Nursing Theory Application: Dorothea Orem’s Self-Care Deficit Theory of Nursing

According to Kearney-Nunnery (2016), a nursing metaparadigm is defined as the overall concern of nursing related to a nursing model. Metaparadigm must be neutral, must address information in an understandable manner, and must provide an identity for a profession that makes the profession distinct from others. Within the metaparadigm of professional nursing, the metaparadigm must incorporate four concepts: human beings, health, environment, and nursing (Kearney-Nunnery, 2016). Patients must not be treated as merely patients, but as human beings. Each person should be treated as unique and autonomous. Additionally, the degree of health must be measured differently based on the patient’s personal health. What may be considered a relatively healthy day for one patient, may not be considered a healthy day for a different patient. Furthermore, the environment of a patient not only includes the physical surroundings, but also the mental state of the patient (“Understanding,” 2018). Depression, for example, can discredit any attempts at recovery. The nurse has a responsibility to provide compassionate care, meanwhile using his or her nursing skills to diagnose the patient’s main problem, develop a plan, and consult with the physician (“Understanding,” 2018). Based on the theories of many nursing theorists, all theorists incorporate the nursing metaparadigms in their theory and the many theorists have different ideas as to the role of human beings, health, environment, and nursing.

Personal Nursing Philosophy

More personally, I would like to discuss my own nursing philosophy and the philosophy incorporates the four metaparadigm components of human beings, health, environment, and nursing. I believe the nurse is responsible for developing a relationship built on trust and benevolence with the patient. It is pertinent the nurse provides care for the patient in a way that encourages the patient to trust the nurse. The nurse maintains a responsibility to treat the patient with compassion, understanding, and providing care with a non-judgmental mindset. Whether the patient is an 85-year-old patient suffering from genetic heart disease or a drug-induced cardiac arrest patient, the nurse should treat the patients with the same level of compassion and care. The nurse’s number one priority should be to deliver safe care to the patient in a safe environment. Being aware of the environment and its surroundings allows the nurse to provide safe care to the patient. For example, the nurse caring for a blind patient will need to manipulate the environment differently than the nurse caring for a patient with normal vision. In addition, I believe the nurse must take time to fully assess the patient’s mental status or to seek family’s advice pertaining to the patient’s mental status if the patient is unable to speak. Notably, the nurse should provide the patient with a level of health that is mutually understood between the patient and the nurse. Meaning, not all patients picture of health maintains life. Some patients may be in hospice care or comfort measures only, and the responsibility of the nurse is to provide the patient with the patient’s personal picture of health. A nurse that encourages the patient to decide his or her healthcare decisions provides the patient with autonomy.

While providing nursing care, the nurse is not only expected to provide compassionate care but is also expected to provide thorough and detailed care. The nurse is expected to complete a detailed history assessment of the patient, carefully monitor the patient’s signs and symptoms of illness, perform detailed and frequent head to toe assessments on the patient, and communicate any abnormal values or information with the physician. Most importantly, the nurse should establish a plan of care that is mutually agreed upon between the patient, the physician, and any family members that have a right of say. I also believe the nurse serves the role as an educator to the patient and the patient’s family members. The nurse should educate the patient on ways to maintain health and better the patient’s health, as well as encouraging the patient to perform all levels of care that he or she can do on their own. Aside from my own personal theory of nursing, Dorothea Orem has published profound work for her own nursing theory.

Dorothea Orem and Background of Theory

Dorothea Orem (1914-2007) was a nurse best renown for her dedication to the classroom and developing her own nursing theory. Orem was born and raised in Baltimore, Maryland, and recieved her Nursing Diploma from the Providence Hospital School of Nursing (“Medical Archives,” 2019). Dorothea Orem’s early life as a nurse was spent working at Providence Hospital. After returning to college and earning advanced degrees, Orem began teaching and researching. She served as the Director of Nursing at Providence Hospital, taught as an associate professor at Providence hospital, and taught as an associate professor at the Catholic University of America. Orem spent many years studying nursing research and teaching as a professor. According to Orem, her many years researching and teaching students developed her passion for nursing. Eventually, Orem decided to publish her own nursing theory. It was not until 1971 that Orem published her nursing theory, known as the Self-Care Deficit Theory of Nursing (“Medical Archives,” 2019).

Introduction to Chosen Theory

A theory that proves most useful to future nursing practice is Dorothea Orem’s Self-Care Deficit Theory of Nursing. The main reason for choosing this theory is my personal belief that all persons are responsible for achieving their own level of health. Although it is arguable that not all persons are physically capable of caring for themselves, how we chose to maintain our health as young adults and children affects how we will be able to maintain our health as adults. Even if people are not physically able to care for themselves, the responsibility exists to find resources that are able to provide care. At the very minimum, persons are responsible for selecting a healthcare representative, in which case the patient is no longer able to make decisions or care for oneself. Failing to elect a healthcare representative makes matters far more difficult for the patient, the family, and the healthcare providers. In addition, Orem’s theory highlights that the nurse is responsible for encouraging patients to maintain self-care and to help patients that cannot maintain self-care to find resources available for providing care. It is my own personal belief that as a nurse, it is my duty to educate patients how to properly provide self-care so that outside of the hospital patients can maintain health. I also believe as a nurse if my patient cannot provide self-care that it is my duty to assist the patient to do so in the hospital, and to help the patient to find resources for maintaining health at home.

Theory Description

The Self-Care Deficit Theory of Nursing highlights the personal actions a patient must take to care for themselves, as well as to care for dependents (Kearney-Nunnery, 2016). Orem’s theory also focuses on the actions of the nurse’s application of nursing systems in order to meet the needs of patients with disabilities. In Orem’s theory, she defines the following concepts: self-care, self-care agency, power components, basic conditioning factors, Therapeutic self-care demand, and self-care deficit (Kearney-Nunnery, 2016). In order to best understand and apply Orem’s theory, it is vital to further analyze the concepts of Orem’s Self-Care Deficit Theory.

Orem defines self-care as a “behavior directed by individuals themselves or toward their environment, to regulate factors that affect their own development and functioning in the areas of life, health, or well-being” (Kearney-Nunnery, p. 39, para. 9). Thus, Orem values encouraging patients to reach a level of self-efficacy that is attainable based on the patient’s condition and level of health. In Orem’s theory, she also defines self-care agency. This is the idea that individuals mature and develop skills to be able to “regulate their own health and development” (Kearney-Nunnery, p. 40, para. 1). Within the self-care agency, Orem also believes that individuals can make their own healthcare decisions and can perform self-care to meet their own needs.

Within Orem’s theory, she also claims that a person’s ability to provide care for themselves is influenced by ten “care components.” (Kearney-nunnery, 2016). In the first care component, Orem claims the ability to provide self-care is based on internal and external factors. Secondly, Orem states there must be a controlled source of energy available for self-care. Thirdly, the individual must be able to control the body and the movement of the body. In addition, the individual must have an ability to reason or make informed decisions regarding health. Also, there must be individual motivation for self -care. The individual not only must be able to make decisions about care but must also be able to carry-out the decisions. Consequently, the individual must be able to obtain knowledge from sources, retain the knowledge, and perform the knowledge learned for self-care. The individual should also be able to develop communicative, cognitive, perceptual, and interpersonal skills. Also, the individual must be able to set goals based on their abilities. Lastly, the individual must be able to consistently perform self-care and integrate the self-care with other areas of life (Kearney-Nunnery, 2016, p. 40). Aside from the ten care components, Orem also defines “basic conditioning factors.”

Orem also claims in her theory that there are ten internal and external factors that influence self-care, Orem calls these factors “basic conditioning factors” (Kearney-Nunnery, 2016). Age, gender, developmental state, health state, and sociocultural orientation are the first five basic conditioning factors. The latter five basic conditioning factors are healthcare system factors, family system factors, patterns of living, environmental factors, and resource availability (Kearney-Nunnery, 2016). In Orem’s work, she also discusses Therapeutic self-care demand.

Orem defines Therapeutic self-care demand as the action of individuals to meet the three types of self-care requirements: universal self-care requisites, developmental self-care requisites, and health deviation self-care requisites (Kearney-Nunnery, 2019). Universal self-care requisites can best be defined as the actions taken to maintain life processes and well-being. Lastly, health deviation self-care requisites are actions that need to be performed in relation to genetic defects, structural and functional defects, and medical diagnosis and treatments prescribed by physicians (Kearney-Nunnery, 2016). In the last portion of Orem’s theory, she defines self-care deficit. According to Orem, a self-care deficit is an inadequacy in the relationship between self-care needs and self-care demands (Kearney-Nunnery, 2016). If the self-care demand exceeds the ability of the patient to meet the needs, then a self-care deficit occurs. Overall, there are many components of Orem’s Self Care-Deficit Theory of Nursing, but Orem’s work has been recognized and resourceful throughout many other fields of nursing.

Testability

A study conducted by Saeedifar, Memarian, Fatahi, and Ghelichkhani (2018) tested Dorothea Orem’s Self-Care Deficit Theory. Rheumatoid arthritis causes physical, psychological, and economic disability. Unfortunately, medications and surgical interventions are often unsuccessful at relieving pain for those with rheumatoid arthritis. However, self-care has been often recognized as important means for pain control. The study was a randomized clinical trial that was performed on 60 women with rheumatoid arthritis. The patients from this study were given a 19-question questionnaire and a Numeric Pain Scale that was numbered from 1-10, 10 being the highest amount of pain. Next, researchers evaluated the needs of the patients, including self-care needs, general needs, deviation from health, and self-care capacity (Saeedifar et al., 2018). Every two weeks the patients returned to the controlled environment to perform therapy on their own. At the end of each session, the patient’s recorded their pain level on a scale of zero to ten and reviewed a self-care checklist. At the end of three months, in the final phase, the subjects also completed an Orem self-care empowerment form. When the results were analyzed, the patient’s level of reported pain dropped significantly from the beginning of the trial to the end of the trial (Saeedifar et al., 2018). Thus, the more self-care the subjects practiced, the less pain the subjects witnessed. Overall, the results showed that the Orem Model can effectively reduce pain in patients with rheumatoid arthritis. This research study also suggests that if the Orem Model has proven helpful for patients with rheumatoid arthritis, that the Orem Model may also be helpful for other chronic diseases.

Additionally, a study by Borji, Ostaghi, and Kazembeigi (2017) proved how Orem’s Self-Care Model can help patients with diabetes. According to the researchers, the number of people with diabetes is expected to reach 522 million by the year 2030 (Borji et al., 2017). In the previous study, 80 patients from diabetes clinics in Islam were chosen for participants. The 80 patients were split in to an experimental and control group. Each of the patients in the control group were given a demographic questionnaire and a quality of life (QOL) survey. The control group was not given the test. The survey contained 36 questions to measure eight dimensions, including: physical function, role limitations related to physical health, role limitations related to emotional health, energy, emotional health, social functioning, bodily pain, and general health (Borji et al, 2017). The highest a patient could score on the QOL test was 100. Patients scoring higher on the QOL test indicated a better quality of life than those that scored lower on the QOL test. The researchers determined the patient’s needs based on the scores on the tests. For the following twelve weeks, the patients attended training sessions and classes to learn about how to live healthier with diabetes and provide better self-care. At the end of the twelve weeks, the patients were then given the QOL test. When comparing the patients scores from the initial QOL test to the QOL test after patient’s received teaching and training sessions, the scores were much higher on the second test. More importantly, the scores of the control group did not change from the initial QOL test to the second QOL test. Thus, providing the patients will skills to better perform self-care positively affected the quality of life of the patients. Once again, proving Orem’s Self-Care Model has a positive effect on patients and their quality of life.

Personal Philosophy and Orem’s Philosophy

Orem’s theory has influenced my own personal theory by providing examples of how an individual can fulfill self-care, as well as providing examples for times when an individual may not be able to deliver self-care. Personally, Orem’s theory has influenced my own personal nursing theory as I believe it is just as much the responsibility of the patient to practice self-care and healthy habits as it is the responsibility of the nurse to teach the patient healthy habits and life-style changes. I agree with Orem’s ten “care components.” If a patient is unable to meet the majority of the care components, then it is unlikely the patient can provide care for themselves. For example, based on care component number three, if a patient cannot control their body or their body movements, it is very unlikely that a patient will be able to provide self-care. Further, the patient that cannot provide self-care requires assistance from the nurse and it is the nurse’s responsibility to assist the patient with care.

I believe my personal nursing theory and Orem’s theory are closely related. Both theories argue that is it the nurse’s responsibility to carefully assess the patient and establish goals and plans of care for the patient based on the assessment. For example, Orem uses the ten care components to establish a patient’s ability of self-care. Based on my theory, the nurse would use his/her assessment skills to establish a patient’s ability to provide self-care. In addition, both theories also agree the nurse has a primary importance to teach the patient how to provide self-care and to encourage the patient to do so as his/her best ability. In contrast, my personal theory focuses on the relationship established between the nurse and the patient. Orem’s theory does not focus on the relationship between the nurse and the patient, nor does her theory focus on the responsibility of the nurse to provide compassionate care. I value developing a close relationship with my patient, where the patient can trust my direction as a nurse. I enjoy getting to know my patients on a personal level and believe I am a better nurse when I take the time to do so. There are many times as a nurse when I have learned more about the patient’s history or background by merely holding conversation with the patient and taking the time to get to know the patient as a human being. Orem does not seem to value having an emotionally close connection with patients.

From my personal experience working in the Coronary Intensive Care, I do not believe Orem’s theory is applicable to certain types of patients in the Intensive Care. Establishing the ability to provide self-care on brain-anoxic patient or patient that is sedated and intubated is rather difficult. At the same time, a patient’s ability to provide self-care is ever-changing. Take for example, an intubated and sedated patient that cannot perform any type of self-care. Once the sedation is turned off and the patient awakens, many patients are then able to perform levels of self-care like feeding oneself or bathing. I believe one thing Orem’s theory fails to address is that a patient’s ability to provide self-care can change overtime and should be re-evaluated frequently. Overall, my personal theory and Orem’s theory hold more similarities than differences. More importantly, Orem’s theory has proven useful in practice and can be applied to nursing situations.