD screening questionnaires, 75 (43%) patients reported having felt depressed during the previous month, resulting in 47 (27%) patient referrals to the mental health clinical nurse specialist. Patients most often reported depressive symptoms due to complex illness care, loss of independence or function, self-care demands, financial concerns, and life stressors. The advanced practice mental health nurse consultations revealed patients most often experienced fatigue and insomnia, grief and situational depression, anger, and regret reactions. Patients were more likely to disclose mental health illnesses, domestic and family issues, and illicit substance use to the mental health clinical nurse specialist than to investigators administering the PHQ-9 and CESD. Implications: Exploring patient and expert mental health nurse narratives identified unique contributing factors of depression in heart failure, which warrant further study. The mental health clinical nurse specialist determined whether patients experienced grief responses or depression, an important distinguishing factor in screening for depression, with implications for research and clinical practice.

Motivation and diabetes self-management

To examine the relationship between autonomous motivation and diabetes self-care activities among individuals with diabetes. Seventy-seven individuals recruited from outpatient clinic registries (64% female, 77% Caucasian, mean age 63 years) completed measures of diabetes-related self-care (Summary of Diabetes Self-care Activities), motivation (Treatment Self-regulation Questionnaire), health literacy (Rapid Estimate of Adult Literacy in Medicine, Newest Vital Sign), health (SF-36v2), social support (Social Support Survey) and self-efficacy (Perceived Competence Scale). Autonomous motivation was the only variable significantly associated with maintaining diet (p<0.0001) and blood glucose testing (p<0.04) in regression analyses. No significant associations were identified for exercise. The variable of age approached significance (p = 0.06), with older individuals being less likely to have exercised in the past week. Individuals in this study had difficulty in maintaining self-care demands, especially exercise. Meeting recommended levels of self-care activity was challenging, even for patients with adequate levels of health literacy. Individuals with higher levels of autonomous motivation reported higher frequencies for maintaining diet and testing blood glucose, however, which supports the utility of Self-Determination Theory in promoting diabetes self-care.

Fallstudie: Praktische Anwendung der Selbstpflegedefizit-Theorie bei einem Patienten mit neuroendokrinem Karzinom des Duodenums

This case describes the nursing care of a 66-year-old electively admitted patient who came to hospital for the treatment of a hepatic secondary neuroendocrine duodenum cancer. A typical liver resection with duodeno-pancreatectomy and sigmaresection was performed. Complications led to more than ten re-laparatomies with resection of the stomach and oesophagus. It was necessary to perform blind occlusion of the jejunum and the disposition of an oesophagus stoma. A diabetes mellitus was caused by the total resection of the pancreas. Mister B. got a percutaneous endoscope jejunostomy but it could not be used because of a new small intestine fistula into the abdominal cavity wherefore a port was implanted. The following different conceptions of the self-care deficit theory have been used to describe and analyse the patient situation as follows: Basic conditioning factors, self-care requisites, therapeutic self-care demands, self-care competence. The future self-management capabilities consist of the following: Care of the oesophagus stoma, care of the percutaneous endoscope jejunostomy, management of the diabetes mellitus, coping with the changed self-image, coping with the restriction of movement and with the needed prophylaxis. Support was given by the transfer of knowledge to the patient. Instructions were given during realisations of new activities and development of skills. It was evaluated if the patient is capable to reflect his actions and to assess if he is able to react on deviations from the normal standards in a correct and appropriate way. After dismissal it was secured by phone call that the patient successfully manages the new self-care demands independently.

Experiences of Living in a Disrupted Situation as Partner to a Man With Testicular Cancer

New knowledge has been gained about how close relatives reorient themselves and handle their life situation when facing close relatives' illness. The aim of this study was to describe and elucidate narrated experiences of living in a disrupted situation as partner to a patient with testicular cancer. A qualitative single-case design with a conversational interview using a semistructured guide with open-ended questions was implemented. A young woman whose partner had testicular cancer with metastases was interviewed. Narrative analysis of the data with focus on corporeality, spatiality, temporality, and communality revealed three themes that reflected the woman's concerns in different existential dimensions: the limitless self-care, the restricted space, and the shortness of time. The findings may facilitate caregivers' awareness of actual and potential self-care demands of both patients and significant others and can be used in developing structured strategies in helping close relatives to cope and manage as caregivers.

Developing a Nurse-Led Education Program to Enhance Self-Care Agency in Leg Ulcer Patients

Patients with leg ulceration face changing self-care demands associated with the consequences of the disease and treatment. Often patients can manage their self-care for some time, but new therapeutic self-care demands may emerge that require more complex self-care actions. The purpose of this article is to describe the development of a nurse-led education program in North-Rhine Westphalia, Germany, that aims to help patients with leg ulcers to meet their therapeutic self-care demands. Orem's self-care deficit nursing theory is used as a framework to provide the conceptual context for this supportive-educative nursing system that is being tested in a multi-site clinical trial.

Spanish Translation and Validation of the Preschool Activity Card Sort

Few standardized assessments exist for children living in the United States who are Hispanic/Latino. This study reports the Spanish translation process for the Preschool Activity Card Sort (PACS), which is a measure of participation in preschool children, and examines content, construct, and concurrent validity. Methods of verifying accuracy of translation included expert review and back translation and supported content validity of the Tarjetas de Actividades Preescolares (TAP). Subsequently, a sample of 37 parents of children between 3 and 6 years of age completed the PACS/TAP by structured interview. Twenty-six parents were Spanish speaking, and 11 were English speaking. A comparison of reported participation by Spanish- and English-speaking children provides initial construct validity of the TAP. Results indicate that the TAP differentiates among children of recent immigrants as compared to preschoolers who were born in the United States on domains of self-care, high and low demand leisure, and educational activities. Results emphasize the importance of considering sociocultural influences when assessing participation. PACS/TAP scores were moderately correlated with Pediatric Evaluation of Disability Inventory scores for the self-care domain, but did not correlate with the mobility or social function domains. The PACS/TAP appears to provide a useful means of understanding preschoolers' participation. Future research is needed to further establish the validity of this assessment.

Mothers' perceptions of self-care in school-age children with diabetes.

To describe mothers' perceptions of the diabetes-related self-care abilities and practices of their school-age children with Type 1 diabetes. Qualitative study using the naturalistic inquiry method. Mothers of school-age children with diabetes were interviewed by means of a semi-structured interview guide. The children were between the ages of 11 and 12 and had been diagnosed with diabetes for a minimum of 2 years. Twelve mothers were interviewed, generating 20 hours of qualitative data. Mothers reported that their children with diabetes had learned skills in a predictable sequence, were usually motivated by events in the here and now, and did not consistently perform all diabetes-related skills of which they were capable. Most of the children were becoming embarrassed about having diabetes. There were considerable gender differences in the children's self-care development. Nurses can use this study to help with anticipatory guidance for parents. It may be helpful for parents to know the sequence in which many children learn diabetes-related skills, and to learn that even though a child is capable of task performance, he or she may not necessarily be ready for the independent practice or daily execution of the skill. Encouraging parents to stay involved with their children's self-care practices past the early adolescent years may be effective in improving self-care practices, and helping children to identify reasons to meet the self-care demands associated with diabetes can be beneficial.