Dorothea Orem

Self Care Deficit Nursing Theory

DOROTHEA OREM: Who is she???

Born: 1914, Baltimore, Maryland.

Father: construction, fishing

Mother: homemaker , reading

Youngest of two girls

Died: June 22, 2007

Education

Degrees:

Diploma (1930's), Providence Hospital School of Nursing, Washington DC

BSN Ed. (1939) and MSN Ed. (1945), Catholic University of America, Washington DC.

Honorary Doctorates:

Doctor of Science (1976) Georgetown University, (1980) Incarnate Word College in San Antonio, Texas

Doctor of Humane Letters (1988) Illinois Wesleyan University, Bloomington, Illinois

Doctor of Nursing Honoris Causae, (1998) University of Missouri-Columbia

Special Awards

Catholic University of America Alumni Achievement Award for Nursing Theory (1980)

Linda Richards Award, National League for Nursing (1991)

Honorary Fellow of the American Academy of Nursing (1992).

Nursing Experiences

OR nurse

Hospital staff nurse (pedia & adult MS units)

Private duty nurse

Night supervisor in the ER

Biological science teacher

Professor of nursing education

Nursing Experiences

1940 – 49 = directorship: both nursing school and department at Providence Hospital, Detroit

1949 – 57(Indiana) = Division of Hospital and institutional Services (Indiana State Board of Health)

1957 –curriculum consultant: Office of Education, US DHEW

1958 – 60 = project (Guides for Developing Curricula for the Education of Practical Nurses)

CUA

Member of the Nursing Models Committee (CUA)

Improvement in Nursing Group

1971 – Nursing: Concepts of Practice

Her Story

…she was asked a substantive question and didn’t have an answer because she “had no conceptualization of nursing” (McLaughlin-Renpenning & Taylor, 2002, p. xii).

she noted (Indiana University) that nurses had

difficulty articulating needs to hospital administrators in the face of demands made upon them regarding such issues as length of stay, scheduling admissions and discharges, etc.

Her Thoughts

What is nursing?”

“What is the domain and what are the boundaries of nursing as a field of practice and a field of knowledge?”

Orem (cited in Fawcett 2005) commented that the task required identification of the domain and boundaries of nursing as a science and an art (1978).

Theoretical Sources

Orem says her ideas are primarily the result of reflecting upon her experiences and she was not influenced by any one person (Hartweg, 1991).

Parsons’ structure of social action

Von Bertalnfy’s System Theory

Eugenia K. Spalding = a friend and teacher

Other nursing theorists

Moderate realism (Kantian Philosophy)

Assumptions

1. Human beings require continuous, deliberate inputs to themselves and their environments to remain alive and function according to their capacity.

2. Human agency is exercised in the form of care for self and others in identifying and meeting needs.

3. Mature human beings experience privations in the form of limitations for action and care for self and others involving life-sustaining and function regulating inputs.

Assumptions

4. Human agency is exercised in discovering, developing, and transmitting ways and means to identify needs and make inputs to self and others.

5. Groups of human beings with structured relationships of clustered tasks and allocate responsibilities for providing care to group members who experience privations for making required deliberate input to self and others.

Orem’s General Theory of Nursing

Three Interrelated Theories:

1. Theory of Self-Care = why and how people care for themselves

2. Theory of Self-Care Deficit = why people can be helped through nursing

3. Theory of Nursing Systems = describes and explains relationships that must be made and maintained for nursing to be produced

Theory #1: Self-Care Theory

Based on the concepts of:

SELF-CARE

SELF-CARE AGENCY

SELF-CARE REQUISITES

THERAPEUTIC SELF-CARE DEMAND

Self Care Theory Concepts

Self Care

Definition: the performance of activities that individuals initiate and perform on their behalf to maintain life, health, and well-being.

Self Care Theory Concepts

Self-Care Agency

Definition: the individual’s ability to perform self-care activities

Consists of TWO agents:

Self-care Agent - person who provides the self-care

Dependent Care Agent - person other than the individual who provides the care (such as a parent)

Affected by basic conditioning factors

Basic Conditioning Factors

Self Care Theory Concepts

Self-Care Requisites

Definition: reasons for which self-care is done; these express the intended or desired results

Consists of THREE categories:

Universal - requisites/needs that are common to all individuals (e.g. air, water, food, elimination, rest, activity, etc.)

Developmental - needs resulting from maturation or develop due to a condition or event (e.g. adjustment to new job, puberty)

Health Deviation - needs resulting from illness, injury & disease or its treatment (e.g. learning to walk with crutches after a leg fracture)

Self Care Theory Concepts

Therapeutic Self-Care Demand

Definition: the totality of “care measures” necessary at specific times or over a duration of time for meeting an individuals self-care requisites by using appropriate methods and related sets and actions.”

Theory #2: Self-Care Deficit Nursing Theory

“The condition that validates the existence of a requirement for nursing in an adult is the health associated absence of the ability to maintain continuously the amount and quality of therapeutic self-care in sustaining life and health, in recovering from disease or injury, or in coping with their effects.”

Self-Care Deficit Nursing Theory

FOR CHILDREN :

“…the condition is the inability of the parent (or guardian) associated with the child’s health state to maintain continuously for the child the amount and quality of therapeutic care.”

Self-Care Deficit Nursing Theory

Is the central focus of Orem’s grand theory of nursing

Nursing is required when adults (parent/guardian) are incapable of or limited in their ability to provide continuous effective self-care.

Describes and explains how people can be helped through nursing

Nursing meets these self-care needs through five methods of help

Five Methods of Nursing Help

1. Acting or doing for another

2. Guiding and directing

3. Providing physical or psychological support

4. Providing and maintaining an environment that supports personal development

5. Teaching

Theory #3: Theory of Nursing Systems

This describes:

How the patient’s self care needs will be met by the nurse , the patient, or both

Nursing responsibilities

Roles of the nurse and patient

Rationales for the nurse-patient relationship

Types of actions needed to meet the patient’s demands

Designed by the nurse

Based on the assessment of patient’s ability to perform self-care activities

The Nursing Agency Concept

A complex property of people educated and trained as nurses that enables them to act, to know, and to help others meet their therapeutic self-care demands by exercising or developing their own self-care agency.

Three Classifications of Nursing Systems

1. Wholly Compensatory : a patient’s self-care agency is so limited that s/he depends on others for well-being.

a. Unable to engage in any form of action (e.g. coma)

b. Aware and who may be able to make observations or judgments, and decisions about self-care but cannot/should not perform actions requiring ambulation and manipulative movements (e.g. patients with C3-C4 vertebral fractures)

c. Unable to attend to themselves and make reasonable judgments about self-care but who can be ambulatory and able to perform some self-care with guidance (e.g. severely mentally retarded)

Wholly Compensatory Nursing System

Three Classifications of Nursing Systems

2. Partly Compensatory : a patient can meet some self-care requisites but needs a nurse to help meet others; either the nurse or the patient have the major role in the performance of self-care

E.g. a patient with recent abdominal surgery

Partly Compensatory Nursing System

Three Classifications of Nursing Systems

3. Supportive-educative : a patient can meet self-care requisites but needs help in decision-making, behavior control, or knowledge acquisition; the nurse’s role is to promote the patient as a self-care agent (teacher/consultant)

E.g. a 16-year-old who is requesting birth control information

Supportive-Educative Nursing System

Orem’s General Theory of Nursing

Orem’s Theory & Nursing’s Metaparadigm - PERSON

“…an integrated whole composed of an internal physical, psychologic, and social nature with varying degrees of self-care ability (1971 def.)” (Chinn & Kramer, 2004)

Orem’s Theory & Nursing’s Metaparadigm - PERSON

The recipient of nursing care

A being who functions biologically, symbolically, and socially

Has the potential for learning & development

Is subject to the forces of nature

Has a capacity for self-knowledge

Can engage in deliberate actions, interpret experiences, and perform beneficial actions

Can learn to meet self-care needs (requisites)

also referred to as individual, patient, multiperson unit, self-care agent, dependent-care agent

Orem’s Theory & Nursing’s Metaparadigm - ENVIRONMENT

“…prevailing internal and external conditions in some time and place frame of reference.”

encompassed by two dimensions ---

Environmental: physical, chemical and biologic features

atmosphere, pollutants, weather conditions, pets, infectious organisms, etc.

Developmental: socioeconomic features

family & community

gender and age roles, cultural roles, and cultural prescriptions of authority

Orem’s Theory & Nursing’s Metaparadigm - ENVIRONMENT

terms used are environment and environment features

Orem’s Theory & Nursing’s Metaparadigm - HEALTH

“a state of physical, mental, and social well-being, and not merely the absence of disease or infirmity”

a state of well-being, which refers to a person’s perceived condition of existence, characterized by experiences of contentment, pleasure, happiness, and movement toward self ideals and continuing personalization

Orem’s Theory & Nursing’s Metaparadigm - HEALTH

Includes promotion & maintenance of health, treatment of disease and prevention of complications

also referred to as health, health state, and well- being

Orem’s Theory & Nursing’s Metaparadigm - NURSING

“an art through which the practitioner of nursing gives specialized assistance to persons with disabilities of such a character that greater than ordinary assistance is necessary to meet daily needs for self care and to intelligently participate in the medical care they are receiving from the physician”

Components of NURSING

NURSING ART

The intellectual quality of nurses which allows them to make creative investigations, analyses, and syntheses of variables and conditioning factors in nursing situations

NURSING PRUDENCE

The quality that enables the nurse to seek advice in new or difficult situations, to make correct judgments, to decide to act in a particular manner, and/or to act

NURSING SERVICE

A human service that focuses on a person’s inabilities to maintain health care

NURSING AGENCY

Orem’s Nursing Process

Consists of 3 steps:

Step 1: determine why a patient needs care

Step 2: design a nursing system & plan the delivery of care

Step 3: management of nursing systems - planning, initiating, & controlling nursing actions

OREM’S THEORY APPLIED

APPLICATION OF OREM’S THEORY

CASE STUDY

For Mrs. X….

She came to the hospital with complaints of pain over all the joints, stiffness which is more in the morning and reduces by the activities.

She has these complaints since 5 years and has taken treatment from local hospital.

The symptoms were not reducing and came to --MC, Hospital for further management.

Patient was able to do the ADL by herself but the way she performed and the posture she used was making her prone to develop the complications of the disease.

She also was malnourished and was not having awareness about the deficiencies and effects.

BASIC CONDITIONING FACTORS

UNIVERSAL SELF-CARE REQUISITES

DEVELOPMENTAL SELF-CARE REQUISITES

HEALTH DEVIATION SELF CARE REQUISITES

MEDICAL PROBLEM AND PLAN

Physician’s perspective of the condition:

Diagnosed with rheumatoid arthritis and is on the following medications:

T. Valus SR OD

T. Pan 40 mg OD

T. Tramazac 50 mg OD

T. Recofix Forte BD

T. Shelcal BD

Syp. Heamup 2tsp TID

Medical Diagnosis: Rheumatoid arthritis

Medical Treatment: Medication and physical therapy.

AREAS AND PRIORITY ACCORDING TO OREM’S THEORY OF SELF-CARE DEFICIT

Area of Inadequacy!!!!

NURSING CARE PLAN

Therapeutic self care demand: Deficient area: food

Adequacy of self care agency: Inadequate

NURSING DIAGNOSIS

Inability to maintain the ideal nutrition related to inadequate intake and knowledge deficit

OUTCOMES AND PLAN

Outcome:

improved nutrition

Maintenance of a balanced diet with adequate iron supplementation.

Nursing Goals and objectives

Goal : to achieve optimal levels of nutrition.

Objectives : Mrs. X will:

state the importance of maintaining a balanced diet.

List the food items rich in iron , that are available in the locality.

Design of the nursing system:

supportive educative

Method of helping:

guidance

Support

Teaching

Providing developmental environment

IMPLEMENTATION

Mutually planned and identified the objectives and the patient were made to understand about the required changes in the behavior to have the requisites met.

EVALUATION

Mrs. X understood the importance of maintaining an optimum nutrition.

She verbalized that she will select the iron rich diet for her food.

She listed the foods that are rich in iron and that are locally available.

The self care deficit in terms of food is decreased with the initiation of the nutritional intake.

The supportive educative system was useful for Mrs. X .

Usefulness of Theory: RESEARCH

Development of research instruments

Exercise of Self Care Agency (Yamashita, Japan)

Appraisal of Self Care Agency

Self-As-Carer Inventory

Studies that test elements of the theory in various populations

Children and adolescents

Diabetes mellitus

Hemodialysis patients

Usefulness of Theory: EDUCATION

Laying out of the structure of nursing knowledge and explicating the domains of nursing knowledge

Strong and effective framework for curricular design

45 schools in the US use the SCDNT as the basis for their curriculum

Usefulness of Theory: PRACTICE

Health promotion and care of the sick

Teaching self-care to individuals

Renal failure, hemo/peritoneal dialysis, renal transplant

Post-stroke conditions

Malignancies

Elderly

Definition and description of various roles for nurses

Clinical nurse-specialist role

Case-management role

Advanced practice role

Primary-care role

Theory Analysis: Simplicity

Presented in a straightforward manner

Relationship among entities can be presented in a simple diagram

Theory Analysis: Clarity

Precisely defined

Consistent with the language used in action theory and philosophy

Congruent

Theory Analysis: Generality

All of those who need nursing care

All of situations in which individuals (including children) cannot meet all their self-care needs

Appears that the theory is illness oriented rather with no indication of its use in wellness settings

Theory Analysis: Empirical Precision

Generates hypotheses

Gives additional knowledge

Extremely contagious