Dorothea Orem: Self-Care Deficit Nursing Theory

Dorothea Orem developed the Self-Care Deficit Nursing Theory, also called the Orem Model of Nursing. It centers on one question that drives bedside decisions: can this patient meet their own self-care needs, and if not, how much do you step in.

She defined nursing as "the act of assisting others in the provision and management of self-care to maintain or improve human functioning at the home level of effectiveness," and self-care as "the practice of activities that individuals initiate and perform on their own behalf in maintaining life, health, and well-being."

Biography of Dorothea E. Orem

Dorothea Elizabeth Orem (July 15, 1914, to June 22, 2007) was one of America's foremost nursing theorists.

Early Life

Orem was born on July 15, 1914, in Baltimore, Maryland. Her father was a construction worker and her mother a homemaker; she was the younger of two daughters.

Education

Orem graduated from Seton High School in Baltimore in 1931 and earned a diploma from the Providence Hospital School of Nursing in Washington, D.C., in 1934. She went on to the Catholic University of America for a B.S. in Nursing Education in 1939 and an M.S. in Nursing Education in 1945. She later received honorary doctorates: Doctorates of Science from Georgetown University in 1976 and Incarnate Word College in 1980, an Honorary Doctorate of Humane Letters from Illinois Wesleyan University in 1988, and a Doctorate Honoris Causa from the University of Missouri in Columbia in 1998.

Appointments

Orem directed both the nursing school and the nursing department at Providence Hospital, Detroit, from 1940 to 1949, where she also taught biological sciences and nursing from 1939 to 1941. At the Catholic University of America she served as Assistant Professor from 1959 to 1964, Associate Professor from 1964 to 1970, and Dean of the School of Nursing from 1965 to 1966.

She consulted widely: to the Office of Education, United States Department of Health, Education and Welfare, Practical Nurse Section in 1958, 1959, and 1960; to the Division of Hospital and Institutional Services, Indiana State Board of Health from 1949 to 1957; to the Center for Experimentation and Development in Nursing at Johns Hopkins Hospital, 1969 to 1971; and to the Director of Nursing, Wilmer Clinic, Johns Hopkins Hospital, 1975 to 1976. In 1982 she was among the nurse theorists who presented Patterns of Unitary Man (Humans), the initial framework for nursing diagnosis, to the North American Nursing Diagnosis Association.

Works

Orem helped publish "Guidelines for Developing Curricula for the Education of Practical Nurses" in 1959. In 1971 she published Nursing: Concepts of Practice, where she laid out the Self-Care Deficit Theory; its success established her as a leading theorist of nursing practice and education. As chairperson of the Nursing Development Conference Group, she edited that group's Concept Formalization in Nursing in 1973.

She wrote many papers and spoke at conferences worldwide through the 1970s and 1980s. The second edition of Nursing: Concepts of Practice appeared in 1980. Orem retired in 1984 but kept developing the theory, publishing the third edition in 1985 and completing the fourth in 1991. She completed the sixth edition, published by Mosby, in January 2001. The International Orem Society was founded to support research and continued development of her work.

Awards and Honors

Orem received the Catholic University of America Alumni Achievement Award for Nursing Theory in 1980, the Linda Richards Award from the National League for Nursing in 1991, and Honorary Fellowship of the American Academy of Nursing in 1992. She was inducted into the American Academy of Nursing and received awards from the National League for Nursing and the Sigma Theta Tau Nursing Honor Society.

Death

Orem died on June 22, 2007, in Savannah, Georgia, where she had spent the last 25 years of her life as a consultant and author. She was 92.

Dorothea Orem's Self-Care Deficit Theory

Orem developed the theory between 1959 and 2001. It is a grand nursing theory, meaning its concepts are broad enough to apply across all of nursing. The idea shows up most clearly in rehabilitation, where the goal is to move the patient back toward independence after the team has carried their care.

What is the Self-Care Deficit Theory?

Nursing exists, in Orem's terms, to assist others in providing and managing self-care so they maintain or improve their functioning. The theory turns on each person's ability to perform self-care. As Orem put it: "The condition that validates the existence of a requirement for nursing in an adult is the absence of the ability to maintain continuously that amount and quality of self-care which is therapeutic in sustaining life and health, in recovering from disease or injury, or in coping with their effects. With children, the condition is the parent's inability (or guardian) to maintain continuity for the child the amount and quality of care that is therapeutic." (Orem, 1991)

Assumptions of the Self-Care Deficit Theory

Orem's theory rests on five assumptions. Humans stay alive and functional through constant communication and connection with each other and their environment. They act deliberately to identify needs and make the judgments those needs require. Mature humans experience limits in caring for self and others when taking life-sustaining and function-regulating action. Human agency develops and transmits to others the ways and means to identify needs and act on them. And groups with structured relationships cluster tasks and assign responsibility for caring for their members.

Nursing Metaparadigm in Orem's Theory

The person is a self-care agent, or when dependent, someone whose care is partly carried out by others. Health relates to functional integrity and the ability to meet self-care needs, which shifts over time and across conditions. The environment is the physical and social context (family, culture, community resources, the care system) that shapes self-care ability. Nursing is a deliberate helping service that fills the gap between what must be done and what the person can do.

Major Concepts of the Self-Care Deficit Theory

Nursing is an art in which the nurse gives specialized assistance to persons with disabilities, where more than ordinary help is needed to meet self-care needs, and intelligently participates in the medical care the physician provides.

Humans are "men, women, and children cared for either singly or as social units," the material object of nurses and others who provide direct care. The environment has physical, chemical, and biological features and includes family, culture, and community. Health is "being structurally and functionally whole or sound," covering both individuals and groups, and includes the ability to reflect on oneself, symbolize experience, and communicate with others.

Self-care is the practice of activities a person initiates and performs to maintain life, health, and well-being. Self-care agency is the person's power to engage in self-care, shaped by basic conditioning factors: age, gender, developmental state, health state, socio-cultural orientation, health care system factors, family system factors, patterns of living, environmental factors, and resource adequacy and availability. Therapeutic self-care demand is the total of self-care actions needed over some duration to meet known self-care requisites using valid methods.

Self-care deficit marks when nursing is needed: when an adult, or the parent or guardian of a dependent, cannot provide continuous effective self-care. Nursing agency is the property of people educated and trained as nurses that lets them act, know, and help others meet their therapeutic self-care demands. The nursing system is the product of the relationship between a legitimate nurse and a legitimate client, activated when the client's therapeutic self-care demand exceeds available self-care agency.

The Three Theories

The Self-Care Deficit Theory is built from three interrelated theories: the theory of self-care, the theory of self-care deficit, and the theory of nursing systems (classified as wholly compensatory, partially compensatory, and supportive-educative).

Theory of Self-Care

This theory covers the activities a person initiates and performs to maintain life, health, and well-being. Self-care requisites are actions directed toward providing self-care, in three categories.

Universal self-care requisites tie to life processes and maintaining human structure and function:

• Maintaining sufficient intake of air
• Maintaining sufficient intake of water
• Maintaining sufficient intake of food
• Providing care for elimination and excrements
• Maintaining a balance between activity and rest
• Maintaining a balance between solitude and social interaction
• Preventing hazards to human life, functioning, and well-being
• Promoting human functioning and development within social groups, in accord with human potential, known limitations, and the desire to be normal

Here, normalcy means what is essentially human and in accord with a person's genetic and constitutional characteristics and talents.

Developmental self-care requisites are either universal requisites particularized for developmental processes or new requisites arising from a condition or event.

Health deviation self-care requisites apply in illness, injury, or disease, or from the medical measures used to diagnose and correct them:

• Seeking and securing appropriate medical assistance
• Being aware of and attending to the effects of pathologic conditions
• Carrying out prescribed diagnostic, therapeutic, and rehabilitative measures
• Attending to and regulating the discomforting or harmful effects of prescribed measures
• Modifying self-concept to accept being in a particular state of health and needing care
• Learning to live with the effects of the condition and its treatment in a lifestyle that supports continued personal development

Theory of Self-Care Deficit

This theory defines when nursing is needed: when an adult, or the parent or guardian of a dependent, cannot provide continuous effective self-care. Orem identified five methods of helping: acting for and doing for others, guiding others, supporting another, providing an environment that promotes personal development toward future demands, and teaching another.

Theory of Nursing Systems

The nursing system is the product of the relationship between a legitimate nurse and a legitimate client, activated when the client's therapeutic self-care demand exceeds available self-care agency.

The wholly compensatory system applies when the person cannot engage in self-care that requires self-directed ambulation and manipulative movement, or is medically ordered to refrain, and depends on others for continued existence and well-being. Examples: care of a newborn, or a client recovering from surgery in a post-anesthesia care unit.

The partially compensatory system applies when both nurse and patient perform care measures, with either taking the major role. Examples: assisting a postoperative client to ambulate, or bringing a meal tray to a client who can feed himself.

The supportive-educative system (also called supportive-developmental) applies when the person can perform, or can learn to perform, the required self-care but cannot do it without help. Examples: guiding a mother on breastfeeding, or counseling a psychiatric client on more adaptive coping.

Orem's Theory and the Nursing Process

The nursing process here determines self-care deficits and defines what the patient and nurse each do to meet self-care demands. Assessment covers diagnosis and prescription (determining why nursing is needed and making a judgment about care), design of a nursing system and plan of care, and production and management of that system.

In step one, the nurse collects data in six areas: the person's health status; the physician's view of that status; the person's own view of their health; health goals within their life history, lifestyle, and status; their self-care requirements; and their capacity to perform self-care.

In step two, the nurse designs a wholly compensatory, partially compensatory, or supportive-educative system. This means organizing the components of the patient's therapeutic self-care demands and selecting the combination of helping methods that will efficiently overcome the self-care deficits.

In step three, the nurse assists the patient or family in self-care, identifies health-related results, and collects evidence to evaluate results achieved against those specified in the nursing system design. The etiology component of the nursing diagnosis directs the actions.

Analysis of the Self-Care Deficit Theory

The strongest part of Orem's work is its focus on self-care; even within the broad theory of nursing systems, the goal of nursing care assisting people comes through in every concept. Her definition of health was framed rigidly and can be refined toward the general view of health as dynamic and changing. She named the environment's role in the nurse-patient relationship but did not develop it. She set the nurse's role in maintaining health with strong coherence around each person's life-sustaining needs. And while she recognized the parent's or guardian's role for dependents, the definition of self-care does not directly fit those who need complete care, such as infants and the aged.

Strengths

The theory works for both beginning practitioners and advanced clinicians and gives a comprehensive basis for practice, education, and administration. The terms self-care, nursing systems, and self-care deficit are easy for students to grasp and deepen with experience. Orem specifically defines when nursing is needed: when the individual cannot continuously maintain the self-care needed to sustain life and health, recover from disease or injury, or cope with their effects. Her self-care approach fits modern health promotion and maintenance, and the three nursing systems are clearly delineated.

Limitations

The theory is treated as a single whole, as Orem defined a system. It is simple yet complex: the many self-care terms (self-care agency, demand, deficit, requisites, universal self-care) can confuse the reader. Her definition of health was confined to three static conditions she called a concrete nursing system, which reads as rigid. There is limited acknowledgment of the individual's emotional needs throughout her work, even though health is often viewed as dynamic and changing.

Conclusion

Orem's theory is relatively simple but generalizes to a wide range of patients, and it explains self-care, nursing systems, and self-care deficit, terms essential to new nurses. Its premise is that patients want to care for themselves and recover more quickly and holistically when they perform as much of their own self-care as they can, which makes it especially useful in rehabilitation, primary care, and other settings that push independence. The main limit stays the same: the definition of self-care does not directly apply to those who need complete care, such as infants and the aged.