Thursday, December 11, 2008

Applications of Dorothea Orem’s Self- Care Deficit Nursing Theory

According to Orem (2001), it is the special focus on human being
that disthinguishes or differentiates nursing from other human
services. From this point of view, the role of nursing in society
is to enable individuals to develop and exercise their selfcare
abilities to the extent that they can provide for
themselves the amount and quality of care required.
According to the theory, individuals whose
requirements for self-care exceed their capabilities
for engaging in self-care are said to be experiencing
a self-care deficit.Moreover, it is the presence of an
existing or potential self-care deficit that identifies
those persons in need of nursing. Thus, Orem’s
Self-Care Deficit Nursing Theory explains when
and why nursing is required.
Orem (2001) describes the Self-Care Deficit
Nursing Theory as a general theory of nursing.
General theories of nursing are applicable across all
practice situations in which persons need nursing
care. As such, the Self-Care Deficit Nursing Theory
describes and explains the key concepts common to
all nursing practice situations (Orem, 1995). The
theory consists of four concepts about persons
under the care of nurses, two nurse-related concepts,
and three interrelated theories (the Theory of
Nursing Systems, the Theory of Self-Care Deficit,
and the Theory of Self-Care). Concepts in the general
theory include, self-care, self-care agency, therapeutic
self-care demand, self-care deficit, nursing
agency, and nursing systems. The theory describes
and explains the relationship between the capabilities
of individuals to engage in self-care (self-care
agency) and their requirements for self-care (therapeutic
self-care demand). The term “deficit” refers
to a particular relationship between self-care
agency and self-care demand that is said to exist
when capabilities for engaging in self-care are less
than the demand for self-care.
The comprehensive development of the self-care
concepts enhances the usefulness of the Self-Care
Deficit Nursing Theory as a guide to nursing practice
situations involving individuals across the life
span who are experiencing health or illness, and to
nurse-client situations aimed at health promotion,
health restoration, or health maintenance.
According to this theory, nurses use their specialized
capabilities to create a helping system insituations
where persons are deemed to have an existentor
potential self-care deficit. Decisions about
what type of nursing system is appropriate in a
given nursing practice situation rests with the
answer to the question, “Who can and should
perform the self-care operations?” (Orem, 2001,
p. 350). When the answer is the nurse, a wholly
compensatory system of helping is appropriate.
When it is concluded that the patient can and
should perform all self-care actions, the nurse assumes
a supportive-educative role and designs a
nursing system accordingly. In nursing practice
situations, the goal of nursing is to empower
the person to meet their self-care requirements by
doing for (wholly compensatory system), doing
with (partly compensatory system), or developing
agency (supportive-educative system).
This chapter focuses on the extent to which
Orem’s theory is offering direction to nurse scholars
and scientists in advancing nursing science and
professional practice. Dorothy Johnson (1959), in
her treatise on nursing theory development, viewed
this attribute of a theory as its value for the profession,
its social utility.
Dorothea Orem’s theory is offering clear direction
to nurses in the advancement of nursing science in
this millennium. Orem describes nursing as a practical
science that is comprised of both theoretical
and practical knowledge, a point of view that is
grounded in modern realism (2001, p. 170). There
are parallels between Orem’s description of nursing
as a practical science and Donaldson and Crowley’s
discussion of nursing as a professional discipline.
Recall that Donaldson and Crowley (1978) stated
that the aim of professional disciplines is to know
and to use knowledge to achieve the practical goal
of the discipline. Both perspectives address the
need for nurses to develop both theoretical and
practical knowledge.
Orem (2001, p. 170) has identified a model
comprised of five stages for nursing science development.
Each stage is intended to yield different
kinds of knowledge about persons with existent or
potential health-related self-care deficits. Stages 1
and 2 of this developmental schema for science
focus on the advancement of the theoretical component
of nursing science. The theory is the result
of Stage 1. Stage 2 is described as the study of con
variations between the concepts proposed
within the Self-Care Deficit Nursing Theory for the
purpose of verifying and further explicating the
propositions (Orem, 2001, p. 171). The propositions
of the Self-Care Deficit Nursing Theory provide
direction to nursing researchers who aim to
focus their inquiry in theory-based research.
Numerous examples of research illustrating scientific
inquiry at the Stage 2 level of development
are contained in the nursing literature. The aspect
of the Self-Care Deficit Nursing Theory that has
generated the most research of this type is the
relationship posited between basic conditioning
factors and self-care agency. The basic conditioning
factors were identified initially by the Nursing
Development Conference Group (1979) and were
formalized later in a proposition linking them to
self-care agency. The second proposition listed in
the Self-Care Deficit Nursing Theory states that individuals’
abilities to engage in self-care (self-care
agency) are conditioned by age, developmental
state, life experiences, sociocultural orientation,
health, and available resources (Orem, 2001,
p. 167). This proposition offers direction to nurses
interested in engaging in theory-based research.
Basic conditioning factors are defined as “conditions
or events in a time-place matrix that affect the
value of person’s abilities to care for themselves”
(Orem). It is important to note that the influence of
the basic conditioning factors on self-care agency is
not assumed to be operative at all times. Nor are all
the basic conditioning factors assumed to be operative
at all times. Because the influence of these factors
occurs within a time-place matrix, research is
necessary to identify those nursing practice situations
in which the factors are operative and to explain
the nature of their influence on self-care
agency. Based upon research findings, relationships
between the basic conditioning factors and the substantive
structure of self-care agency can then be
made explicit. Programs of research designed in
this way can verify the existence of linkages between
these concepts and can explain the nature of
the linkages. Scholarly work of this type is vital to
the advancement of the theoretical knowledge of
nursing science.
Over the past decade, nurse researchers have
studied the influence of basic conditioning factors,
singularly and in combination, on individuals’ selfcare
abilities. Foremost among the basic condition-
ing factors studied is health state. Several studies
designed to determine the nature of the influence of
variations in health state on self-care abilities are reported
in the research literature. Research suggests
that this relationship is particularly salient in practice
situations in which persons are experiencing
chronic health problems. The work of selected investigators
is presented here to exemplify this line of
inquiry. The influence of change in health state on
the self-care abilities of persons with coronary
artery disease has been studied with both American
and Dutch adult patient populations (Isenberg,
1991; Isenberg, Evers, & Brouns, 1987). Across these
studies, changes in health state were found to be
critical determinants of the quality of the self-care
abilities of this patient population. As the health
state of patients improved, so did their capabilities
for self-care. Conversely, self-care capabilities
tended to decline as patients experienced recurrence
of pain and declining health. The findings revealed
a positive relationship between health state
and self-care agency in patients with cardiac disease.
In addition to the study of variation in health
state due to pathophysiology, the conditioning influence
of health state on self-care agency has also
been explored in situations in which the variation
in health state is due to psychopathology. West
(1993) investigated the influence of clinical variations
in the level of depression, conceptualized as a
health-state factor, on the self-care abilities of
young American women.West (1993) reported that
of the basic conditioning factors studied, the level of
depression (health state) was the dominant predictor
of the quality of the self-care abilities of her
sample. In a study with Dutch psychiatric patients,
Brouns (1991) also reported that variations in mental
health state significantly influenced patients’
self-care capabilities. In both studies a positive relationship
between health state and self-care agency
was revealed. Higher levels of mental health were
correlated with higher self-care agency scores.
These findings verified the conditioning influence
of health state on the self-care agency of patients’
experience variations in physical and mental health.
Moreover, the research findings clarified the nature
of the influence of health state on self-care agency.
The conditioning influence of other basic factors
on the self-care abilities of clinical and nonclinical
populations has been the focus of inquiry
of several nurse scholars. For example, Brugge
(1981) studied the influence of family as a social
support system on the self-care agency of adults
with diabetes mellitus. Vannoy (1989) explored the
influence of basic conditioning factors on the selfcare
agency of persons enrolled in a weight-loss
program. Schott-Baer (1989) studied the influence
of family variables and caregiver variables on the
self-care abilities of the spouses of patients with a
cancer diagnosis. Baker (1991) explored the predictive
effect of basic conditioning factors on the selfcare
agency and self-care in adolescents with cystic
fibrosis. McQuiston (1993) investigated the influence
of basic conditioning factors on the self-care
capabilities of unmarried women at risk for sexually
transmitted disease.Horsburgh (1994) conceptualized
personality as a basic conditioning factor
and tested the model with a healthy population and
a comparative clinical population with chronic
renal disease. O’Connor (1995) studied the influence
of basic conditioning factors on the self-care
abilities of a healthy and clinical adult population
enrolled in a nurse-managed primary care clinic.
Baiardi (1997) explored the influence of health
state and caregiving factors on the self-care agency
of the caregivers of cognitively impaired elders.
Artinian, Magnan, Sloan, and Lange (2002) examined
the influence of personal and environmental
factors on the self-care behaviors among patients
with congestive heart failure.
Opportunities to test elements of the Self-Care
Deficit Nursing Theory have been greatly enhanced
by the measurement work with self-care concepts
that has transpired over the past 20 years. It is important
to note that the theory-testing studies cited
above were made possible by the development and
psychometric testing of instruments to measure the
theoretical concepts. Instruments are currently
available to measure the self-care agency of adolescent
populations (Denyes, 1982), adult populations
(Evers, Isenberg, Philipsen, Senten, & Brouns, 1993;
Geden & Taylor, 1991; Hanson & Bickel, 1985), and
elderly populations (Biggs, 1990). The availability
of valid and reliable measures of self-care agency
has been vital to the advancement of the theoretical
component of self-care nursing science.
In addition to the theory verification line of
research, the Self-Care Deficit Nursing Theory is
being used to guide research programs to identify
the self-care requisites and self-care behaviors of
specific clinical populations. Intervention studies
designed to enhance self-care performance are also
under way. For example, Dodd has launched a program
of research focused on the self-care of cancer
patients who were receiving chemotherapy or radiation
therapy. Her early descriptive studies clarified
the health-deviation self-care requisites of this population
and documented the therapeutic self-care
demand (Dodd, 1982, 1984).More recent work described
specific self-care behaviors initiated by patients
receiving these therapies and led to the
identification of a patient profile of self-care that
can be used in practice to target specific patient
groups who are in most need of nursing interventions
(Dodd, 1997). Dodd’s intervention studies
demonstrated that with targeted information,
patients can learn more about their treatment and
can perform more effective self-care behaviors
(Dodd, 1997). Her work has advanced to conducting
randomized control trials to test a selfcare
intervention called PRO-SELF© to decrease
chemotherapy-related morbidity (Dodd, 1997).
Through her 20-year program of descriptive, predictive,
and intervention studies based on self-care
theory, Dodd’s research has demonstrated how to
enhance patients’ knowledge of their treatment and
how to increase effective self-care activities. Dodd
clearly qualifies as a pioneer in self-care theorybased
Investigators have used Orem’s theory to identify
the self-care requisites and self-care capabilities
of patients across a broad range of health deviations.
Based on the theory, Utz and Ramos (1993)
have conducted a sequence of studies to explore
and describe the self-care needs of people with
symptomatic mitral valve prolapse. The self-care
capabilities and the self-care needs (requisites) of
persons with rheumatoid arthritis have also been
described. The most frequently reported universal
self-care requisites for these clients were the maintenance
of a balance between activity and rest, the
promotion of normalcy, and the prevention of hazards
(Ailinger & Dear, 1997). Duration of illness
(health state) and educational level were found to
be related to self-care agency (Ailinger & Dear,
1993). Aish (1993) tested the effect of an Orembased
nursing intervention on the nutritional
self-care of myocardial infarction patients. A
supportive-educative nursing system was reported
to be effective in promoting healthy low-fat eating
behavior (Aish, 1993). Metcalfe (1996) studied the
therapeutic self-care demand, self-care agency, and
the self-care actions of individuals with chronic obstructive
lung disease. Health state was found to
offer significant explanation of variations in the
self-care actions of this population. Based on the
universal, developmental, and health deviation selfcare
requisites, Riley (1996) developed a tool to
measure the performance and frequency of the selfcare
actions of patients with chronic obstructive
lung disease. This tool has the potential to be useful
as an outcome measure in future intervention studies
designed to enhance the self-care abilities of this
Moore (1995) has used the Self-Care Deficit
Nursing Theory as the basis for her program of research
with children. She has developed the Child
and Adolescent Self-Care Practice questionnaire,
which can be used to assess the self-care performance
of children and adolescents. In a study of
children with cancer, Mosher and Moore (1998)
reported a significant relationship between selfconcept
and self-care. Children with higher
self-concept scores were found to perform more
self-care activities than children with low selfconcept
scores (Mosher & Moore, 1998).

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