SELF-CARE DEFICIT THEORY OF NURSING

By: A. Banate and J. Albaladejo

OBJECTIVES: 
Relate life history of Dorothea Orem  Explain theoretical sources of Orem¶s

theory  Enumerate Orem¶s Metaparadigm in Nursing  Explain the acceptance by the nursing community of this theory 

Analyze and apply the theory to present day

situation ( particularly in Nursing Practice, Nursing Education, and Nursing Research)

SELF - CARE DEFICIT THEORY OF NURSING

DOROTHEA OREM
1914- June 22, 2007 93 years old 

One of America¶s foremost nursing theorists  in Baltimore, Maryland in 1914.  She began her nursing career at Providence

Hospital School of Nursing in Washington, D.C, where she received a Diploma of Nursing in the early 1930¶s.  Later, she received a BS in Nursing Education (1939) and MS in Nursing Education (1946) at Catholic University of America (CUA). 

Her early nursing experiences included OR nurse,

private duty nursing (home and hospital), hospital staff nursing on pediatric and adult medicalsurgical units, evening supervisor in the ER, and biology science teaching. 
In 1957, she became a curriculum consultant at

the Office of Education, US Department of Health, Education and Welfare. 

³Nursing: Concepts of Practice´, was her

first book, published in 1971. Subsequently, editions of this book were published in 1980, 1985, 1991, 1995, and 2001. 

She was given many honors and awards, to

mention: Honorary Degree of Doctor of Science, Georgetown University in 1976; Doctor of Humane Letters, Illinois Wesleyan University in 1988; Linda Richards Award, National League for Nursing in 1991; Honorary Fellow of the American Academy of Nursing in 1992. Also, she was awarded the Doctor of Nursing Honoris Causae from the University of Missouri in 1998. 

Orem¶s many papers and presentations provide

insight to her views on nursing practice, nursing education and nursing science. Other papers of Orem and scholars who worked with her in the development of the theory are archived in johns Hopkins University. 

She continues working, alone and with

colleagues (NDCG), on the development of Self-Care Deficit Nursing Theory ( SCDNT).

THEORETICAL SOURCES 
Well-versed in contemporary nursing literature

and thought, Orem was not influenced directly by any particular nursing leader. Her association with nurses over the years provided many learning experiences. 

Although she does not credit a major influence,

she does cite many other nurses¶ works in terms of their contributions to nursing, including, but not limited to, Abdellah, Henderson, Johnson, King, Levine, Nightingale, Orlando, Peplau, Riehl, Rogers, Roy, Travelbee, and Weidenbach.

Also cited numerous authors in other disciplines including, but not limited to: 
Gordon Allport ± Theory of Personality and

one of founding figures of Personality Psychology  Chester Barnard - Author of pioneering work in Management Theory and Organizational Studies  Rene Dubos ± pathologist, humanist, microbiologist ( devoted most of his professional life to the analysis of environment and social factors that affect the welfare of humans) 

Erich Fromm ± social psychologist,

psychoanalyst, humanistic philosopher and democratic socialist  Gartly Jaco ± The Social Epidemiology of Mental Disorders: A Psychiatric survey of Texas  Robert Katz - American novelist, screenwriter, and non-fiction author  Kurt Lewin ± Founder of Social Psychology (nature and nurture interact to shape each person)  Ernest Nagel ± He expounded the different kinds of explanation in different fields 

Talcott Parsons ± sociologist, developed a

general theory for the study of society called Action Theory (voluntarism and analytical realism)  Hans Selye ± General Adaptation Syndrome  Magda Arnold ± Appraisal Theory ( reasoning and understanding of one¶s emotional reaction becomes important for future appraisals or evaluation  Bernard Lonergan ± philosopher-theologian (by realism, he affirmed that we make true judgement of fact and of value) 

Ludwig von Bertalanffy ± General Systems theory

( defined new foundations and development as generalized theory of systems with applications to numerous areas of study, emphasizing holism over reductionism, organism over mechanism)

MAJOR CONCEPTS AND DEFINITIONS
Self-Care Deficit Nursing Theory ± general theory  The theory of Self-Care ± describes why and how people care for themselves  The theory of Self-Care Deficit ± describes and explains why people can be helped through nursing  The theory of Nursing Systems ± describes and explains relationships that must be brought and maintained for nursing to be produced. It also describe how the patient¶s self-care needs will be met by the nurse, patient or both. 

Self-Care- is an activity that promotes a persons

well-being. It is performed by persons who are aware of the time frames on behalf of maintaining life, continuing personal development and a healthy functional living. 

Self-Care Requisites ± are insights of actions or

requirements that a person must be able to meet and perform in order to achieve well-being. 1.Universal Self-Care Requisites ± these are universally set goals that must be undertaken in order for an individual to function in scope of a healthy living.  Maintenance of a sufficient intake of air,  Maintenance of a sufficient intake of food,  Maintenance of a sufficient intake of water,  Provision of care associated with elimination, 

Maintenance of balance between activity and rest,  Maintenance of balance between solitude and

social interaction,  Prevention of hazards to human life, human functioning, and human well-being; and  Promotion of human functioning and development. 2.Developmental Self-Care Requisites ± associated with developmental processes or derived from a condition 

Health Deviation Requisites ± these are

requisites required for a person to be considered as sick or ill. Disease affects the structures within the integral part of a person and its functioning. These healthcare deviations set standards to which the degree of self-care demand is needed 

Therapeutic Self-Care Demand ± These are the

summation of all activities needed to alleviate the existing disease or illness. Controlling or managing the factors will result to appropriate care of plan.  Self-Care Agency ± is a human ability which is ³the ability for engaging oneself in self-care 

Agent ± is the individual who is engage in meeting the

needs of a person. They are like bridges that facilitate what has been done and what needs to be done.  Dependent Care Agent ± These are individuals who takes full responsibility of taking care of a person who are incapable of providing care for themselves or those who are living dependently with others aid.  Nursing Agency ± is set of established capabilities of a nurse who can legitimately perform activities of care for a client. Nursing agency helps a person achieve their health care demand.

METAPARADIGM IN NURSING
PERSON  - According to Orem, human beings are very much different from other living things in terms of their capacity. Humans can reflect upon events, themselves and their environment. They can symbolize experiences that they have been through by using words or ideas.  - Human functioning is an integrated system comprised of physical, psychological, interpersonal, and social aspects. Orem believes that individuals have the potential to be developed and learned. 

³a substantial or real unity

whose parts are formed and attain perfection through the differentiation of the whole during the process of development.´

HEALTH 
- Orem supports the World Health

Organization¶s definition of health as the ³state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity.´  - Health should be perceived this way since she believes that these integrated aspects of health are inseparable.

ENVIRONMENT 
Orem¶s view of health as a phenomenon affected

by inseparable entities shows her view of the surrounding environment as an external source of influence in the internal interaction of a person¶s different aspects.

NURSING 
Nursing is helping clients to establish or identify

ways to perform self-care activities. Nursing actions are geared towards the independence of the client.  - Further, she defines nursing as a human service. It is distinguished human service since its focus is on persons with inabilities to maintain continuous provision of healthcare. 

³an 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´

Self ± Care Deficit Theory of Nursing
Self care R Self Care Agency R R
Therap eutic Self care deman ds

Deficit R Nursing Agency R

R ± relationship < - deficit relationship, current or projected

DOROTHEA OREM¶S THEORY

ACCEPTANCE BY THE NURSING COMMUNITY

EVIDENCES: 
MAGNITUDE OF PUBLISHED

MATERIALS ± Over 800 references can be found through computerized search dealing with a variety of subjects 

LITERATURE, PHONE CALLS

AND E-MAIL MESSAGES AND QUESTIONS RECEIVED IN THE SCDNT WEB PAGE ±Reflects that it has great appeal to practicing nurses. 

WORLD WIDE

± Translated into several languages like Italian, French, Spanish, Dutch, and Japanese. ± Some of her work was also translated German, Thailand and Norway

PRACTICE 
First documented use is in John hopkin¶s

Hospital in a nurse-managed clinic as a basis for structuring practice  Clinical populations and other age groups
± Pain management in Mexican-American culture ± Management of DM ± Community population-based care in Vancouver was formulated using Orem¶s theory. 

Occupational health nursing had based their

practice in SCNDT. ± Health hazards and job related factors that nurses must be aware of had been discussed. ± Learns how to identify, interpret and draw correct conclusion. 

Orientation process

± For new graduate nurses. To be clarified from school teaching conflicts with the actual work settings or values. 

To define various nursing roles:

± Clinical nurse specialist ± Case management role ± Advance practice role ± Primary care role 

Development of clinical measurement

approach
± Which focus around the universal self requisites and health deviation self requisites ± Which then leads to the development of Dependent Care Agent Questionaire which was used to measure mother¶s performance care for their children 

IN VARIOUS SETTINGS ± COMMUNITY POPULATION BASED CARE ± OCCUPATIONAL HEALTH NURSING

NOTE 
MUCH OF PUBLISHED LITERATURE IS

LIMITED TO SELF CARE AND SELF DEFICIT THEORY  THE THEORY OF JURSING PRACTICE CAN BE INFERRED FROM LITERATURE; IT IS NOT USE EXPLICITLY, PERHAPS BECAUSE OF THE COMPLEXITY OF THE PRACTICE.

EDUCATION 
THEORY WAS ARTICULATED BY

1950¶s  PUBLISHED IN 1972  GUIDES FOR DEVELOPING CURRICULUM FOR EDUCATION OF PRACTICAL NURSES-1959  FOUNDATION OF NURSING ANS IT¶S PRACTICE

SCNDT 
HAD BEEN USED AS BASIS FOR A

CURRICULUM in Sinclair School of Nursing.
± PRESERVICE NURSING EDUCATION IN TEACHING ± USED AT ALL LEVELS FOR CONTINUING EDUCATION ± FRAMEWORK FOR CURRICULAR DESIGN

1. DEVELOPMENT OF RESEARCH

INSTRUMENTS FOR MEASURING THE RESEARCH CONCEPTUAL ELEMENTS OF THE THEORY like in the development of Exercise of Self Care Agency 2. STUDIES THAT TEST ELEMENTS OF THE THEORY IN SPECIFIC POPULATION like in the use of Appraissal of Self Care Agency with ill and well population in a number of cukture 3. DEVELOPMENT OF NEW MODELS OR MIDDLE RANGE THEORY

ANALYSIS 
SIMPLICITY ± It is presented in a straight forward manner ± Her theory comprises of self care, self care deficit and nursing systems ± SELF CARE DEFICIT THEORY includes self care(and dependent care), self care agency(and dependent care agency), therapeutic self care demand, self care deficit, nursing agency and nursing system. 

GENERALITY

± Operates upon the combination of several conceptualized properties or features common to all instances of nursing ± The theory also helps nurses to validate nursing knowledge and in teaching and learning the nursing profession. 

ACCESSIBILITY . It must be noted

that Orem¶s theory has been used for research using both qualitative and quantitative methodologies. The theoretical entities are well defined and lend themselves to being measurable; however, instruments have not been developed for all of the entities, for example, nursing agency. 

IMPORTANCE. The Self-Care Deficit

Nursing Theory differentiates the focus of nursing from other disciplines. The theory of nursing systems provides the unique focus for nursing. There is ample evidence in the literature that the theory is useful in developing and guiding practice and research 

EMPIRICAL PRECISION

± Generating hypotheses ± Additional knowledge ± The significant value of her theory is in it¶s scope, complexity and clinical usefulness ± It could be effectively used in generating hypothesis and adding to the body of knowledge of nursing 

DERIVABLE CONSEQUENCES ± give direction to nursing specific outcomes (FOCUS) ± Her theory gives direction to nursing-specific outcomes related to identifying and meeting the therapeutic self care demands and self management systems. ± She also defined nursing as a scientific structure and as practical as science with on going develoment of the nursing knowledge

THE SELF CARE DEFICIT THEORY OF NURSING IS NOT AN EXPLANATION OF THE INDIVIDUALITY OF A PARTICULAR CONCRETE NURSING PRACTICE SITUATION, BUT RATHER THE EXPRESSION OF A SINGULAR COMBINATIONOF CONCEPTUALIZED PROPERTIES OR FEATURES COMMON TO ALL INSTANCES OF NURSING. AS A GENERAL THEORY, IT SERVES NURSES ENGAGED IN NURSING PRACTICE, IN DEVELOPMENT AND VALIDATION OF NURSING KNOWLEDGE AND IN TEACHING AND LEARNING NURSING

SITUTATION 
KUYA EDDIE, A 45 YEAR-OLD DRIVER SUFFERED A

VEHICULAR ACCIDENT ALONG HIS WAY HOME. HAVING FOUND STILL ALIVE BY THE PARAMEDICS HE WAS RUSHED TO THE HOSPITAL. HE WAS GIVEN EMERGENCY TREATMENT FOR BLOOD LOSS. HIS LEFT LOWER LEG WAS TORN OFF DUE TO IMPACT. UPON ASSESSMENT, IT WAS FOUND OUT THAT HE SUFFERED A SEVERE FRACTURE OF THE LEG, SEVERE INJURY IN RIGHT INNER THIGH AND FOOT, MUSCLE DAMAGE AND HEAD INJURIES. 

EMERGENCY SURGERY WAS GIVEN TO

REPAIR THE DAMAGE BUT HE WENT INTO COMA DUE TO DEVELOPED BLOT CLOT IN THE BRAIN. ANOTHER OPERATION WAS DONE TO REMOVE THE BLOOD CLOT, AND IT WAS SUCCESSFUL. HOWEVER, KUYA EDDIE DID NOT WAKE UP AFTER THE SURGERY. PHYSICIANS STARTED TO GIVE UP BUT HIS FAMILY STILL PRAYS FOR HIS MIRACULOUS RECOVERY. 

THEN, AFTER A MONTH, HE WOKE UP BUT

HIS BODY WAS LIKE A VEGETABLE AND SEEMED TO BE PARALYZED FOR LIFE.  KUYA EDDIE, BEING A MAN OF FAITH DID NOT LOSS HOPEA AND STATED THAT NOTHING IS IMPOSSIBLE WITH GOD.  EVERYDAY, WITH THE DESIRE BURNING IN HIS FOCUSED MIND, HE WILLED HIMSELF TO WALK. HE IMAGINE HIMSELF WALKING AS THE NURSES DO PASSIVE RANGE OF MOTION EXERCISES, MASSAGED, CARED AND CLEANED HIS BODY. 

AFTER A FEW MONTHS OF THERAPY, THE

PHYSICIANS WERE VERY MUCH SURPRISED TO SEE HIM SITTING AT HIS BEDSIDE. HE COULD MOVE HIS LEGS LITTLE BY LITTLE BUT AFTER A AFEW WEEKS HE COULD STAND AND WALK WITH A LIMP. HE WAS INSTRUCTED TO USE CRUTCHES AS AN AID BY NURSE LISSA AND SHE ALSO PERFORMS HEALTH TEACHINGS AND GIVE GUIDANCE TO KUYA EDDIE. 

ASSESSMENT

± IDENTIFICATICATION OF PATIENT¶S NEEDS ‡ START AT A WHOLLY COMPENSATORY STATE ‡ PROCEED TO PARTIALLY COMPENSATORY ‡ PATIENT WAS TAUGHT THE USE OF ASSISTIVE DEVICE ‡ NURSE TEACHES THE USE OF CRUTCHES, POSTURE AND PACING 

DIAGNOSIS
± SELF CARE DEFICIT RELATED TO TOTAL PARALYSIS ± KNOWLEDGE DEFICIT RELATED TO USE OF CRUTCHES ± POTENTIAL FOR IMPAIRED SKIN INTEGRITY RELATED TO TOTAL PARALYSIS 

PLANNING

± COLLABORATE WITH PATIENT IN SETTING ATTAINABLE GOALS ± WITH EMPHASIS ON CLIENT EMPOWERMENT AND ATTAINING INDEPENDENCE AS QUICKLY AS POSSIBLE 

IMPLEMENTATION

1. ASSESS PATEINT¶S PERCEPTION ON DISABILITY, LIFESTYLE CHANGES, AND COPING MECHANISMS 2. DEMONSTRATE THE USE OF CRUTCHES USING VISUAL AIDS, DEMO, AND THERAPEUTIC COMM. 3. INVOLVE SUPPORT SYSTEM 4. REFER TO PT FOR COLLABORATIVE MGT AND FURTHER GUIDANCE 5. ASK CLX TO DEMONSTRATE KNOWLEDGE AND COMPETENCY TO EVALUATE SELF CARE CAPACITY 

EVALUATION ± THE NURSE, YOGETHER WITH THE CLIENT AFTER A FEW DAYS OF INSTRUCTION AND COUNSELING, WOULD AGREE ON WHETHER THE GOAL IS MET OR NOT. EDDIE WOULD THEN BE ENCOURAGED TO SET NEW GOALS FOR HIMSELF.

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