Middle-Range Theory of Self-Care of Chronic Illness: 2025 Update Summary and Key Takeaways
Self-care is one of the most important ideas in chronic illness management. For people living with long-term conditions, health is not only shaped by hospital appointments, prescriptions, investigations or clinical reviews. It is also shaped by the small decisions made every day: taking medicines correctly, noticing symptoms, pacing activity, resting when needed, eating in a supportive way, asking for help early and knowing when something has changed.
The article “An Update to the Middle-Range Theory of Self-Care of Chronic Illness” by Barbara Riegel, Tiny Jaarsma and Anna Strömberg provides an updated explanation of how self-care works for people living with chronic illness. The theory was first published in 2012, then revised in 2019 to integrate symptoms more clearly, and updated again to reflect how self-care is now understood in research and clinical practice. The updated theory continues to centre on three core behaviours: self-care maintenance, self-care monitoring and self-care management. (PubMed)
For a more focused overview of the Middle-Range Theory of Self-Care of Chronic Illness, it is useful to understand the theory as a practical framework for how people preserve health, detect changes and respond to symptoms.
What is the Middle-Range Theory of Self-Care of Chronic Illness?
The Middle-Range Theory of Self-Care of Chronic Illness explains self-care as a process used by people with long-term conditions to maintain health and manage illness. It is called a “middle-range” theory because it is not so broad that it becomes abstract, but not so narrow that it applies to only one disease. It can be used across many chronic illnesses, including heart failure, diabetes, chronic obstructive pulmonary disease, kidney disease, cancer survivorship and multimorbidity.
The theory is especially relevant because chronic illness often requires ongoing decisions outside the clinic. A person may only see a doctor or nurse occasionally, but they live with the condition every day. This means that much of chronic illness care happens at home, at work, during family life and in ordinary routines.
The updated theory helps explain why self-care is not simply “following advice”. It is a complex process involving knowledge, skill, judgement, motivation and reflection.
The three main parts of chronic illness self-care
The updated theory is organised around three central concepts: self-care maintenance, self-care monitoring and self-care management. These are separate ideas, but in real life they overlap.
1. Self-care maintenance
Self-care maintenance refers to the behaviours people use to preserve health, maintain stability and support wellbeing. These are the regular actions that help a person live as well as possible with a chronic condition.
Examples may include taking medication, attending appointments, eating appropriately, staying active within safe limits, avoiding triggers, sleeping well, reducing risk factors, keeping vaccinations up to date and following agreed care plans.
Importantly, the updated theory describes self-care maintenance as more than just preventing deterioration. It includes actions that maintain physical and emotional stability. This is significant because chronic illness affects mood, energy, confidence, relationships and identity, not only the body. (University Medical Center Utrecht)
For example, someone with heart failure might weigh themselves regularly, take medication and limit salt intake. Someone with diabetes might monitor glucose, plan meals and recognise hypoglycaemia. Someone with COPD might use inhalers correctly, pace activity and follow an exacerbation plan. These are all maintenance behaviours because they support day-to-day stability.
2. Self-care monitoring
Self-care monitoring means watching for changes. This includes noticing symptoms, measuring signs, listening to the body and recognising when something is different from normal.
Monitoring can involve formal measurements, such as blood pressure, peak flow, blood glucose, weight or oxygen saturation. It can also involve bodily awareness, such as noticing breathlessness, swelling, fatigue, pain, dizziness, mood changes or reduced appetite.
This part of the theory is crucial because chronic illnesses often fluctuate. A person may feel stable one week and worse the next. Symptoms may come on gradually, and early recognition can make a major difference to outcomes.
The 2019 revision to the theory was important because it integrated symptoms more clearly into self-care maintenance, monitoring and management. The updated article continues this direction by emphasising symptom detection, interpretation and response. (PubMed)
In simple terms, monitoring is the “noticing” stage. It is the point where a person asks: “Is this normal for me, or is something changing?”
3. Self-care management
Self-care management is what happens after a person notices a sign or symptom. It involves interpreting the change, deciding what it means and taking action.
This action may be simple, such as resting, drinking fluids, using an inhaler, adjusting activity or following a written action plan. It may also involve contacting a GP, nurse, pharmacist, specialist team or emergency service.
Self-care management depends heavily on judgement. A person needs to know when a symptom is safe to monitor and when it requires help. This can be difficult, especially when symptoms are vague, frightening, new or similar to previous episodes.
For example, a patient with asthma may follow an asthma action plan when wheeze or breathlessness increases. A patient with heart failure may respond to sudden weight gain or ankle swelling by following agreed clinical advice. A patient with diabetes may treat low blood sugar quickly after recognising symptoms.
Management is therefore not just about action. It also includes interpretation, decision-making and evaluation.
The major update: six requirements for effective self-care
One of the most useful parts of the updated theory is its emphasis on six intrapersonal requirements for self-care. These are:
Experience, knowledge, skills, reflection, decision-making and motivation.
These six requirements explain why self-care is easier for some people than others, and why giving information alone is often not enough. A person might understand their condition but still struggle to manage it because they lack confidence, practical skills, motivation or support.
Experience
Experience matters because people learn self-care over time. Someone newly diagnosed with a chronic illness may not yet know what symptoms feel like, what triggers deterioration or what actions help. Over months or years, many people develop personal expertise.
This does not mean patients should be left to “figure it out” alone. It means healthcare professionals should recognise that self-care develops through practice, feedback and support.
Knowledge
Knowledge is essential. People need to understand their condition, medication, symptoms, warning signs and treatment plan. Without knowledge, it is difficult to make safe decisions.
However, the theory makes clear that knowledge alone is not enough. A person may know what they should do but still face barriers such as low confidence, poor health literacy, fatigue, depression, cost, lack of time or limited support.
Skills
Skills are the practical abilities needed to carry out self-care. These may include using an inhaler, checking blood glucose, monitoring blood pressure, taking medication correctly, using medical equipment, recording symptoms or communicating clearly with healthcare professionals.
Skill development often requires demonstration, practice and correction. For example, inhaler technique is not simply a fact to learn; it is a skill that often needs to be observed and refined.
Reflection
Reflection is one of the most important additions in the updated theory. It means thinking about what happened, what worked, what did not work and what could be done differently next time.
Reflection turns experience into learning. For example, after a symptom flare, a person might consider: What were the early warning signs? Did I delay seeking help? Did the action plan work? What should I do sooner next time?
This reflective element makes self-care more adaptive and personal.
Decision-making
Chronic illness requires constant decision-making. People may need to decide whether to rest or continue activity, whether to adjust a routine, whether symptoms are serious, whether to seek help or whether to follow an action plan.
Decision-making is especially challenging when symptoms are ambiguous. The updated theory recognises that self-care is not a simple checklist; it often involves judgement under uncertainty.
Motivation
Motivation influences whether self-care behaviours are started and maintained. Chronic illness can be exhausting, and motivation may change depending on mood, symptoms, beliefs, support, culture, confidence and previous healthcare experiences.
This is why compassionate support matters. If a patient is not managing self-care well, it should not automatically be seen as non-compliance. It may reflect low confidence, poor support, treatment burden or emotional fatigue.
Why symptoms are so important in the updated theory
Symptoms are central because they connect monitoring and management. A person must first detect a symptom, then interpret it, then decide whether to respond. This may sound simple, but it can be difficult in real life.
Symptoms can be subtle, confusing or easy to normalise. A person with chronic breathlessness may struggle to know when breathlessness is “usual” and when it is a sign of deterioration. Someone with fatigue may not know whether it reflects poor sleep, medication side effects, anaemia, infection, depression or disease progression.
The updated theory helps clinicians think more carefully about symptom work. Patients may need help recognising their baseline, identifying red flags and knowing what action to take.
This is why self-care of chronic illness should be understood as an active process, not a passive instruction to “look after yourself”.
Why the theory matters for healthcare professionals
The updated theory is valuable for nurses, doctors, allied health professionals and researchers because it provides a structured way to identify where self-care is breaking down.
For example, if a patient is not responding to symptoms appropriately, the problem may not be motivation. It may be that they do not recognise symptoms early enough. Or they may recognise symptoms but not know what they mean. Or they may know what they mean but lack confidence to act.
The theory encourages more precise support. Instead of saying “the patient is not engaging”, clinicians can ask:
Does the patient understand the condition?
Can the patient perform the required skills?
Does the patient know what symptoms to monitor?
Can the patient interpret changes?
Does the patient have a clear action plan?
Is the patient motivated and supported?
Has the patient had a chance to reflect on previous experiences?
This approach is more practical and more compassionate.
Why the theory matters for patients and carers
For patients and carers, the updated theory validates the complexity of living with chronic illness. It recognises that self-care is work. It involves routines, decisions, learning, uncertainty and emotional effort.
Carers may also play a major role in self-care. They may help notice symptoms, organise medicines, attend appointments, encourage rest, support lifestyle changes or help decide when to seek help. Although the theory focuses on the person with chronic illness, real-world self-care often happens within families, relationships and communities.
A useful way to understand the theory is this:
Self-care maintenance is what you do to stay stable.
Self-care monitoring is how you notice change.
Self-care management is what you do when change occurs.
Practical examples of the theory in everyday life
A person with COPD may maintain health by using inhalers, avoiding smoke, keeping active and having vaccinations. They monitor by noticing changes in breathlessness, sputum colour, wheeze or activity tolerance. They manage by following an exacerbation plan, using rescue medication if prescribed and seeking help when symptoms worsen.
A person with diabetes may maintain health through medication, food choices, activity and glucose monitoring. They monitor for symptoms of high or low blood sugar. They manage by treating hypoglycaemia, adjusting behaviour according to professional advice and contacting healthcare services when readings or symptoms are concerning.
A person with heart failure may maintain stability through medication, fluid awareness, diet and activity pacing. They monitor weight, swelling and breathlessness. They manage by following their care plan and seeking advice when deterioration is suspected.
These examples show why self-care is not one behaviour. It is a cycle.
What the 2025 update adds
The 2025 update to the Middle-Range Theory of Self-Care of Chronic Illness strengthens the theory by making self-care more practical, dynamic and patient-centred. It keeps the three major concepts of maintenance, monitoring and management, while placing greater emphasis on the human requirements behind effective self-care: experience, knowledge, skills, reflection, decision-making and motivation.
The updated theory is useful because it explains both what people do and what they need in order to do it well.
It also helps healthcare professionals move beyond generic advice. Effective chronic illness support should not only tell patients what to do; it should help them build knowledge, practise skills, recognise symptoms, make decisions, stay motivated and learn from experience.
A small note on everyday self-care
While this theory focuses on chronic illness, its wider message is relevant to daily wellbeing too. Self-care often begins with small repeated cues: pausing, noticing, reflecting and responding. For anyone building gentle routines around rest and emotional wellbeing, a simple item such as a self-care mug gift for mental health can act as a small reminder to slow down, breathe and reset during the day.
Final takeaway
The updated Middle-Range Theory of Self-Care of Chronic Illness shows that self-care is not just about compliance or lifestyle advice. It is a learned, reflective and decision-based process.
People with chronic illness need to maintain health, monitor changes and manage symptoms. To do this well, they need experience, knowledge, skills, reflection, decision-making ability and motivation.
For healthcare professionals, the theory offers a practical framework for patient education, chronic disease management and personalised support. For patients and carers, it recognises the real work involved in living with long-term illness and the importance of being supported, not blamed.
References
Riegel B, Jaarsma T, Strömberg A. An Update to the Middle-Range Theory of Self-Care of Chronic Illness. Advances in Nursing Science. 2025/2026. PubMed record: https://pubmed.ncbi.nlm.nih.gov/40956127/ (PubMed)
Riegel B, Jaarsma T, Strömberg A. A Middle-Range Theory of Self-Care of Chronic Illness. Advances in Nursing Science. 2012;35(3):194–204. DOI: 10.1097/ANS.0b013e318261b1ba. (PubMed)
Riegel B, Jaarsma T, Lee CS, Strömberg A. Integrating Symptoms Into the Middle-Range Theory of Self-Care of Chronic Illness. Advances in Nursing Science. 2019;42(3):206–215. DOI: 10.1097/ANS.0000000000000237. (PubMed)
University Medical Center Utrecht research record for An Update to the Middle-Range Theory of Self-Care of Chronic Illness: https://researchinformation.umcutrecht.nl/en/publications/an-update-to-the-middle-range-theory-of-self-care-of-chronic-illn/ (University Medical Center Utrecht)