1. Self-Care Deficit Nursing Theory in
Ingolstadt – An Approach to Practice
Development in Nursing Care
Monika Hohdorf, RN; M.Sc
Abstract system. As such, they were expected to assume
The Diagnostic Related Groups (DRG) system was introduced
more responsibility for their own health situation,
into the German health care system in 2004. This change on the premise that they best understand their own
placed increased responsibility on the nurses as they shifted health needs and thus are competent to decide
focus toward more health promotion strategies that included what resources they need. The consumers of
a greater emphasis on teaching patients to assume more
responsibility toward self-care. One hospital in Germany
health care services are now expected to actively
sought to address this new focus by moving toward a nursing participate in health care decisions; and, as a
theory-based service. Orem’s Self-care Deficit Nursing Theory result, contribute to direct cost control of national
was chosen to conceptualize nursing practice. A program health care resources. In order to facilitate this,
of change was implemented with emphasis placed on the
structure of the nursing process as a means to coordinate
German health care policy now mandates health
patient care in the hospital setting, thus enhancing the care professionals to strengthen the consumers’
decision making competency of the nursing staff. Although no competency to participate in planning and
empirical evaluation has been conducted thus far, anecdotal determining their health care. Consequently,
findings suggest a positive effect on shortening length of stay
for hospitalized patients and on the quality of nursing care
the nursing profession is challenged to change
provided to complex patients (especially those who show a traditional nursing care delivery systems. Nurses
high demand for case management due to risks related to are now asked to take over responsibility for the
unmet self-care demands). quality of care provided, to justify the need for
Keywords: clinical nursing practice, Orem Self-care Deficit nursing actions targeted to individual needs, and
Nursing, self-care, practice development, nursing education, to quantify nursing services in order to clarify
Germany nursing’s contribution to the nation’s health.
Nurses must focus on health care problems
involving multi-system disorders, co-morbidity,
case complexity, and duration of health care
Introduction: Context of Proposed Change
needs which impact the clients’ ability to care
The Diagnostic Related Groups (DRG) for themselves. Nurses are also called upon to
system was introduced into the German health actively control the length of stay in hospitals and
care system in 2004. This was done in response ensure that health deviation self-care requisites
to exploding expenditures for social welfare are met by the patients and their dependent care
and healthcare due to chronic illness, an aging agents when they are discharged from hospital.
society, and the complexity of treating patients Unfortunately, the German nursing force is ill
with multi-system health care problems. The prepared to respond to the national demand for the
goals of this initiative were to reduce the length of increased scope of nursing care required. There is
patient stay in acute care hospitals and to lessen a need for more advanced educational preparation
the consumption of costly inpatient resources. to meet the new challenges facing nurses.
This new payment system represented a radical In addition, the issues of professional versus
shift from traditional reimbursement and led to technical status of nurses, the lack of professional
increased pressure to meet the needs of medically autonomy, domination by a strong medical model,
complex patient situations. Consequently, the role and the absence of a clear statement of the scope
of the nurse in the health care system needs to of nursing practice remain unresolved.
be reorganized with the focus shifted to the health In 1992, nursing education in Germany
care demands of patients from the moment they became available in the university setting. With
enter the health care system, throughout the this move, studies in nursing science, nursing
hospital stay, and continued care at home. research, and professional role development were
With this shift, German health care consumers recognized as crucial components of nursing.
became the ‘third party’ in the national health care However, there is no history of a nursing theory
Vol: 18 • No: 01 • October 2010 • Self-Care, Dependent-Care & Nursing • 19

2. component in Germany compared to some Conceptualizing the Program
other countries. Indeed, attempts to establish a
scientific infrastructure based on nursing theory In 2005, the nurse management team at
has been met with resistance from the nursing one hospital in Germany decided to implement a
professional organizations (Brandenburg et al., program for the nursing work force. The goals of
2003). Thus, there remains a lack of awareness the program were to improve the quality of nursing
about the specific perspective of nursing – what care provided and to adequately respond to the
it is, what it should be and what impact nursing needs of future health care development. This
has on the person’s state of health. It seems decision was based on the belief that the “future
more and more obvious that without a nursing nurse” would have to work in increasingly complex
perspective on health related issues, nursing situations and would have to manage increasingly
is only a superficial and subordinate activity complex care. To meet this challenge, the role of a
that cannot be named or measured. If nursing clinical nurse case manager was introduced. In this
is to justify itself as a profession with actions role, nurses would be asked to identify patients’
separate from that of medicine, it must be able to health care demands on admission to the hospital,
articulate its overall relevance to the health care to devise nursing strategies to address these
system and to the health outcomes of patients. demands during the hospital stay, and to develop
Nursing knowledge needs to be made explicit, ways to meet these demands as patients segue
meaning that what nurses think and how they from the hospital environment to the home. The
finally decide to act must be set in the context of team selected Orem’s Self-Care Deficit Nursing
patient needs. Therefore, nurses must be able to Theory (SCDNT) to provide the organizational
relate nursing actions to the actual care needs framework for the new program and for the
of people when those people are not able to new nursing system. This decision provided a
provide continuously for themselves because of theoretical approach to shape the decision-making
the amount and quality of self-care they require process and describe the operational process of
(Orem, 1997). Thus, practitioners of nursing must nursing (Orem Study Group, 2004, Taylor, 1998).
develop nursing knowledge that provides “in depth Use of a nursing theory “...suggests appropriate
nursing knowledge and experience based on a facts to be gathered and the relatedness of data
theoretical nursing framework, which continues to and provides the structure for the reasoning
explore, explicate and develop nursing knowledge process” (Taylor, 1998 p.112).
and technologies based on the concepts of that Orem (1997) postulated that people can and
theory” (Nickle, 1998). want to learn self-care. In order to meet what she
In addition, nursing education in Germany defined as self-care requisites, they use their
does not adequately address nursing diagnosis. self-care abilities (or access help in the form of a
There is no common understanding about dependent-care agent) to meet the demands they
the structure, the process and the relevance face. As long as self-care abilities equal or exceed
of nursing diagnosis to nursing practice. The self-care demands, they (or their dependent care
process of care is defined as a process of agents) have no need for nursing. When the
systematically gathering information that justifies demands exceed the abilities, a self-care deficit
health care assistance, health care support, or occurs. Orem defines self-care deficit as the
complete delivery of health care actions. Nurses relationship between the existing self-care agency
often fail to collect information in a systematic and self-care demand of persons, when self-care
manner and fail to communicate their findings competencies are inadequate to satisfy self-care
effectively with other health care professionals. demand. Within this theoretical framework, nurses
As a result, their information does not provide can identify self-care problems and plan care
a clear understanding of the patients’ deficits. based on case complexity and health related risks,
Consequently, while the pathophysiology of the select the related demand for case coordination
patient’s condition may be understood, other during hospital stay, and plan for the acquired
factors that impinge on overall health are not need of information and education for patients.
analyzed. Often those assessments nurses Information can also be organized quantitatively
consider relevant for nursing care are not and qualitatively and be classified according to
addressed. Thus, a nursing theoretical structure nursing interventions.
that systematizes the process of data collection, According to Taylor (1998) “...the way the
relates the information gathered to the individual individual nurse conceptualizes nursing is
patient’s self-care needs, and guides the reflected in the process of information gathering,
interventions and action considered necessary to diagnostic reasoning, and clinical decision
adequately respond to them might prove helpful making as well as in the selection of methods
to structuring nursing care. of assisting and designs for action that produce
20 • Self-Care, Dependent-Care & Nursing • Vol: 18 • No: 01 • October 2010

3. nursing results” (p.112). The SCDNT provides the proposed changes as painful and unnecessary.
basis for nurses to systematically collect data and They did not consider nursing diagnosis as a
appraise the individual demand for nursing care, change that was necessary nor did they value
shape communication, select nursing objectives a nursing theory based nursing service. There
appropriate to meet patient’s self-care demands were three major obstacles in the attempt to move
and guides the development of instruments and forward with the changes:
technologies. Adopting the view that the need
for nursing exists the moment self-care demand • “Nurses in practice settings do not accept
exceeds self-care agency supports the change theoretical concepts which in their view are
toward a patient centered approach of care. a contrast to their practice fields.
• Nurses in practice settings are critical of
Selecting a communication tool theories, often viewing theory as something
that is incompatible with practice.
In order to improve and coordinate patient care, • Nurses’ efforts in practice mostly relate to
decisions made by nurses must be individualized human behaviours, even if no scientific or
to the patient situation, information collected by nursing specific system of explanation for
nurses must be clearly communicated to other a course of nursing actions exist” (Bekel,
health care providers and nurses must actively 1998 p.7).
intervene and support the therapeutic self-
care demands of patients. Orem stated, “The Within this atmosphere, strategies had to be
conclusions or judgements made by nurses must developed to successfully implement a theoretical
be labelled in order to communicate what is known approach to guide daily nursing practice. Hence the
about the situations and what has been done and team decided on measures which hopefully would
should be done” (Orem Study Group, 2004, p.13). impact practice development quickly, result in
Nursing diagnosis helps achieve a systematic short term success to satisfy hospital management
process for organizing and communicating nursing concerns, and demonstrate positive results to the
judgements. Thus, nursing diagnosis as “...a nurses in order to change their personal beliefs
means of communication became the term used and knowledge about the effectiveness of using
to refer to a series of judgements about nursing theory to guide practice. The long range
goal was to stabilize practice development and
• a therapeutic self-care demand present at introduce a model of patient-centered care in
a point in time, which the patients’ health care needs would
• self-care capabilities and limitations and stimulate organizational development. The
a judgement about potential for change, hospital management team set the following goals
and for implementing the program:
• the relationship between the two” (Orem
Study Group, 2004, 14). • “Decrease in discontinuity of nursing
processes related to patient treatment.
Applying Orem’s theory to practice provides • Decreasing discontinuity of interdisciplinary
a guide to predict, describe and explain the treatment processes of patients.
phenomena of nursing and helps nurses to • Development and utilization of nursing
discover why patients need nursing care. The specific language related to nursing theory”
introduction of the SCDNT focuses nursing care (Bekel 1998 p.7).
on the determination of patients’ abilities to provide
self-care in order to strengthen their self-care Implementing the Program
competency. Coupled with nursing diagnosis,
nurses can finally come to a statement where Between the years 2005 to 2007, the nurse
they describe these phenomena that indicate management team developed an educational
that patients or their dependent-care agents program introducing the SCDNT for all nurses
show deficiencies of competencies to maintain who had completed three years of basic nursing
self-care. education. To encourage and strengthen the use
of theory in practice, the nurses were taught the
Initiating the program method of case analysis as a way of gathering and
synthesizing data. Case analysis is an approach
Initially, there was resistance to this program. to problem solving where nurses develop their
Traditional hospital structures, work load and work ability to conceptualize and develop creative
environment did not favour organizational change. nursing care in actual clinical practice. This relates
Indeed, the nurses themselves considered the theoretical concepts to clinical reality, enabling
Vol: 18 • No: 01 • October 2010 • Self-Care, Dependent-Care & Nursing • 21

4. nurses to relate their implicit knowledge to what Indeed, therapeutic self-care demand exceeding
they perceive when they look at an individual self-care capability is a contributory cause of
patient’s health care situation (Andrews, 1996). hospital admission. Using the foundations of
The SCDNT provides a frame of reference that Orem’s theory enables nurses to identify factors of
sets data into context enabling nurses to ‘frame self-care demand that exceed self-care abilities.
the problem’ and reduce case complexity, thus
providing nurses with a cognitive structure which Selecting and Educating the Participant
they internalize as a ‘cognitive map on demand’ in Nurses
order to guide their reasoning process. By focusing
on issues that impinge on a patient’s health care, A human resource program designed to
nurses develop strategies and actions specific to sustain the integration of nursing theory based
nursing to help the patient achieve the necessary practice and to provide the basis for organizational
self-care abilities to regulate therapeutic self-care change was implemented. Specifically selected
demand. To this end, an Orem based instrument nurses participated in this 2 year training program.
for systematic data collection was created (Bekel, Nurses were chosen based on two criteria: first,
2004). This instrument helped guide nurses to for their potential for leadership in health care and
look at data they had not previously considered second, for their ability to deal with controversial
as relevant prior to implementing the plan of care. change issues, such as the demand for change
(see Table 1) in the processes of care, the structure of hospital
Nurses were also taught to use Orem’s basic organization and the provision of health care
conditioning factors (BCFs) in their assessments. services. Since university programs designed to
The BCFs influence an individual’s ability to help nurse practitioners acquire the necessary
take part in self-care. BCFs include age, sex, skills were either non- existent, or the nursing
developmental stage, socio-cultural orientation, staff did not have the entrance qualifications
dynamics of health care system, dynamics of for enrolment, it became necessary to develop
family system, patterns of living, environmental a hospital based program. While this program
factors and resource adequacy and resource was supported and recognized by the hospital,
accessibility (Orem, 2001, p. 167). For example, no academic credits were awarded at the end of
a patient’s age, health state, the existing family the course.
system, existing access to the general practitioner, In this program, emphasis was placed on
and access to the health care system are the development of a deep understanding of
characteristics that influence an individual’s self- the concept of self-care. Nurses were taught
care agency and affect whether patients are able to systematically analyze health deviations
to meet their therapeutic self-care demands. and their impact on self-care abilities versus
Table 1: Orem-based instrument for systematic data collection (Bekel, 2004).
1. Issues of degree of severity of patient needs:
a. Primary medical issues like symptoms of the disease which caused admission
b. Medical procedures to be considered during hospitalization
c. Medical prognosis as predicted by the medical doctor
2. Issues of the existing care system before admission
a. Impact of disease on present self-care abilities
b. Recent changes in self-care demand or self-care abilities
c. Relevant basic conditioning factors and patient power components
d. Ongoing needs for dependent-care agent or a professional nurse
3. Issues relevant to coordination of care while in hospital
a. Case complexity
b. Nursing systems applicable in relation to patients self-care deficits
c. Health care professionals involved
22 • Self-Care, Dependent-Care & Nursing • Vol: 18 • No: 01 • October 2010

5. demand, self-care deficits and the identification of relationship between nurses and doctors has
therapeutic self-care demands. They were taught improved considerably due to the fact that nurses
to isolate a health care phenomenon perceived now contribute specific information related to
within their daily practice, aggregate knowledge changes in patients’ self-care demands or self-
available by literature research as through data care abilities that affect self-care agency. This
collection from different sources (including information has proved to be relevant to medical
patients or relatives), synchronize with existing decisions made.
information and develop solutions and strategies Positive effects have been seen in the delivery
to improve patient care or provide educational of care and in individual nursing competence and
programs for patients to strengthen self-care. nurse agency. Nurses develop an understanding
Nurses were introduced to aspects of evidence of patients’ health situations and gain an insight
based strategies of research. There was a strong that enables them to understand how these
focus on the patient’s perspective as an essential situations developed, sometimes over a long
part of all aspects of nursing care provided in order period of time. They look more closely at factors
to effectively strengthen autonomy, to enhance that impinge on an individuals’ health status,
participation, and strengthen self-care abilities in determining individual demand for nursing and
order to improve the quality of care provided. increasingly setting immediate or long term health
In addition, the program covered aspects targets with individuals and their families. Nurses
of knowledge development including literature manage to develop a more comprehensive view
reviews, ways and methods to collect and process of health demands as well as the facts that directly
patient information, nursing diagnoses and nursing affect individual care situations. Results are:
classifications, aspects of diagnostic reasoning
and decision making, aspects of nursing science • improvement of communication between
and research and issues of leadership. Nurses nurses and patients/ family members
demonstrated knowledge development through a concerning quantity and quality of care
written final report following standards for a thesis • consideration of self/dependent care needs
with a formal defense of their projects. Reports beyond hospital discharge – a phenomenon
were presented publically to the hospital’s nursing nurses never perceived before
community and are archived in the hospital’s • early referral to other health care agencies
library. Nurses who participate in the program also and social care experts
present the results of their work internally at an • earlier application for rehabilitation following
annual conference open to the hospital staff. This discharge
program has now been in effect since 2005. • improved quantity and quality of docu-
mentation.
Results
Hospital management proposed a catalogue of
Although, to date, there has been no empirical measures where qualified nurses who underwent
evaluation of the educational program and the 2 years academic training are now considered
its impact on professional and organizational jointly responsible when generating protocols and
change, anecdotal results can be reported (see codes relevant for reimbursement (as requested
Box 1). Nurses who participated in the training by the DRG-System). Measured results show a
initiative were positioned at points where patients slight decline in length of hospital stay in complex
enter the hospital, such as in the emergency care situations, specifically linked to nurse
department. They identify risks related to unmet assisted case management.
self-care demands and demands of increasingly A percentage distribution of care systems in
dependent patients (for instance, patients who a group of patients screened by case managers
have increased self-care or dependent-care between February 2006 and November 2008
needs due to beginning dementia, or missing is presented in Figure 1.The “rate screening”
or unstable support systems. They assess the refers to the overall number of 18,175 patients
potential therapeutic demands and self-care being screened by nurse case managers. The
abilities needed when the patient is first admitted “rate CM” refers to these patients within this
to the hospital, develop a plan of care for the group, who show a need of nurse assisted case
period spent in hospital, and plan for continued management.
care after the patient has been discharged. At present, specially trained nurses can
The results of this program indicate improved compensate for about half of the patients
communication with other health care professionals who would need special attention due to their
as noticed by such colleagues as physicians, therapeutic self-care demand and their existing
physiotherapists and social workers. The work self-care system. Anecdotal information suggests
Vol: 18 • No: 01 • October 2010 • Self-Care, Dependent-Care & Nursing • 23

6. Figure 1: Percentage distribution of care systems in patients admitted between February 2006 and
November 2008
certain characteristics of patients showing need investment in a program designed to provide a
for attention. A slight reduction of days spent in foundation for its nursing work force that enhanced
hospital can be noticed in this group of patients the professional skills of the nurses and enabled
who receive special attention through a nurse case them to play a key role in the provision of patient
manager (see Box 1). care. This project resulted in an improvement in
nursing practice with a focus on the development
Summary of the diagnostic reasoning process used by
nurses through the use of the SCDNT. The goals
In 2005, hospital management in one agency to improve nursing language, strengthen the
in Germany decided to implement a clinical nurse process of care and emphasize clinical decisions
assisted case management in order to enhance that are specific to nursing were met. Nurses now
quality of patient care and reduce length of hospital assume responsibility and determine the demand
stay. Hospital management made a significant for nursing care of patients on admission, identify
Box 1: Anecdotal Information about the Success of this Program
Characteristics of patients showing a need for a nurse case manager include
• age > 70 years,
• mean age 74.3 years, 50% of patients are between 68 and 83 years old
• in general make use of professional nursing care services, like home care services or reside in a nursing home
• show existing demand for wholly or partially compensatory nursing care when admitted
• show existing self-care demand due to
- cognitive imbalance
- liquid imbalance
- nutrition imbalance
- altered respiration
- altered communication
- problems with medication
24 • Self-Care, Dependent-Care & Nursing • Vol: 18 • No: 01 • October 2010

7. risks related to an imbalance between self-care
demands and self-care abilities and the need
for a dependent-care agent and then effectively
coordinate patient care during a hospital stay. The
SCDNT remains a strong foundation for practice
at this hospital. 
Acknowledgements
My acknowledgements to Gerd Bekel, who
with much patience continuously guided practice
development in Ingolstadt Hospital. He served
as consultant in the development of this program
and continues to provide consultation in its
implementation.
My acknowledgements also to hospital
management for providing continuous support
and assistance in the program development and
evaluation.
References
Andrews M., Jones P.R. (1996). Problem based learning
in an undergraduate nursing Programme: A case
study. Journal of Advanced Nursing. Vol 23, pp
357-365.
Bekel G. (1998) Theory-Based Nursing Practice
in Germany. The International Orem Society.
Newsletter. Vol 6 (2), pp 6-7.
Bekel G. (2004) Erfassung der Fallproblematik.
Fallmanagement Übungsbogen. Version 5.5. 2004-
2008. gbconcept.
Brandenburg H., Dorschner S. (2003) Pflegewissenschaft
1. Lehr- und Arbeitsbuch zur Einfuehrung in die
Pflegewissenschaften. Verlag Hans Huber Bern.
Nickle L. (1998) Some Thoughts About Advanced
Nursing Practice. The International Orem Society.
Newsletter. Vol 6(2), 1-6.
Orem D.E. (1971) Nursing Concepts of Practice. New
York: McGraw-Hill.
Orem D.E. (1997) Strukturkonzepte der Pflegepraxis.
Deutsche Ausgabe von Gerd Bekel. Verlag Ullstein/
Mosby Berlin/Wiesbaden.
Orem D.E. (2001) Nursing Concepts of Practice (6th
Edition). St. Louis: Mosby.
Taylor S.G (1998) Clinical Decision-Making from The
Perspective of Self-Care Deficit Nursing Theory. The
International Orem Society Newsletter. Vol. 6(1).
The Orem Study Group (2004) Publication on the Occasion
of the 8th World Congress S-CDNT, Sept.29-Oct.3,
2004 Ulm Germany. Diagnostische Schriften.
Institut für Pflegediagnostik und Praxisforschung.
Cloppenburg. Germany.
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