http://prism.troy.edu/~martin/DorotheaE.Orem'sTheory.pdf
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Running Head: DOROTHEA E. OREM’S SELF-CARE DEFICIT THEORY
Dorothea E. Orem’s Theory
Elaine Martin
Troy University School of Nursing
Nursing 5504
December 2, 2005
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Dorothea E. Orem’s Theory
Orem presented a conceptual framework in 1959. Since then her work has
continued to evolve. Orem’s general theory of nursing was formulated and expressed in 1979-
1980. Orem (2001) states her general theory as 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 that amount and quality of self-care that is therapeutic in sustaining life and health,
in recovering from disease of injury, or in coping with their effects. With children, the condition
is the inability of the (or guardian) associated with the child’s health state to maintain
continuously for the child the amount and quality of care that is therapeutic (p.82). Orem’s Self-
Care Deficit Theory of Nursing is conceptual model, which is comprised of three related
theories: (1) the theory of self-care, (2) the theory of self-care deficit, and(3) the theory of
nursing systems. Included within these three theories are six central concepts and one peripheral
concept. You must understand these central concepts of self-care and dependent care, self-care
agency and dependent care agency, therapeutic self-care demand, self-care deficit, nursing
agency, and nursing systems in addition to the peripheral concept of basic conditioning factor, to
understanding her theory (George 2002).
The theory of self-care is the practice activities that individuals initiate and perform on
their own behalf in maintaining life, health, and well-being. The theory of self-care deficit is the
core of Orem’s general theory of nursing because it explains when nursing is needed. Nursing is
required when an adult (or in the case of dependent, the parent or guardian) is incapable or
limited in the provision of continuous effective self-care. The nursing system, designed by the
nurse, is based on the self-care needs and abilities of the patient to perform self-care activities.
In this theory, Orem states how the patient’s self-care needs will be met by the nurse, the patient,
or both.
Orem identified three classifications of nursing system to meet the self-care requisites of
the patient. These systems are: the wholly compensatory system, the partly compensatory system
and the supportive educative system (George, 2002). In the wholly compensatory system a nurse
provides complete universal and health care functions for the patient. This phase is when the
patient is most vulnerable and totally dependent upon the nurse to meet their self-care requisites.
When the patient is able to assist and perform some self-care needs, but must rely on someone
else to meet all self-care requisites in the partly compensatory system. Within the supportive/
educative system, the patient is able to perform their self-care requirements and the nurse simply
acts as a resource for guidance and support.
Orem’s theory is based on explicit and implicit assumptions. Meleis (1997) summarizes
the explicit assumptions as:
1) Nursing is a deliberate, purposeful helping service performed by
nurses for the sake others over a period of time,
2) Persons (human agency) are capable and
willing to perform self-care for self or for dependent members of the family,
3) Self-care is part
of life that is necessary for health, human development, and well-being,
4) Education and culture influence individuals,
5) Self-care is learned through human interaction and communication,
6) Self-care includes deliberate and systematic actions performed to meet known needs for care,
7) Human agency is exercised in discovering, developing and transmitting to others ways and
means to identify needs for and make inputs to self and others.
In brief, Meleis states the
implicit assumptions as:
1) People should be self-reliant and responsible for their own care needs
as well as for others in the family who are not able to care for themselves,
2) People are individuals with entities that are distinct from others and from their environment.
The metaparadigm is the most abstract component of the structural hierarchy of nursing
knowledge. Nursing’s metaparadigm consist of concepts and propositions that are global with
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Orem 4
phenomena which is limited to the discipline of nursing with no specific perspective.
The metaparadigm of nursing is composed of four concepts, which are person, environment, health
and nursing. These four concepts are reflected in Orem’s theory Self-Care Framework (Fawcett,
2000).
Orem defines person as human beings who are “distinguished from other living things by
their capacity (a) to reflect upon themselves and their environment, (b) to symbolize what they
experience, and (c) to use symbolic creations (ideas, words) in thinking, in communicating, and
in guiding efforts to do and to make things that are beneficial for themselves or others” (Orem,
2001, p 182). The functions of human beings are integrated to include physical, psychological,
interpersonal, and social aspects. A person’s self-care needs are met by a learned behavior.
Factors which may affect an individual learning include age, mental capacity, culture, society
and emotional state. When learning of self-care measures does not occur, others must learn the
care and provide it (George, 2002).
Orem’s (2001, p. 184) concept of health is defined as “a state of physical, mental and
social well-being and not only the absence of disease of infirmity” (p. 184) as well as speaking to
the relationship between health, well-being, and being whole or sound. Through a sense of
personalization well-being is a perception of contentment, happiness and pleasure. An individual
is an integrated whole composed of internal physical, psychologic and social nature with varying
degrees of self-care ability.
Orem (2001) speaks to nursing as a specific type of human service based on self-help and
help to others. Adults are expected to be self-reliant and responsible for themselves and for the
well-being of their dependents. Whenever the maintenance of continuous self-care requires the
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use of special techniques and the application of scientific knowledge then nursing is required in
providing the care or in designing it.
Orem (2001) further defines nursing as a human service. Nursing is distinguished from
other human services by its focus on persons with inabilities to maintain the continuous
provision of health care. Nursing is needed when the adult is unable “to maintain continuously
that amount and quality of [health-associated] self-care that is therapeutic in sustaining life and
health” (p. 82).
Environment as defined in the metaparadigm of nursing, refers to the person’s significant
others and physical surroundings, as well as the setting in which nursing occurs, which ranges
from the person’s home to clinical agencies, to society as a whole (Fawcett, 2000). According to
Orem, environment is tri-dimensional, encompassing the physical, socioeconomic, and
community features. The physical features involve maintaining the human structure, functioning,
and well being. Socioeconomic features focus on the family, including composition by roles and
ages, cultural prescriptions of authority, responsibilities and rights for the family unit.
Community features are inclusive of the population and its composition by family units, by other
function, collaborating social units, and by governmental voices (Fawcett, 2000).
The metaparadigm concept nursing is represented in the Self-Care Framework by the
concept Nursing Agency. Nursing Agency is the action of nurses in determining the needs for,
design of, and production of nursing for persons with a range of types of self-care deficits.
Nursing Agency includes three dimensions which are the social system, interpersonal system and
professional-technologic system. The social system includes the relationship between the nurse
and the patient forming an agreement for the purpose of obtaining nursing care when an actual or
potential self-care of dependent-care deficit has evolved. The interpersonal system involves the
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contact, association, and communication between the nurse and the patient. The professional
technological system is the system of action productive of nursing. The existence of the
professional-technological system is dependent on the existence of the interpersonal system,
which in turn, is dependent on the existence of the social system (Fawcett, 2000).
The Self-Care framework has been accepted by the nursing community to guide research
and practice throughout the U.S. and other countries. Before the use of the Self-Care framework,
it is vital to understand its focus and content. Nurses and nursing students have to learn the
particular “style of thinking and communicating nursing.” (Orem, 1995, p. 167)
Nurse administrators have found the theory adaptable to implementation in a number of
institutions and a great number of chief nurses of the Department of Veteran Affairs medical
centers reported using either Orem’s theory or a combination Orem with other theorists. Orem
herself proposed a framework for nursing administration. Miller (1980) challenged nursing
administrators to create a climate to enhance the use of theory, although she did not give much
guidance or exemplars for implementation on a large scale involving nursing administrators. She
offered a model for nursing practice based on Orem’s’ theory, demonstrating its utility for care in
acute illness, convalescence, and restored. The model was based more on a developmental,
health/illness continuum than on Orem’s theory.
The theory evolved from interest in curricula for diploma and baccalaureate programs and
the need to differentiate between technical and professional education. Therefore its utility to
nursing education is enhanced by theorist’s interests. It is no surprise that the theory has been
used as conceptual framework in associate degree programs. There has been documentation
published regarding the use of the framework as a curriculum guide for the diploma nursing
program at Methodist Medical Center of Illinois in Peoria, Illinois; the associate degree nursing
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program and the baccalaureate programs at George Mason University in Fairfax, Virginia,
Georgetown University in Washington, DC, just to name a few. Some of the uses of the
framework has been used in the administrative settings at the nurse-managed clinics at the Johns
Hopkins Hospital in Baltimore, Maryland, the basis for structuring nursing practice and roles and
functions of nurses at the Mississippi Methodist Hospital and Rehabilitation Center since 1976
and also structuring nursing practice a the Betty Bachrach Rehabilitation Center for Immunology
and Respiratory Medicine in Denver, Colorado.
In nursing research numerous master’s theses and doctoral dissertation have used the Self-
Care Framework as a guide. A literature review of the Self-Care Framework revealed that it
guided a wide range of research design, from psychometric studies of framework-based
instruments to experimental studies. Correlational studies have focused on the identification
of variables associated with the exercise of self-care agency. Moore(1993) found that basic
conditioning factors , self-care agency, and mothers’ dependent-care performance were related
to children’s self-care performance. Several Self-Care Framework –based experimental studies
have been conducted. The findings of some of those studies provide evidence that supports the
effectiveness of Self-Care Framework-based nursing interventions.
The utility of the Self-Care Framework for nursing practice is fully documented. The
Self-Care Framework has been used to guide the care of patients who seek care in different
inpatient and outpatient settings. Publications document the use of the framework as a guide to
patient care in such settings as: intensive care and critical care units, operating rooms, obstetrical
units, and nursing homes. Self-Care Framework –based nursing care is also documented in
outpatient settings such as: Ambulatory clinics, emergency departments industry and hospices.
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This framework has been used to design nursing care for patients of various ages and with a
variety of self-care requisites. The theory’s circle of contagiousness in research, education, and
administration is limited, but it has the widest circle of all theories in practice (Meleis, 1997).
The goal of nursing is to meet the self-care needs of individuals when they cannot. It is
the goal that nursing will help the client maintain, regain, or stabilize his or her state of health.
The major focus is the degree of therapeutic self-care demand as related to the capabilities one
may provide for a deficit relationship in which capabilities become necessary (Torres, 1986).
Therefore, the ultimate goal of Orem’s work is to allow the patient to achieve an optimal level of
self-care.
The application of Orem’s Self-Care Deficit Theory on Nursing can be utilized in Mr.
Jones case study within the nursing process. Orem (2001) defines, “Nursing process is a term
nurses use to refer to nurses’ performance of the professional-technologic operations of nursing
practice”. The first step is to investigate and collect data about the patients’ self-care agency and
their self-care demand and the existent or projected relationships between them. Mr. Jones was
able to meet all of his self-care needs prior to being diagnosed with a massive myocardial
infarction and CVA. Mr. Jones basic conditioning factors were listed as a 45 year old male,
accountant, and married with five children. His universal self-care demands were: stressful job,
little physical rest, did not take medicine, no annual checkup and only seeked medical attention
when he had chest pain. Mr. Jones worked 12-14 hours per work day, had a supportive family,
wife has never worked and no workable skill, with five children from age 1-17, and a 17 year old
son graduating from high school were developmental self –care requisites identified. His stage of
development is generativity, which he displayed a sense of accomplishment, providing for his
family, and giving loving care, rearing children as a contribution to humankind and the larger
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society. His family is very supportive and financially stable. Health –derived limitations, Mr.
Jones were characterized with non-functional on right side, limited mobility, barely speak
clearly, poor bilateral coordination, and family history of mother died of a stroke and father died
of a heart attack. These conditions diverted Mr. Jones from the theory of self-care to the theories
of self-care deficit and nursing systems. (Bufalin, 1991).
Nursing diagnosis based on self-care deficits are: Impaired verbal communication r/t
aphasia: Feeding self-care deficit r/t sensorimotor impairment, unilateral neglect, communication
difficulties; Body image disturbance r/t loss of body function, physical changes, role changes.
The plan of care to be provided for Mr. Jones, but not limited to: To establish/reestablish an
effective means of communication; Mr. Jones will perform basic ADLs with success and some
independence, and will be able to perform a schedule of activities appropriate to condition and
mental readiness; Mr. Jones and family will adapt effectively to altered lifestyle, and changes in
roles resulting from his altered health status. (Bufalin, 1991)
Measures implemented to improve self-care deficits: 1) assess patient’s ability to
communicate (express self, understand other, remain oriented),maintain eye contact wit patient
when communicating, address patient in a slow and unhurried manner, consult and coordinate
efforts with speech therapist; 2) determine patient’s ability to perform ADLs, obtain necessary
assistance devices to enable patient to function maximally, provide tasks that can be easily
accomplished, encourage patient to use affected extremity in as many tasks as possible, offer
positive feedback for gains in self-care activities, 3) assess patient’s/family previous lifestyle
roles and responsibilities, acknowledge patient’s frustration with limitations, reinforce abilities
and progress, encourage patient to dress in own clothes to focus positively on abilities and return
to a more normal lifestyle. (Bufalino, 1991)
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The following outcomes will enable Mr. Jones to become an effective self-care agent:
1) Mr. Jones communicates needs with verbal and/or nonverbal cues, 2) Mr. Jones can feed,
bathe, and dress self with increasing independence; verbalizes/demonstrates ability to care for
self at home, 3) Mr. Jones/family verbalize acceptance of necessary lifestyle change; interacts
positively with others. The designed nursing system for Mr. Jones would be the wholly
compensatory nursing system. Orem (2001) identifies this system as a situation in which the
individual is unable “to engage in those self-care actions requiring self-directed and controlled
ambulation and manipulative movement or the medical prescription to refrain from such activity
…Persons with these limitations are socially dependent on other for their continued existence
and well-being.”
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References
Bufalin, P.M., & Caine, R. M. (1991).
Williams & Wilkins.
Fawcett, J. (2000).
and theories.
Foster, P.C., & Bennett, A.M. (2002). Self-Care Deficit Nursing Theory: Dorothea E. Orem. In
J.B. George (5
125-149). Upper Saddle River, New Jersey: Prentice Hall.
Meleis, A.I. (1997).
Lippincott-Raven.
Orem, D. E. (2001).
Torres, G. (1986).
Nursing care planning guides for adults. Baltimore.Contemporary nursing knowledge: Analysis and evaluation of nursing modelsPhiladelphia: F.A. Davis Co.th edition), Nursing theories the base for professional nursing practice (pp.Theoretical Nursing: Development & Progress (3rd ed.). Philadelphia:Nursing: Concepts of practice (6th ed.). St. Louis: Mosby.Theoretical foundations of nursing. East Norwalk, CT: Prentice Hall.