1. Self-Care Deficit Nursing Theory inIngolstadt – An Approach to PracticeDevelopment in Nursing CareMonika Hohdorf, RN; M.ScAbstract system. As such, they were expected to assumeThe 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 ownplaced increased responsibility on the nurses as they shifted health needs and thus are competent to decidefocus toward more health promotion strategies that included what resources they need. The consumers ofa greater emphasis on teaching patients to assume moreresponsibility toward self-care. One hospital in Germany health care services are now expected to activelysought to address this new focus by moving toward a nursing participate in health care decisions; and, as atheory-based service. Orem’s Self-care Deficit Nursing Theory result, contribute to direct cost control of nationalwas chosen to conceptualize nursing practice. A program health care resources. In order to facilitate this,of change was implemented with emphasis placed on thestructure of the nursing process as a means to coordinate German health care policy now mandates healthpatient 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 andempirical evaluation has been conducted thus far, anecdotal determining their health care. Consequently,findings suggest a positive effect on shortening length of stayfor hospitalized patients and on the quality of nursing care the nursing profession is challenged to changeprovided to complex patients (especially those who show a traditional nursing care delivery systems. Nurseshigh demand for case management due to risks related to are now asked to take over responsibility for theunmet self-care demands). quality of care provided, to justify the need forKeywords: clinical nursing practice, Orem Self-care Deficit nursing actions targeted to individual needs, andNursing, self-care, practice development, nursing education, to quantify nursing services in order to clarifyGermany 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 careIntroduction: Context of Proposed Change needs which impact the clients’ ability to care The Diagnostic Related Groups (DRG) for themselves. Nurses are also called upon tosystem was introduced into the German health actively control the length of stay in hospitals andcare system in 2004. This was done in response ensure that health deviation self-care requisitesto exploding expenditures for social welfare are met by the patients and their dependent careand 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 illwith multi-system health care problems. The prepared to respond to the national demand for thegoals of this initiative were to reduce the length of increased scope of nursing care required. There ispatient stay in acute care hospitals and to lessen a need for more advanced educational preparationthe 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 versusshift from traditional reimbursement and led to technical status of nurses, the lack of professionalincreased 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 scopeof 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 Germanycare demands of patients from the moment they became available in the university setting. Withenter the health care system, throughout the this move, studies in nursing science, nursinghospital 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 produce20 • 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 aappraise the individual demand for nursing care, change that was necessary nor did they valueshape communication, select nursing objectives a nursing theory based nursing service. Thereappropriate to meet patient’s self-care demands were three major obstacles in the attempt to moveand guides the development of instruments and forward with the changes:technologies. Adopting the view that the needfor nursing exists the moment self-care demand • “Nurses in practice settings do not acceptexceeds self-care agency supports the change theoretical concepts which in their view aretoward a patient centered approach of care. a contrast to their practice fields. • Nurses in practice settings are critical ofSelecting 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 todecisions made by nurses must be individualized human behaviours, even if no scientific orto the patient situation, information collected by nursing specific system of explanation fornurses 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 beconclusions or judgements made by nurses must developed to successfully implement a theoreticalbe labelled in order to communicate what is known approach to guide daily nursing practice. Hence theabout the situations and what has been done and team decided on measures which hopefully wouldshould be done” (Orem Study Group, 2004, p.13). impact practice development quickly, result inNursing diagnosis helps achieve a systematic short term success to satisfy hospital managementprocess for organizing and communicating nursing concerns, and demonstrate positive results to thejudgements. Thus, nursing diagnosis as “...a nurses in order to change their personal beliefsmeans of communication became the term used and knowledge about the effectiveness of usingto 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 interdisciplinarya guide to predict, describe and explain the treatment processes of patients.phenomena of nursing and helps nurses to • Development and utilization of nursingdiscover 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 provideself-care in order to strengthen their self-care Implementing the Programcompetency. Coupled with nursing diagnosis,nurses can finally come to a statement where Between the years 2005 to 2007, the nursethey describe these phenomena that indicate management team developed an educationalthat patients or their dependent-care agents program introducing the SCDNT for all nursesshow deficiencies of competencies to maintain who had completed three years of basic nursingself-care. education. To encourage and strengthen the use of theory in practice, the nurses were taught theInitiating 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 theirTraditional hospital structures, work load and work ability to conceptualize and develop creativeenvironment did not favour organizational change. nursing care in actual clinical practice. This relatesIndeed, 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 involved22 • 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 hastherapeutic self-care demands. They were taught improved considerably due to the fact that nursesto isolate a health care phenomenon perceived now contribute specific information related towithin 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. Thiscollection from different sources (including information has proved to be relevant to medicalpatients or relatives), synchronize with existing decisions made.information and develop solutions and strategies Positive effects have been seen in the deliveryto improve patient care or provide educational of care and in individual nursing competence andprograms for patients to strengthen self-care. nurse agency. Nurses develop an understandingNurses were introduced to aspects of evidence of patients’ health situations and gain an insightbased strategies of research. There was a strong that enables them to understand how thesefocus on the patient’s perspective as an essential situations developed, sometimes over a longpart of all aspects of nursing care provided in order period of time. They look more closely at factorsto effectively strengthen autonomy, to enhance that impinge on an individuals’ health status,participation, and strengthen self-care abilities in determining individual demand for nursing andorder 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. Nursesof knowledge development including literature manage to develop a more comprehensive viewreviews, ways and methods to collect and process of health demands as well as the facts that directlypatient information, nursing diagnoses and nursing affect individual care situations. Results are:classifications, aspects of diagnostic reasoningand decision making, aspects of nursing science • improvement of communication betweenand research and issues of leadership. Nurses nurses and patients/ family membersdemonstrated knowledge development through a concerning quantity and quality of carewritten final report following standards for a thesis • consideration of self/dependent care needswith a formal defense of their projects. Reports beyond hospital discharge – a phenomenonwere presented publically to the hospital’s nursing nurses never perceived beforecommunity and are archived in the hospital’s • early referral to other health care agencieslibrary. Nurses who participate in the program also and social care expertspresent the results of their work internally at an • earlier application for rehabilitation followingannual conference open to the hospital staff. This dischargeprogram 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 underwentevaluation of the educational program and the 2 years academic training are now consideredits impact on professional and organizational jointly responsible when generating protocols andchange, anecdotal results can be reported (see codes relevant for reimbursement (as requestedBox 1). Nurses who participated in the training by the DRG-System). Measured results show ainitiative were positioned at points where patients slight decline in length of hospital stay in complexenter the hospital, such as in the emergency care situations, specifically linked to nursedepartment. They identify risks related to unmet assisted case management.self-care demands and demands of increasingly A percentage distribution of care systems independent patients (for instance, patients who a group of patients screened by case managershave increased self-care or dependent-care between February 2006 and November 2008needs 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 patientspotential therapeutic demands and self-care being screened by nurse case managers. Theabilities needed when the patient is first admitted “rate CM” refers to these patients within thisto the hospital, develop a plan of care for the group, who show a need of nurse assisted caseperiod 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 patientscommunication with other health care professionals who would need special attention due to theiras noticed by such colleagues as physicians, therapeutic self-care demand and their existingphysiotherapists 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 medication24 • Self-Care, Dependent-Care & Nursing • Vol: 18 • No: 01 • October 2010
7. risks related to an imbalance between self-caredemands and self-care abilities and the needfor a dependent-care agent and then effectivelycoordinate patient care during a hospital stay. TheSCDNT remains a strong foundation for practiceat this hospital. Acknowledgements My acknowledgements to Gerd Bekel, whowith much patience continuously guided practicedevelopment in Ingolstadt Hospital. He servedas consultant in the development of this programand continues to provide consultation in itsimplementation. My acknowledgements also to hospitalmanagement for providing continuous supportand assistance in the program development andevaluation.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. Vol: 18 • No: 01 • October 2010 • Self-Care, Dependent-Care & Nursing • 25
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