self-care activity as a structure

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SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY 2000;7:183 189

Self-care Activity as a Structure: A Phenomenological Approach

OLLE SO DERHAMN

From the Department of Nursing , Trollhattan :Udde alla Uni ersity , Vanersborg , Sweden

Soderhamn O. Self -care acti ity as a structure : a phenomenological approach . Scand J Occup Ther 2000; 7:183189.

Self-care activity is traditionally viewed as a goal directed activity with the aim to maintain, restore orimprove health and well-being. However, it should be possible to situate the phenomenon of self-care withinan alternative paradigm and get a new understanding of it in terms of phenomenological knowledge. Thepurpose of this article was to analyse the notion of self-care activity and elaborate it within a phenomeno-logical frame of reference based on the philosophy of Merleau-Ponty. Using arguments from analyticalphilosophy, especially action theory, and Orems self-care decit theory, some self-care related concepts haverst been elucidated. In order to get another understanding of self-care activity, certain parts of the writingsof Merleau-Ponty were then applied to the phenomenon. It was stated that there is a dialectical relationbetween self-care ability as potentiality for self-care activity and self-care activity itself. Both may beregarded as structures given only to perception. Self-care ability is not in-itself a necessary means tomaintain, restore or improve health and well-being but rather the potentiality for self-care activity as anintegral part of the lived body. The actualization of the ability for self-care may possibly come aboutthrough a certain meaning. Key words : phenomenology , self -care ability , self -care agency .

INTRODUCTION

There is a growing interest within the domain of caring science and health philosophy to explore andinvestigate central phenomena from a phenomenolog-ical point of view [1, 2]. However, self-care is ahealth-related concept that has not been given muchattention among phenomenologically oriented scien-tists. But it should be possible to get a new under-

standing of the phenomenon of self-care activity bydrawing inspiration from the phenomenology of theFrench philosopher Maurice Merleau-Ponty and hisview on the body [3].

According to Merleau-Ponty, the phenomenologi-cal project does not begin with a pure constitutingconsciousness but with a lived body engaged andcaught up in a world of meaning. The body is funda-mentally ambiguous. It is neither subject nor objectin a traditional sense. Merleau-Ponty rejects the ideaof a pure consciousness and maintains that an ego is

always an embodied ego that is both constituting andconstituted [2, 3].

Self-care is traditionally considered as a multi-di-mensional concept, which can be given different in-terpretations. Orem [4] views self-care as an activityof mature and maturing persons who have developedthe abilities to take care of themselves in their envi-ronmental situations. It is the practice of activitiesthat individuals initiate and do on their own behalf inmaintaining health and well-being. When performedeffectively, it contributes to human structural in-

tegrity, human functioning and human development.Self-care behaviour consists of the individuals im-

mediate and continuing behavioural reactions to ill-

ness, the basic coping strategies, and steps taken topreserve and maintain personal health. Initiativestaken by the individuals on behalf of their own healthencompass preventive healthcare as well as be-havioural and other health interventions. Basic dailyhealth maintenance behaviour, e.g. good nutritionand dental hygiene, recognition and interpretation of symptoms, interaction with social support networksand the healthcare system are cornerstones in self-care behaviour. This view includes taking an assertiverole in healthcare decision-making, self-treatment,compliance and health education [5].

In nursing science, the phenomenon of self-care hasmainly been addressed within the traditional man-en-vironment totality paradigm [6], where Orems con-ceptualizations [4, 7, 8] have been of great value. Onecentral phenomenon in her self-care decit theory isself-care agency, which is the power to assess, decideand perform self-care activities [4]. This specicpower, self-care ability, may be conceptualized aspotentiality and considered as a necessary conditionfor self-care activities. When self-care ability is exer-cised, the result is self-care actions.

It should be possible to situate the phenomenon of self-care within an alternative paradigm and get anunderstanding of it in terms of phenomenologicalknowledge. In one phenomenological study, per-formed among elderly Swedish people, an eideticstructure of self-care ability was found that was two-fold. It entailed (i) being present to the opportunityto act on certain perceived inuences on the body and

(ii) alone or with the support from somebody else tobe able to bring about a change in attitude towardsones personal lifestyle or life situation. The meaning

2000 Taylor & Francis. ISSN 1103-8128


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of actualizing this self-care ability was interpreted asself-realization or self-transcendence [9]. These nd-ings suggest that it should be meaningful to recon-sider the traditional view on self-care and elaboratethe phenomenon phenomenologically as a body-re-lated phenomenon.

The purpose of this article was to analyse the

notion of self-care activity and elaborate it within aphenomenological frame of reference based on thephilosophy of Merleau-Ponty.

SELF-CARE VIEWED IN THE TRADITIONALPARADIGMSelf -care acti itySelf-care activity may be considered to be a goaldirected activity with the aim to maintain, restore orimprove health and well-being. The notion of self-care activity has been addressed by Orem [4, 7, 8],who in her work also introduced the concept of self-care agency. Human beings are viewed as needingcontinuous self-maintenance and self-regulationthrough a type of action called self-care. This meanscare that is performed by oneself for oneself whenone has reached a state of maturity that enablesconsistent, controlled, purposeful and effective ac-tion. Self-care is a learned and goal-centred activityof individuals. In the self-care decit theory, two of the core concepts are the patient variables therapeuticself-care demand and self-care agency [4].

Therapeutic self-care demand stands for a summa-tion of measures of self-care required by individualsto meet self-care requisites in relation to their condi-tions and circumstances. The conceptualization ismodelled on deliberate action. The self-care requisitecomponent consists of purposes or goals to beachieved. Self-care requisites can be met throughmethods and technologies, and together with theself-care agency component they form the course of action. Self-care agency is the complex developedability that enables adults and maturing adolescents

to see and understand factors that must be controlledor managed in order to regulate their own function-ing and development as well as the ability to decideabout and perform proper care measures [4].

Self-care agency develops in everyday life throughthe spontaneous process of learning. Its developmentis aided by intellectual curiosity, by instruction andsupervision from other persons. The developmentand operability can be affected by genetic and consti-tutional factors, culture, life experiences and health-state. Self-care agency contains three broadconceptual elements: (i) the ability to engage in twospecic types of action called estimative and produc-tive operations of self-care; (ii) estimative operations

of self-care; (iii) productive operations of self-care.No one of these three can stand in isolation from theothers. The second and third elements specify thetype of action and make the rst element a specicpower. Estimative operations of individuals are ac-tion systems performed with a goal of determiningwhat is to be done with respect to self-care, and

productive operations are performed with the goal of meeting existing and known self-care requirements [7,8].

Self-care agency has the nature of an action reper-toire. Estimative and productive operations focus ondifferent but related types of action systems withdifferent goal orientations. In the estimative opera-tions the way of acting is that of investigation orinquiry, i.e. to determine what is to be done withrespect to self-care. In the productive operations theway of acting is that of regulation, and the actionsare performed with the goal of meeting existing andknown self-care requirements using particular tech-nologies. The transition from estimative to produc-tive type operations is effected by the individualsdecision about what will be done. In self-care opera-tions of the transitional type, the individual is reect-ing in order to determine which course of self-careshould be followed and deciding what to do withrespect to self-care [4].

Orems theory [4, 7, 8] is rooted in empiricism [10]and may possibly be connected to a Cartesian frame-work, where the components of self-care activity can

be considered as external to each other and, at leastto some extent, bound together by relations of causality.

Self -care acti ity and its teleological explanationIndividuals who can produce effective self-care haveknowledge about their environment and themselves.In their estimative operations the goal is to determinewhat is to be done with respect to self-care, and theknowledge extends to internal and external condi-

tions relevant to health and well-being, characteristicsof these conditions, the meaning of these conditionsto health and well-being, and the benecial or harm-ful results that will come about when one course of action is taken [4].

The estimative operations such as investigation andinquiry are productive actions [11]. The agent mustbe able to perform the cognitive act of investigationof factors relevant for self-care, i.e. he or she musthave sufcient internal resources for doing it, and theright opportunities must be obtained [12]. The personmust have some understanding of the meaning andvalue of self-care to make rational and reasonable judgements and decisions. Knowledge, level of matu-


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rity, life experience, habits of thought, and health-state all inuence this understanding [4]. Wants maybe reasons [13] for estimative operations.

Following the estimative operations in time are theself-care operations of the transitional type, i.e. theagents determination which course of self-careshould be followed, and deciding what to do with

respect to self-care [4, 5]. In the transitional type of self-care operations, the agent sets himself to do theaction. Wants may also here be important reasons foraction [13]. This type of action leads up to the actionintended [14], i.e. self-care operations of the produc-tive type. Tacitly, and probably sometimes uncon-sciously, formulated norms may be relevant reasonsfor action.

The choice made sets the goal for the productionoperations, and the agent decides what he must do [4]in accordance with his wants [13] and actualizes hispower for self-care. Self-care activity is intended bythe agent, and the components of self-care agency,i.e. estimative, transitional, and productive self-careoperations, are all intended. Wants to maintain, re-store or improve health and well-being must be re-garded as reasons for self-care activity.

The explanation of self-care activity for the agent(a ) may be expressed as a practical syllogism, wherethe rst premise reects a want to maintain, restoreor improve health and well-being ( q ) and the secondpremise a statement of means to an end comprised of the components of self-care agency ( p):

a wants q.

Unless a does p, he will not get q.

thus: a must do p.

The agent must do self-care operations of theestimative, transitional, and productive type in orderto be able to perform self-care activity and reach thegoal, i.e. to maintain, restore or improve health andwell-being. It is likely that there is a causal relation-ship between the components of self-care agency and

health and well-being.There is, however, some ambiguity in the conceptof self-care agency, since it consists of both abilityand activity. This can be handled by considering it asa productive means in the case when the componentsof self-care agency produce the state of affairs, i.e.health and well-being, and as a necessary means whenthe production of health and well-being requires thedoing of the components of self-care agency [14].Examples of productive means are for instance whenthe agent takes measures to maintain sanitary condi-tions in his or her environment, maintains his or herbody weight at an appropriate level or gets enoughsleep. Necessary means are, for example, when the

agent has sufcient energy to care for him or herself in an appropriate way or when he or she is able to getthe information needed when his or her health isthreatened.

Potentiality and self -care ability

Aristotle, 384322 BC, used the concept of potential-ity. It is the capacity of an object to pass from onestate to another. For example, a man asleep is poten-tially a man awake. Generally speaking this conceptmeans that A can change to B because some condi-tions of B-ness are already inherent in A [15]. In theNicomachean Ethics Aristotle said that ``of all thosefaculties with which nature endows us we rst acquirethe potentialities, and only later effect their actualiza-tion ([16], p. 91).

Potentiality is a necessary condition for explaininghow change occurs, but it can not by itself explainchange. The concept of actuality must also be in-voked. The actual is the realization of the potential,which can only be raised to the level of the actual bythe agency of something actual. If you look at anobject from a standpoint of its history the potentialpresupposes the actual, and in time the capacityprecedes the activity. However, if you look at it in theorder of thought, actuality is prior to potentiality.When considering the real nature of an object apartfrom its process of development one looks rst at theactuality which it embodies. The adult is philosophi-

cally prior to the embryo, and for Aristotle the acornis explained by the oak [15].

Self-care ability is the capacity to perform self-careactions with the goal to maintain, restore or improvehealth and well-being. Self-care ability is a necessarycondition for the realization of self-care activity andpresupposes it in time. Philosophically, however, self-care ability is explained by self-care activity and itsgoals, i.e. health and well-being.

Self -care ability based on the theory of health and adaptednessThe following construct of self-care ability [17], basedon the concept of adaptedness [18, 19], has beenformulated in order to get a tentative health relatednotion of the power for self-care that may be used inresearch and practice. It is grounded in the belief thathuman beings are rational, acting subjects, have theirown free will and can act in relation to themselvesand other individuals. Intuitively self-care ability ap-plies to grown up individuals.

It may be stipulated that, in the perspective of adaptedness, self-care ability can be considered as theindividuals capacity for care of self, where care is an


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action with the purpose to cause improvement, pre-vent a change for the worse, or to establish a good oran acceptable position in one or more positions in theeld of the welfare of the individual. For the actingsubject the capacity is the same as adaptedness. Fur-thermore, in the dynamics of the acting subject thethree basic factors, i.e. goal, environment and reper-

toire, are central to what may be called self. We nowconsider self-care ability to be the capacity for care of adaptedness. Self-care ability is the individuals ca-pacity for care of the person in order to raise thispersons capacity or adaptedness. Adaptedness orcapacity can be assessed from a point of view of ameaningful life and current well-being. When self-care ability is exercised, self-care actions based onadaptedness are obtained [17].

If the different parts of the construct of self-careability are looked upon and discussed within anaction-theoretic frame of reference, the capacity forcare will rst be considered. The capacity consists of the three-dimensional notion of goal, environmentand repertoire. The goal is reected in the intentionsof the agent. Porn [13] has analysed the question of the nature of an intention and under what circum-stances the agent will or is likely to do that which heintends to do. These circumstances are together theenvironment in the three-dimensional notion of capacity.

The power of an agent to act lies in the fact that hecan do certain things and that he has certain abilities.

The repertoire dimension in the capacity for careconsists of certain abilities, which can be categorizedinto an act repertoire, a cognitive repertoire and adecision repertoire.

The agents abilities (repertoire) with a set of envi-ronmental circumstances constitutes a capacity that issufcient in order to realize a particular goal. Theabilities in question may be cathegorized as genericabilities, i.e. abilities that may be qualied by theconditions that usually occur in the agents environ-ment and also by requiring that the outcome is

important or signicant from the agents point of view. These qualications are important in the con-text of health [19].

The goal in this part of the structure consists of goals that are signicant for the agent. These goalsnormally comprise subgoals. The ability to realize agoal breaks up into the abilities to realize each one of the subgoals that make up the goal. The environmentis here the agents actual physical, psychosocial andcultural environment.

The operationalization of self-care ability as capac-ity for care of capacity can now be characterized bythe agents (i) intention to care for repertoire, envi-ronment and goals, and his or her (ii) abilities to care

for repertoire, environment and goals under prevail-ing circumstances. Repertoire, environment and goalsare relative and different for different groups of individuals [17].

SELF-CARE ACTIVITY VIEWED AS ASTRUCTURE

There is, in the analysis presented above, a more orless external relation between means and ends, andactivity is more or less considered as a series of eventsexternal to each other. Within an empirical frame-work, an approach of linear causality, i.e. of a me-chanical cause and effect approach with stimulus andresponse, could be applied to the phenomenon of self-care activity. However, by applying the phe-nomenological notion of the structure of behaviourto the analysis of self-care activity, another under-standing of the phenomenon than that outlinedabove may be achieved. Behaviour should then ratherbe regarded as a structure, given only to perception,and this structure is neither thing nor consciousness[20].

Self-care activity is a learned and goal-centred ac-tivity, and persons who can produce effective self-care have knowledge about their environments andthemselves [4]. To have knowledge is to have ac-quired it through learning, and to learn is to be ableto provide an adapted response to the situation bydifferent means. Learning is not a real operation in

space and time and it does not follow causalities, butit is characterized by a certain signication or mean-ing. The stimulus is not the one dened by thenatural sciences, the reaction is not a particular seriesof movements, and the connection between them isnot a simple series of events. The learning experiencemust have a general relevance. At the decisive mo-ment of learning, a ``now acquires a particular valueand transforms the singular situation of experienceinto a typical situation and the effective reaction intoa capacity. It has detached itself from the order of

in-itself and becomes the projection outside the subject of a possibility [20].In doing the estimative operations of self-care [4],

the person must have sufcient internal resources,and the right opportunities must obtain [12]. Investi-gation and inquiry may also be considered as aprocess of learning, and learning is a general alter-ation of behaviour manifested in a multitude of ac-tions [20]. Wants are important reasons for action[13], and the actual wants must have a certain mean-ing in the self-care operations of the estimative type.

Following the estimative operations in time are thetransitional operations of self-care. The subject deter-mines what course of self-care should be followed [4,


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7, 8] and sets himself to do the action [13]. Whenconsidering self-care activity as a structure, it doesnot unfold in objective time and space like a series of physical events. To determine what course of self-carethat should be taken, the subject is reecting aboutthe situation and uses the knowledge that has beenacquired by learning, i.e. he exercises his knowledge

capacity. Just as in the case of estimative self-careoperations, wants may here be reasons for action [13],and these wants must have a certain signication.

The transitional operations lead up to the actionsintended [14], i.e. the productive operations of self-care. Reasons for this type of actions, i.e. both normsand wants, may also have a certain signication. Itshould also be possible to classify productive self-careoperations as behaviour at the level of symbolicforms. The structure is so detached from the condi-tions that it can be the proper theme of consciousness[20]. Norms about health and well-being given assymbolic signs, in verbal and non-verbal language,from people in the social environment are mediatedand make possible the execution of productive self-care operations. Like a person who ``knows how toexecute a certain action, most people who havereached a certain level of maturity are able to impro-vise and perform necessary self-care operations inaccordance with actual self-care needs.

To look at self-care activity as estimative, transi-tional, and productive operations of self-care as threeexternal parts that follow each other in a time se-

quence [4] is a Cartesian approach not consistent withphenomenological thought. By applying Merleau-Pontys conclusions regarding the forms of behaviour[20] on self-care activity, it i s possible to state thatself-care activity does not belong to the order of things as a series of physical events, nor to the levelof consciousness as a series of ideas. In other words,it is possible to state that self-care activity is notin-itself and not for-itself, and it is not directed to thetrue objective world. It is not primarily guided byknowledge but rather through the discrimination of a

situation. Like other behaviour, self-care activity isintentional. It is directed to the situation of thehuman subject, and it is a way of being-in-the-world.

When regarding self-care activity as estimative,transitional, and productive operations of self-care[4], we can also refer to Husserls theory of meaning,wherein he distinguishes between signifying acts, ful-lling acts and identifying acts [21]. Mohanty [22] hasoutlined Husserls theory of meaning arguing thatthis theory is an attempt to take into account themany facets of our experience of and commerce withmeanings, without invoking metaphysical and episte-mological preconceptions. In the theory, meaningsare seen as ideal entities. Meanings can be character-

ized by a sort of identity and contextual indepen-dence, and as ideal objects they can be sharedinter-subjectively so that it is legitimate to say thatthey are objective. Meanings are immanent and standinternally related to thought, feeling and intentions of the person who is participating in them.

In the estimative operations of self-care, conscious-

ness is oriented towards the world (signifying acts of consciousness). The object is meant, and it is emptilypresent [23]. In self-care operations of the transitionaltype, the subject is reecting on which course of self-care should be followed and deciding what to dowith respect to self-care [4]. This is a fullling act of consciousness where the person recognizes self-careactions that are adequate with respect to his or herself-care needs. When exactly the right self-care activ-ity is ``found that matches the actual self-care needs,there is an identifying act, which afrms that thefulllments meet the criteria of meaning as expressedby the signifying act [23]. Merleau-Ponty [24] doesnot look upon signifying acts and fullling acts asseparate entities but rather as a temporal process of determinate intention, i.e. attention.

In a study by Persson [25], womens motivation toperform breast self-examination was investigated.The results showed, among other things, that womenneglected to examine their breasts because of fear of discovering a lump, which could be cancer. Thissuggests that self-care activity is a certain way of treating the world, i.e. a way of being-in-the-world.

Norms saying that breast cancer is a life threateningcondition and that breast self-examination is an easyway to nd a tumour may not be a sufcient reasonfor some people to perform such an examination.Here we can see that self-care activity is not primarilyguided by knowledge and that it is difcult to dis-criminate a dangerous and life threatening situation,when this situation does not exist in the objectiveworld. The risk of getting cancer is not more than just a risk in the real world. The actualization of theability for self-care may possibly come about through

a certain meaning.The variables upon which a conduct depends aswell as the conduct itself is a relation of meaning, i.e.an intrinsic relation [20], and between self-care abilityand self-care activity there must be such a relation of meaning. It may be possible that the actualization of a persons self-care ability into self-care activity isdetermined by this meaning.

The parts of self-care ability, i.e. wants for care of repertoire :goal :environment and repertoire for careof repertoire :goal :environment cannot be consideredas ``partes extra partes but rather as constituents ina structure of self-care ability. In the three-dimen-sional notion of adaptedness [19] used in the concep-


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tualization of self-care ability above, a structure isalready implied. However, it may be argued that alinear causality between self-care ability and self-careactivity seems inherent in the concept. But i t shouldalso be possible to see the person in a given environ-ment as an individual with his or her optimal condi-tions of self-care activity given by a general attitude

towards the world. The relations of that person andthe environment are dialectical relations that bringabout new relations in the structure of repertoire,goal and environment. The same is possible betweenthe person and the goals and the repertoire, respec-tively, and a kind of circular causality is obtained.

If self-care ability is considered as potentiality forself-care activity, we base the possible in the actual,that is what I want (goal) and what I can (repertoire)under prevailing circumstances for the care of reper-toire, goal and environment. This capacity must be

within my body. Merleau-Ponty [24] distinguishesbetween the body as object and the body as lived. Byapplying the notion of the lived body we can elabo-rate self-care ability in the following way.

A person has a certain degree of self-care ability.He wants and he can, for example, in a satisfying waymaintain his personal hygiene. He knows the neces-sary procedures when he gets out of bed in themorning and steps into the shower, and certain inten-tional threads link him to the soap, the water taps,and the water stream given. The body as the poten-tiality of a part of the world ``surges towards objectsto be grasped and perceives them [24, p. 106].

He is his body, and his body is a potentiality of acertain world. The body is available not only in realsituations into which it is drawn. It can turn asidefrom the world and take its place in the realm of thepotential. The body understands its world. When theperson has the goals and repertoire to care for reper-toire, goal and environment, self-care ability is notin-itself a necessary means to maintain, restore orimprove health and well-being but has rather becomethe potentiality for self-care activity as an integralpart of his body.

A dialectical relation between self-care ability aspotentiality and self-care activity as the actualizationof this potentiality can be considered both in anAristotelian view, where the actuality is prior to thepotentiality, and in a view of circular causality. Toregard both self-care ability and self-care activity asconstituents of one structure of general self-care re-veals a situation that seems relevant. When doingself-care activities, the perceived efcacy of doingsuch activities is supported and an enhanced self-careability may inuence the self-care activities positively.

CONCLUSIONS

In conclusion, the components of self-care agency, i.e.estimative, transitional and productive self-care oper-ations, are all intended actions. Estimative operationsof self-care are productive actions, where the agentmust have sufcient internal resources and the rightopportunities must be obtained. Reasons for this type

of action may be wants. In the self-care operations of the transitional type the agent decides what course of action should be taken and sets himself to do theaction, where the reasons for action may be wantsand norms. This type of action leads up to theproductive operations of self-care. The agent decideswhat he must do and then actualizes his potential forself-care in accordance with his wants. It is likely thatthere is a causal relationship between the componentsof self-care agency and health and well-being. Self-care agency is a productive means when its compo-

nents produce health and well-being, and a necessarymeans when the production of health and well-beingrequires the performance of the components of self-care agency. Wants to maintain, restore or improvehealth and well-being may be reasons for self-careactivity.

Using phenomenological philosophy, it could beclaimed that there is a dialectical relation betweenself-care ability as potentiality for self-care activityand self-care activity itself. Both may be regarded asstructures given only to perception. Self-care ability isnot in-itself a necessary means to maintain, restore orimprove health and well-being but rather the poten-tiality for self-care activity as an integral part of thelived body. The actualization of the ability for self-care may possibly come about through a certainmeaning.

ACKNOWLEDGMENTS

Substantial parts of this article have previously been pub-lished in Soderhamn O. Potential for self-care. Assessingand describing self-care ability among elderly people. Dis-

sertation. Linkoping: Department of Medicine and Care,Division of Nursing Science, Faculty of Health Sciences,Linkoping University, 1998.

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25. Persson K. Breast self-examination. Licentiate thesis.Linkoping: Department of Caring Sciences, LinkopingUniversity, 1996.

Accepted September 15, 2000

Address for correspondence :Olle Soderhamn, PhDDepartment of NursingTrollhattan :Uddevalla UniversityP.O. Box 1236SE-462 28 VanersborgSwedenTel: 46 521 26 42 03Fax: 46 521 26 42 99

self-care activity as a structure

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