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Theory of Self Care Dorothea Orem

Theory of Self Care Dorothea Orem

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Theory of Self Care Dorothea Orem

  1. 1. Dorothea Orem’s Theory of Self-Care Fronk, BSN, RN
  2. 2. Orem’s Grand Theory of Nursing Composed of three interwoven Middle-Range Theories Self-Care Deficit Nursing Systems Occurs when the demand of self-care is greater than the individual’s ability to satisfactorily attain it. --- A deficit in self-care brings about a need for nursing care. Self-Care Activities that an individual completes or assists with in order to maintain life and/or a higher level of well-being. --- Humans have an innate desire to care for themselves. Identifies actions that the nurse and client can take to reduce or eliminate the identified self-care deficit. --- Role of the nurse and client.
  3. 3. Concepts of Self-Care Self-Care “A human regulatory function that is a deliberate action to supply or ensure the supply of necessary materials needed for continued life, growth, and development and maintenance of human integrity” (McEwen & Wills, 2014, p. 144) Self-Care Requisites The requirements needed to bring about or maintain optimal functioning --- Universal Developmental Health Deviation Self-Care Agency The ability to engage in and/or perform fulfilling self-care activities --- Influenced by conditioning factors such as development, age, sociocultural factors, health and education --- Agent provides care Dependent agent receives care Therapeutic Self- Care Demand The combined actions necessary to meet the prescribed self-care activities in a given period in time --- The agent utilizes appropriate and validated measures identified by the self-care requisites
  4. 4. Conceptual Model R=relationship; <=deficit relationship, current or projected (Alligood & Marriner-Tomey, 2002, p. 192) Self-Care Self-Care Agency Self-Care Demands < Nursing Agency
  5. 5. Sub-Concepts  Nursing – Deliberate actions that assist clients and their families in regaining and/or maintaining optimal health.  Human being – Has developmental and universal health related needs. Is capable of providing self-care. Is the object of nursing.  Environment – Influences self-care knowledge and behaviors. Includes family and sociocultural factors.  Health – A dynamic state that may “impose new or different demands for self-care on the person” (Fawcett, 2005, p. 250).  Nursing Client – Has a health related deviation and is incapable of providing adequate self-care. Requires assistance from nursing.  Developmental self-care requisites – Occur due to a health condition or life event. Includes disease processes, injury, effects related to aging, etc..  Universal self-care requisites – Are common to all human beings. Consists of basic life requirements such as air, food, elimination, activity, etc.  Health deviation requisites – Actions necessary to employ when a deficit in self-care exists. Procuring medical treatment and nursing interventions.
  6. 6. Assumptions Based on the philosophy that “all patients wish to care for themselves” (Paraska & Clark, 2012, p. 63).  Individuals can and should strive for optimal health and life through self-care  Individuals should care for themselves as well as their dependents  Each individual is distinct and separate from others and the environment  Nursing is deliberate and requires action as well as interaction  Achieving the universal and developmental requisites of self-care is integral to attaining optimal health  Knowledge and the environment influences self-care behaviors and activities  The art of nursing is a therapeutic form of self-care that assists individuals in recovery from disease and/or injury  Nursing enhances self-care behaviors and activities
  7. 7. Relationships & Influences  Nursing exists due to deficits in self-care.  Humans are self-reliant and desire to take responsibility for self-care.  Health is a state of individual well-being that is influenced by the nurse as well as the environment.  When a deficit or need for maintenance in self-care exists the nurse and the environment can be modified to restore and/or preserve the state of health.  Optimal performance of self-care requisites minimizes the therapeutic self-care demand.  Universal, developmental and other conditioning factors can alter the agent’s ability to complete self-care requisites.  The nursing system is developed based upon the self-care deficit identified by the nurse.  Self-care needs can be met by the nurse, the client or both.
  8. 8. Theory Development  1914: Born in Baltimore, Maryland  1939: BSN, Catholic University of America  1959: Experienced in many areas of nursing, including: staffing, private duty, education, administration, and consulting; Orem began developing her definition of nursing practice and the concept of self-care  1971: First formal publication of Orem’s Theory of Self-Care (Orem, 1971)  1976: Honorary Doctor of Science Degree  2001-2007: Orem refined and publish her theories throughout the remainder of her life  Considered a “pioneer” of nursing theory (McEwen & Wills, 2014, p. 142) Orem developed her theory in the late 1960’s when tasked with designing a national curriculum for practical nursing education. Orem wished to revitalize nursing education in order to keep it current with the healthcare needs of modern society.
  9. 9. 1960’s The “scientific foundation for healthcare” moved nursing toward a more professional role (Taylor & McLaughlin Renpenning, 2003, p. 18) The American Nurses Association recommended institutional education with the baccalaureate degree as the basic foundation for nursing practice. The U.S. Public Health Service recommended increasing the quality of patient care. The Nurse Training Act allocated millions of dollars in government funds to improve and enhance nursing schools and education. Nursing scholars strived to build their own body of knowledge Nurses were employed in a variety of settings. This increased the number and complexity of problems nurses encountered. Passage of the Civil Rights Act Medicaid and Medicare provided government- funded healthcare to millions of Americans. Vietnam War Women’s movement focused on equality in pay and employment
  10. 10. Theory Origin & Support  Orem’s theory was developed and revised over the course of four decades.  The combination of practice, experience, education and collegiate collaboration influenced values and theory development.  Orem’s Values: Optimal health for every individual, independence in caring for the self, the art of nursing is valuable to society  Orem refers to but has never directly credited an author or work as the foundational basis for her theory.  Significant influential nurses referred to by Orem include: Rogers, Roy, Nightingale, Henderson, Abdullah & Orlando.  Theoretical influences: Aristotle & Thomas Aquinas. Action Theory. An area of philosophy concerned with “agent-causal” relationships. (O’Connor & Sandis, 2010, p. 7).
  11. 11. Motivation  While employed as a nursing consultant, Orem began to question the reality of nursing.  Orem was motivated by the ability to perform yet not communicate nursing services.  Orem wished to create a framework that organized nursing knowledge What is Nursing? “What is the human condition that occasions requirements for nursing?” (Orem, 2001) Why do some individual’s need nursing care and others not? What is the subject matter of the discipline of nursing? Orem asked…
  12. 12. Development Strategy Incorporates both inductive & Deductive reasoning processes Concepts were identified and conceptualized based on experience in practice Worldview of reciprocal interaction A Human Needs Theory Orem utilized a developmental model to conceptualize her theory The theory can also be regarded as an interaction model
  13. 13. Usefulness  Useful in everyday practice settings  Applicable across the lifespan  Contributes to nursing’s body of knowledge  Research findings can be applied to practice  Can guide interventions to enhance outcomes  Generate research & research instruments  Utilized by schools of nursing as a base for curriculum  Generates testable hypothesis for use in a multitude of settings  Identifies the focus of nursing
  14. 14. Practicality in Practice  Orem’s theory provides a practical means to guide and enhance nursing practice.  The theory can be utilized to positively influence the motivation that drives the deliberate actions of self-care.  Patient outcomes can be enhanced through easily identifiable requisites and interventions.  The self-care requisites within the theory encompass practical concepts that can be developed to assist in daily practice.  Universal requisites are common to all humans; Eliminative functions of self-care can be addressed by encouraging the patient to bathe daily.  Developmental requisites occur with growth and development; Proper growth and development can be facilitated through skill and knowledge enhancement.  Health Deviations occur due to internal and external forces; Primary, secondary and tertiary interventions can be employed to maintain and/or restore function.
  15. 15. Contribution to Care  Nurses make judgments for recommendations and adjustments in nurse-patient roles and interventions.  Theory that uncovers self-care needs, requisites and demands as well as the interventions to meet these requirements contribute to nursing’s body of knowledge.  Orem thoroughly describes each concept within the theory of self-care and predicts relationships between them. This aids in determining outcomes.  Identification of inadequacies in the self-care agency and within self-care requisites aids in predicting the degree of disability and the need for nursing activities.  Determines the effect and outcomes of self-care activities  Identifies the needs of the patient  Evaluates the success of interventions  Identifies need for modification of interventions
  16. 16. Example in Practice The theory of self-care can provide a theory-based approach to assist nurses and patients in hospital burn units Burn units significantly lack theory in care interventions Wilson and Gramling suggest utilizing Orem’s Self-Care Model “as a valid basis for delivering care and increasing the level of professionalism in this specialty area” (Wilson & Gramling, 2009, p. 852). The authors also suggest that the application of the theory in the practice of burn care units will provide a unique way to view this phenomenon. Many theories present gaps in care due to lack of comprehensiveness. Additional theories such as Roy’s Adaptation Model can complement matters not addressed by Orem in this specialty area of care. Orem’s theory however, “is the most applicable to burn care and provides a beginning point for theory usage in burn nursing care” (Wilson & Gramlin, 2009, p. 852).
  17. 17. Theory Testing Despite the popularity and feasibility of the theory of self-care, a 1993 review noted only 4 of 31 related research studies met the criteria for making “‘adequate use’ of Orem’s theory” in testing (Spearman, Duldt & Brown, 1993, p. 1629). Orem did not believe that “nursing research should be focused on testing her theory as much as on developing knowledge related to the different components” of her theories (Meleis, 2011, p. 220). Theory Applications:  Descriptive studies related to self-care practices  Assesses needs of clients  Development of interventions  To generate research instruments  To identify categories of self-care needs in specific populations  The self-care agency has been used to focus on the development of research tools capable of measuring aspects of self-care  To form a basis for the testing of a hypothesis  To identify relationships between the concept of the self-care agent and other influencing concepts in a variety of populations Usage:  Easily tested with a variety of methods and in various settings and populations.  Has generated numerous dialogues and stimulating thinking across disciplines  Broad clinical utility  The theoretical concepts of the grand theory has been applied as a whole and independently as well as in coordination with other theories to complement research studies
  18. 18. Research Examples  Computer-assisted reinforcement of instruction: effects on adherence in adult atopic asthmatics. A randomized pretest-posttest experimental design to determine effects of an intervention on adherence to dust mite avoidance in adults with atopic asthmatics (Huss, Salerno, Huss, R., 1991).  Health and illness self-care in adolescents with IDDM: a test of Orem's theory. Differentiates and proposes hypotheses related to adolescent diabetics and the various types of self-care identified by Orem (Frey & Denyes, 1989, p. 67-75).  Orem's model used for health promotion: directions from research. Utilized Orem's theory to test propositions associated to general health and health promotion (Denyes, 1988, p. 13-21).  Self-care agency as a function of patient-environmental factors among nursing home residents. Examined the relationships of environmental and personal factors on the ability of residents in nursing homes to provide self-care (Jirovec & Kasno, 1990, p. 303-309).  The effect of Orem's self-care model on nursing care in a nursing home setting. Determine patient perspectives and outcomes of nursing staff utilizing Orem’s theory of self-care compared to nursing staff employing other methods of assessments and goals (Faucett, Ellis, Underwood, Naqvi & Wilson, 1990, p. 659-666).  Influence of selected factors and self-care behavior on abdominal distention in patients with abdominal surgery. A descriptive and prospective study to explore self-care factors that influence abdominal distention in patients with recent abdominal surgery (Wattanawech, Srimoragot, Kasemkitwattana, Kimpee, 2003, p. 19-32).
  19. 19. Validity… Strengths Weaknesses  Provides a general foundation for the nursing discipline  Can be utilized to formulate nursing curriculum  Can enhance the development of nursing education, research and administration  Identifies when nursing is required  Contemporary with nursing trends in health promotion and maintenance  Promotes independence  Repetitive terms can be confusing (self-care agency/requisites/deficit, etc..)  Psychological/emotional needs not well developed within the theory  Assumes “all” are capable of self- care activities and does not address infants or the frail elderly  Oriented more toward illness than wellness
  20. 20. Example: Case Study A case study was performed to identify “facilitators and inhibitors to clinical application of Orem’s theory of self-care” (Clark, 1986, p. 127).  Facilitators were described as factors that aided the utilization of self-care theory while inhibitors deterred its use.  Subjects: Gerontological Patients  Setting: Community health nursing  Premise of theory: Individuals desire the ability and responsibility of self-care.  The nurse’s role is to identify self-care deficits and provide assistance with self-care activities to enhance health and well-being.  Design: Following the nursing assessment, the individual’s ability to engage in identified self-care requisites was evaluated. A nursing plan of care was implemented to achieve therapeutic self-care demands. Contributing and inhibiting factors to the outcomes were communicated and evaluated.  Findings:  Facilitators: Patient desire, attitude and beliefs Positive nurse-patient relationship Patient education, values, collaboration, communication Nurse, knowledge, collaboration, advocacy, communication Nursing plan of care  Inhibitors: Managing large numbers of concepts within the theory Lack of additional case studies and research to guide the study  Considerations: The study revealed numerous areas with potential for furthering nursing research. (Clark, 1986, p. 127-135)
  21. 21. Research Methodologies  Descriptive studies - Focus on the comprehension, number and type of self- care behaviors. Proposition: The nurse must assess and identify the client’s ability and potential to complete self-care activities.  Correlational studies - Examine the relationships between self-care variables. Proposition: The ability to perform self-care activities is influenced by the self-care agency, requisites and demands.  Quasi-Experimental studies - Identifies causal relationships as well as the significance of those relationships. They are necessary to determine the effectiveness in fulfilling therapeutic self-care demands. Proposition: Self-care deficits are balanced between therapeutic self-care demands and the ability of the self-care agency to meet those demands. The inability to achieve optimal self-care indicates a degree of dependency.  Experimental studies – Explore client outcomes related to the application of interventions. Proposition: Nurses are tasked with identifying valid and reliable interventions required to meet self-care needs. The intertwined concepts of self-care, self-care requisites, the self-care agency and therapeutic self-care demands must function in harmony for optimal health and well-being to be realized.
  22. 22. Evaluation  Orem’s generalized theory of nursing consists of three interrelated theoretical constructs.  Self-Care  Self-Care Deficits  Nursing Systems  The self-care component of the general theory is “common to the health professions and to all members of social groups.” (Basavanthappa, 2007, p. 85)  It identifies broad, comprehensive activities that are required by the individual to maintain health. It can be applied across the lifespan and within a variety of settings yet focus is on the ill.  The scope is more specific when applied to administration, education and research.  The concepts are simple and easy to understand. Simple * Logical * Organized
  23. 23. Theory in Practice  As a provider I will utilize this theory to identify appropriate and validated measures required by self-care requisites.  Professional nursing practice is based on the assumption that patient’s desire and need the self-care agency. The ability to engage in self-care activities is innate as well as learned. As a provider, I will assist patients in learning as well as performing self-care activities.  My role is to facility the self-care agency of the patient. Utilizing the theory of self-care, along with the theories of self-care deficit and nursing systems, I will be able to identify self-care deficits and the degree and competency of the patient’s self-care requisites and abilities. With this data, the appropriate nursing system of action with interventions can be implemented.  This theory will assist me in identifying and encouraging appropriate self- care activities across the lifespan.
  24. 24. Thank You
  25. 25. References  Alligood, A., & Marriner-Tomey, A., (2002). Nursing Theorists and Their Work. (5th Ed.). St. Louis: Mosby.  Allison, S. (2007). Self-care requirements for activity and rest: an Orem nursing focus. Nursing Science Quarterly, 20(1), 68-76.  Basavanthappa, BT. (2007). Nursing Theories. New Delhi: Jaypee Brothers Publishers.  Clark, M. (1986). Application of Orem's theory of self-care: a case study. Journal of Community Health Nursing, 3(3), 127-135.  Denyes, M. (1988). Orem's model used for health promotion: directions from research. Advances In Nursing Science, 11(1), 13-21.  Fawcett, J. (2005). Contemporary Nursing Knowledge: Analysis and Evaluation of Nursing Models and Theories (2nd ed.). Philadelphia, PA: F. A. Davis Company.  Faucett, J., Ellis, V., Underwood, P., Naqvi, A., & Wilson, D. (1990). The effect of Orem's self-care model on nursing care in a nursing home setting. Journal Of Advanced Nursing, 15(6), 659-666.  Frey, M., & Denyes, M. (1989). Health and illness self-care in adolescents with IDDM: a test of Orem's theory. Advances In Nursing Science, 12(1), 67-75.  Huss, K., Salerno, M., & Huss, R. (1991). Computer-assisted reinforcement of instruction: effects on adherence in adult atopic asthmatics. Research In Nursing & Health, 14(4), 259-267.  Jirovec, M., & Kasno, J. (1990). Self-care agency as a function of patient-environmental factors among nursing home residents. Research In Nursing & Health, 13(5), 303-309.  McEwen, M. & Wills, E. (2014). Theoretical basis for nursing. (4th ed.). Philadelphia: Wolters Kluwer. Lippincott Williams & Wilkins.  Meleis, Afaf Ibrahim. (2011). Theoretical Nursing: Developmengt and Progress. (5th ed., p. 220). Philadelphia: Wolters Kluwer. Lippincott Williams & Wilkins.  O’Conner, T., & Sandis, C. (2010). A companion to the philosophy of action. Oxford, Wiley-Blackwell.  Orem, D.E. (1971). Nursing: Concepts of Practice. McGraw-Hill, New York.  Paraska, K., & Clark, C. (2012). Health promotion in nursing practice. Burlington, MA: Jones & Bartlett Publisher.  Simmons, L. (2009). Dorthea Orem's self-care theory as related to nursing practice in hemodialysis. Nephrology Nursing Journal, 36(4), 419-421.  Spearman, S., & Duldt, B., & Brown, S. (1993). Research testing theory: a selective review of Orem's self-care theory, 1987-1991. Journal Of Advanced Nursing, 18(10), 1626-1631.  Taylor, S., & McLaughlin Renpenning, K. (2003). Self-Care Theory in Nursing: Selected Papers of Dorothea Orem (p. 18). New York: Springer Pub.  Wattanawech, T., Srimoragot, P., Kasemkitwattana, S., & Kimpee, S. (2003). Influence of selected factors and self-care behavior on abdominal distention in patients with abdominal surgery. Self-Care, Dependent-Care & Nursing, 11(3), 19-32.  Wilson, J., & Gramling, L. (2009). The application of Orem's Self-Care Model to burn care. Journal Of Burn Care & Research, 30(5), 852-858.

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