Dorothea Orem’s Grand Nursing Theory

Introduction

Theories can provide nurses with the basis or rationale for making decisions. Dorothea Orem’s theory, also known as Dorothea Orem’s model of nursing, evolved with the idea that when one is unable to perform activities individually to maintain activities of daily living such as maintaining health and well-being, nurses will have the opportunity to organize and provide nursing interventions based on their clinical findings (Hartweg, 1991). The theory was chosen to give clarity of what the nursing role can provide to assist patients in accommodating or adapting to their self-care deficit.

Theorist Biography

Dorothea Orem was born in Baltimore, Maryland, in 1914. Dorothea studied and received a nursing degree at Providence Hospital School of Nursing. In 1939 Orem obtained an undergraduate degree, a Bachelor of Science in nursing and 1945 a graduate degree, a Master of Science in nursing (Dorothea Orem’s self-care theory, n.d.). Orem received various honorary degrees from Illinois Wesleyan University and Georgetown University and received a great number of Doctor of Science degrees as well as Sigma Theta Tau International awards. Orem died in Savannah, Georgia in June 2007 as a known consultant and author.

Theorist Category

Orem’s theory is recognized as a grand theory, which provides a framework for the concepts and principles of the theory. Self-care deficit theory is classified as a theory based on individual needs. Because of the complex and diverse nursing knowledge, Orem outlined three interrelated theories: the theory of self-care; a theory based on an individual capable of caring for themselves; the self-care deficit theory; a theory of when an individual isn’t able to meet their needs on their own, and theory of nursing systems; a theory based on interventions given by nurses to meet a patient’s needs. These systems have been recognized as a framework to meet an individual’s needs. Within the theory, very little attention was given to the patient’s emotional needs.

Assumptions

Orem’s self-care deficit theory includes assumptions related to individuals and nursing. Individuals are unique human beings and are responsible for their care as well as the care of family members that need it. To establish self-care behaviors, an individual must know potential health problems. A person’s self-care behaviors are learned within their socio-cultural environments and promoting self-care behaviors is necessary for primary care prevention and health. Nursing requires an interaction between two or more people and is considered a form of action (Self-care deficit theory, 2016).

Concepts and Propositions

Orem’s theory defines metaparadigm concepts including the nurse, human beings, environment, and health. Orem describes the nurse as an intelligent participant in the care an individual receives from the physician, and nursing is defined as giving “specialized assistance to persons with disabilities… more than ordinary assistance necessary to meet self-care needs” (McEwen & Wills, 2014, p. 143). Humans are thought to be either single or social units and are the objects of direct care providers, including nurses (McEwen & Wills, 2014). Orem includes families and communities in the concept of environment, along with physical and chemical factors. Health for human beings is defined as “the ability to reflect on one’s self, to symbolize experience, and to communicate with others” (McEwen & Wills, 2014, p. 143). This is thought to be a state that can be described as an individual as well as a group. Orem’s concept of self-care is the human function acted upon deliberately to sustain life and promote growth and development to maintain integrity (McEwen & Wills, 2014).

Orem’s theory involves three related components: “theory of self-care, theory of self-care deficit, and theory of nursing systems” (McEwen & Wills, 2014, p. 144). The theory of self-care is explained as the human function that an individual can either perform independently or have performed for them by nursing or dependent care. Within the self-care component, there are three requirements for self-care: universal, developmental, and health deviation (Hartweg & Pickens, 2016). Universal self-care requisites involve normal processes and the maintenance of human functioning and structure, also known as the activities of daily living, or ADLs. Developmental self-care requisites usually arise from a condition or are associated with a particular event. Health deviation self-care requisites are involved with disease and injury and can include seeking appropriate healthcare, complying with prescribed medications or orders, and adjusting to life with a diagnosis. Self-care deficit, the second component of Orem’s theory, identifies when nursing is necessary. When an individual is no longer capable of self-care, that individual must receive nursing care. Methods of nurse care include: doing for others, guiding, supporting, teaching, and promoting an environment that aids personal development to achieve outcomes. The third component, nursing systems, identifies how the individual’s self-care needs will be attained by the individual, the nurse, or both. Three classifications of nursing systems are “wholly compensatory, partly compensatory, and supportive-education” (Self-care deficit theory, 2016).

A major concept behind Orem’s theory is the relationship between humans and the environment. According to Orem, human beings are involved in a continuous exchange of energy between themselves and their environment that allows them to function as living beings. Humans act deliberately and doing so allows the identification of needs and decision-making abilities. Through this act, an individual can communicate the needs of themselves and others around them. A group of individuals with structured relationships can divide and conquer responsibilities for care to group members that have identified themselves, or been identified by others, as requiring care (McEwen & Wills, 2014).

The technical component of Orem’s nursing process provides a framework for determining self-deficits and clarifying roles to meet the demands of self-care. The first step in this process is the assessment, allowing for the collection of data to determine the problem that needs to be addressed. The nursing care plan is the next step, created after identifying the diagnosis. The final step of Orem’s nursing process is implementation and evaluation. While this process is technical, Orem stresses the importance of relating technical components with interpersonal and social pressures of nursing situations (Self-care deficit theory, 2016).

Literature

The health deviation component of Orem’s self-care theory involves seeking appropriate health care. In current literature, Orem’s theory has been used with patients that suffer from chronic illnesses, such as heart failure. This study has shown how individuals with chronic illnesses can provide self-care through Orem’s nursing theory by self-monitoring, taking medication properly, diet and exercising (White, 2013). The importance for patients with heart failure to obtain daily weights monitor for swelling and eating low sodium diets all played a part in the self-care that was provided. Patients were able to provide this level of care to them through education that was provided by nurses, which is another part of Orem’s theory. This portion is identified as a self-care deficit. It was also discovered that patients with heart failure relied on healthcare professionals in the early stages of the disease. It was in their deficit stages that patients began to retain the knowledge needed to provide self-care (White, 2013). In this article, it was determined that patients with chronic heart failure could be managed with proper self-care practices such as the ones listed above (White, 2013).

Integrated

Orem’s theory will be integrated into our facility in the outpatient setting as well as the acute patient setting. In the outpatient clinics, patients with heart failure will have a flag placed on their chart by their primary care provider’s nurse. This flag will alert every healthcare provider that opens that patient’s chart of heart failure. In-clinic appointments the patients will be weighed, blood pressure will be obtained, and medication will be reviewed for compliance. The patient will receive a medication card. On this card will be a list of all current medication with a grid that has days, times, and frequencies of the medication as listed in figure 1. This medication card will be provided and updated by the pharmacist. Lastly, in the outpatient clinics, patients with heart failure will have been provided a scale that will be used every morning. This scale will send the patient’s weight directly to their primary care provider’s nurse to ensure adequate weight. Patients that actively participate in these activities will gain points that can be redeemed for merchandise from the gift shop.

Patients that have heart failure who are admitted into the acute patient setting will go through all the steps listed above as well as ensure they are set up with a primary care provider and a cardiologist. During admission, the nurse from the primary care clinic will visit the patient and discuss the reasons for the admission and ways that readmission can be prevented. The action plan from both settings would require a great deal of communication, the patient and nurse must have a relationship in which there is open, non-judgmental dialogue. These items are all important and can positively impact the patient in providing self-care to one’s own healthcare needs.

Communication is a key component not only among the patient and staff but also among the colleagues coordinating care. If the patient qualifies for home health care, additional education can be provided in the home. Home health nurses can not only provide education but also coordination of care to reduce the chances of rehospitalization. Patients with a new diagnosis of heart failure deal with not only self-care behavior, but abilities to care for themselves as well as the quality of life. A three-dimensional scale for self-behavior in patients with heart failure can be classified as assessing the functional capabilities, symptoms, and psychological adjustment to the illness. The assessment can utilize pre-interventions and post-intervention. In a study conducted by Jaarsma et al. (2000), the study concluded that the group who had interventions specific to heart failure and symptom management had a decrease in symptom frequency as well as symptom distress. Furthermore, the study concluded that providing patients with supportive nursing interventions was effective in improving self-care behavior in patients who had advanced heart failure. The recommendation from the study was to provide a more intensive intervention to improve the patient’s quality of life (Jaarsma et al., 2000).

Conclusion

There are many models and strategies to manage a fragile patient population. Orem’s self-care theory focuses on the patient population can care for one’s themselves independently assuming proper resources are available. Orem also links the theories of self-care, self-care deficit, and nursing together encompassing the overall structure of the self-care deficit (McEwen & Wills, 2014). Orem’s theory of self-care is an important tool to focus on the care of a patient as it provides a better patient understanding of the pathology of their disease, therapeutic process, and informed consent for treatment. Additionally, Orem’s theory postulates that individuals have the normal capacity for self-care and nursing should focus on recognizing the deficit areas. Nurses recognizing the knowledge deficit from the patient can provide the patient with self-care knowledge. Utilizing Orem’s theory in daily practice to identify self-care deficits, knowledge-deficits, and provide the tools necessary will improve the patient’s quality of life. Orem’s theory also encourages patient engagement and gives the patient a sense of control over health maintenance, thus providing improved outcomes (O’Shaughnessy, 2014). It is through research and evidence-based practice that nursing knowledge continues to grow and improve the quality of care that is delivered to patients across the healthcare continuum. Health care providers need to provide patients with clear communication, education, seamless coordination of care, and support to assist the patient with self-care.

References

Dorothea Orem’s self-care theory, (n.d.) Web.

Hartweg, D. L. (1991). Dorothea Orem: Self-care deficit theory. Newbury Park, Calif: Sage Publications.

Jaarsma, T., Halfens, R., Tan, F., Abu-Saad, H. H., Dracup, K., & Diederiks, J. (2000). Self-care and quality of life in patients with advanced heart failure: the effect of a supportive educational intervention. Heart & Lung: The Journal of Acute and Critical Care, 29(5), 319-330.

McEwen, M. & Wills, E.M. (2014). Theoretical basis for nursing (4th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

O’Shaughnessy, M. (2014). Application of Dorothea Orem’s Theory of Self-Care to the Elderly Patient on Peritoneal Dialysis. Nephrology Nursing Journal, 41(5), 495-498.

Self-care deficit theory (2016). Nursing Theory. Web.

White, M. L. (2013). Spirituality Self-Care Effects on Quality of Life for Patients Diagnosed with Chronic Illness. Self-Care, Dependent-Care & Nursing, 20(1), 23-32.