Dorothea Orem's Self-Care Theory Dorothea Orem (1914-2007) This page was last updated on January 4, 2011 ========== ================ ================ INTRODUCTIONyOne of foremost nursing theorists. yBorn 1914 in Baltimore. yEarned her diploma at Providence Hospital ± Washington, DC y1939 ± BSN Ed., Catholic University of America y1945 ± MSN Ed., Catholic University of America yInvolved in nursing practice, nursing service, and nursing education yDuring her professional career, she worked as a staff nurse, private duty nurse, nurse educator and administrator and nurse consultant yReceived honorary Doctor of Science degree in 1976 yPublished first formal articulation of her ideas in Nursing: Concepts ofPracticein 197, second in 1980, and in 1995. DEVELOPMENT OF THEORYy1949-1957 Orem worked for the Division of Hospital and Institutional Services of the Indiana State Board of Health. yHer goal was to upgrade the quality of nursing in general hospitals throughout the state. During this time she developed her definition of nursing practice. y1959 Orem subsequently served as acting dean of the school of Nursing and as an assistant professor of nursing education at CUA. She continued to develop her concept of nursing and self care during this time. yOrem¶s Nursing: Concept of Practice was first published in 1971 and subsequently in 1980, 1985, 1991, 1 995, and 2001. MAJOR ASSUMPTIONSyPeople should be self-reliant and responsible for their own care and others in their family needing care yPeople are distinct individuals yNursing is a form of action ± interaction between two or more persons ySuccessfully meeting universal and development self-care requisites is an important component of primary care prevention and ill health yA person¶s knowledge of potential health problems is necessary for promoting self-care behaviors ySelf care and dependent care are b ehaviors learned within a socio-cultural context DEFINITIONS OF DOMAIN CONCEPTS Nursing ± is art, a helping service, and a technology yActions deliberately selected and performed by nurses to help individuals or
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y Maintaining interpersonal, intra group or inter group relations for coordination
of efforts
y
Maintaining therapeutic relationship in light of psychosocial modes of functioning in health and disease
y Giving human assistance adapted to human needs ,action abilities and
limitations
2. Regulatory technologies
y Maintaining and promoting life processes
y Regulating psycho physiological modes of functioning in health and disease
y Promoting human growth and development
y Regulating position and movement in space
OREM¶S THEORY AND NURSING PROCESS
y Orem¶s approach to the nursing process presents a method to determine the
self care deficits and then to define the roles of person or nurse to meet the
self care demands.
y The steps within the approach are considered to be the technical component
of the nursing process.
y Orem emphasizes that the technological component "must be coordinated
with interpersonal and social processes within nursing situations.
OREM¶S WORK AND THE CHARACTERISTICS OF A THEORY
y Theories can interrelate concepts in such a way as to create a different way of looking at a particular phenomenon
y Theories must be logical in nature
y Theories must be relatively simple yet generalizable
y Theories are the basis for hypothesis that can be tested
y Theories contribute to and assist in increasing the general body of knowledge within the discipline through the research implemented
to validate them
y
Theories can be used by the practitioners to guide and improve their practicey Theories must be consistent with other validated theories ,laws and principles
Theory Testing
y Orem¶s theory has been used as the basis for the development of research instruments to assist researchers in using the theory
y A self care questionnaire was developed and tested by Moore(1995) for the special purpose of measuring the self care practice of
children and adolescents
y The theory has been used as a conceptual framework in assoc. degree programs also in many nursing schools
y Provides a comprehensive base to nursing practice
y It has utility for professional nursing in the areas of nursing practice nursing curricula ,nursing education administration ,and nursing
research
y Specifies when nursing is needed
y Also includes continuing education as part of the professional component of nursing education
y
Her self care approach is contemporary with the concepts of health promotion and health maintenancey Expanded her focus of individual self care to include multi person units
Limitations
y In general system theory a system is viewed as a single whole thing while Orem defines a system as a single whole ,thing
y Health is often viewed as dynamic and ever changing .Orem¶s visual presentation of the boxed nursing systems implies three static
conditions of health
y Appears that the theory is illness oriented rather with no indication of its use in wellness settings
Summary
y Orem¶s general theory of nursing is composed of three constructs .Throughout her work ,she interprets the concepts of human beings
health, nursing and society .and has defined 3 steps of nursing process. It has a broad scope in clinical practice and to lesser extent
y Dorothy E. Johnson was born August 21, 1919, in Savannah, Georgia.
y B. S. N. from Vanderbilt University in Nashville, Tennessee, in 1942; and her M.P.H. from Harvard University in Boston in 1948.
y From 1949 until her retirement in 1978 she was an assistant professor of pediatric nursing, an associate professor of nursing, and aprofessor of nursing at the University of California in Los Angeles.
y Dorothy Johnson has had an influence on nursing through her publications since the 1950s.
y
Johnson stressed the importance of research-based knowledge about the effect of nursing care on clients.
Johnson¶s behavior system model
y In 1968 Dorothy first proposed her model of nursing care as fostering of ³the efficient and effective behavioral functioning in thepatient to prevent illness".
y She also stated that nursing was ³concerned with man as an integrated whole and this is the specific knowledge of order we require´.
y In 1980 Johnson published her conceptualization of ³behavioral system of model for nursing´ this is the first work of Dorothy thatexplicates her definitions of the behavioral system model.
Definition of nursing
She defined nursing as ³an external regulatory force which acts to preserve the organization and integration of the patients behaviors at an
optimum level under those conditions in which the behaviors constitutes a threat to the physical or social health, or in which illness is found´
Based on this definition there are four goals of nursing are to assist the patient:
y Whose behavior commensurate with social demands.
y Who is able to modify his behavior in ways that it supports biological imperatives
y Who is able to benefit to the fullest extent during illness from the physicians knowledge and skill.
y Whose behavior does not give evidence of unnecessary trauma as a consequence of illness
Assumptions of behavioral system model
There are several layers of assumptions that Johnson makes in the development of conceptualization of the behavioral system model
There are 4 assumptions of system:
1. First assumption states that there is ³organization, interaction, interdependency and integration of the parts and elements of behaviorsthat go to make up The system ´
2. A system ³tends to achieve a balance among the various forces operating within and upon it', and that man strive continually tomaintain a behavioral system balance and steady state by more or less automatic adjustments and adaptations to the natural forcesimpinging upon him.´
3. A behavioral system, which both requires and results in some degree of regularity and constancy in behavior, is essential to man thatis to say, it is functionally significant in that it serves a useful purpose, both in social life and for the individual.
4. The final assumption states ³system balance reflects adjustments and adaptations that are successful in some way and to some
degree.´
The integration of these assumptions provides the behavioral system with the pattern of action to form ³an organized and integrated functionalunit that determines and limits the interaction between the person and his environment and establishes the relation of the person to the objects,events and situations in his environment.
Assumptions about structure and function of each subsystem
y ³from the form the behavior takes and the consequences it achieves can be inferred what ³drive´ has been stimulated or what ³goal´ isbeing sought´
y Each individual has a ³predisposition to act with reference to the goal, in certain ways rather than the other ways´. This predispositionis called as ³set´.
y Each subsystem has a repertoire of choices or ³scope of action´
y The fourth assumption is that it produce ³observable outcome´ that is the individual¶s behavior.
y System must be ³protected" from noxious influences with which system cannot cope´.
y Each subsystem must be ³nurtured´ through the input of appropriate supplies from the environment.
y Each subsystem must be ³stimulated´ for use to enhance growth and prevent stagnation.
y Johnson believes each individual has patterned, purposeful, repetitive ways of acting that comprise a behavioral system specific to
that individual.
y These actions and behaviors form an organized and integrated functional unit that determines and limits the interaction between the
person and his environment and establishes the relationship of the person to the objects event situations in the environment.
y These behaviors are ³orderly, purposeful and predictable and sufficiently stable and recurrent to be amenable to description and
explanation´
Johnson¶s Behavioral Subsystem
y Attachment or affiliative subsystem: ³social inclusion intimacy and the formation and attachment of a strong social bond.´
y Dependency subsystem: ³approval, attention or recognition and physical assistance´
y Ingestive subsystem: ³the emphasis is on the meaning and structures of the social events surrounding the occasion when the foodis eaten´
y Eliminative subsystem: ³human cultures have defined different socially acceptable behaviors for excretion of waste ,but theexistence of such a pattern remains different from culture to Culture.´
y Sexual subsystem:" both biological and social factor affect the behavior in the sexual subsystem´
y Aggressive subsystem: " it relates to the behaviors concerned with protection and self preservation Johnson views aggressive
subsystem as one that generates defensive response from the individual when life or territory is being threatened´y Achievement subsystem: " provokes behavior that attempt to control the environment intellectual, physical, creative, mechanical
and social skills achievement are some of the areas that Johnson recognizes".
Representation of Johnson's Model
Goal ----- Set --- Choice of Behavior --- Behavior
y Affiliation
y Dependency
y Sexuality
y Aggression
y Elimination
y
Ingestiony Achievement
The four major concepts
Johnson views ³human being´ as having two major systems, the biological system and the behavioral system. It is role of the medicine to focus
on biological system where as Nursling's focus is the behavioral system.
y ³Society´ relates to the environment on which the individual exists. According to Johnson an individual¶s behavior is influenced by theevents in the environment
y ³Health´ is a purposeful adaptive response, physically mentally, emotionally, and socially to internal and external stimuli in order tomaintain stability and comfort.
y ³Nursing´ has a primary goal that is to foster equilibrium within the individual. She stated that nursing is concerned with the organizedand integrated whole, but that the major focus is on maintaining a balance in the Behavior system when illness occurs in an individual.
Nursing process
Assessment
Grubbs developed an assessment tool based on Johnson¶s seven subsystems plus a subsystem she labeled as restorative which focused onactivities of daily living. .An assessment based on behavioral model does not easily permit the nurse to gather detailed information about the
Diagnosis tends to be general to the system than specific to the problem. Grubb has proposed 4 categories of nursing diagnosis derived from
Johnson's behavioral system model:
y Insufficiency
y Discrepancy
y Incompatibility
y Dominance
Planning and implementation
Implementation of the nursing care related to the diagnosis may be difficult because of lack of clients input in to the plan. the plan will focus onnurses actions to modify clients behavior, these plan than have a goal ,to bring about homeostasis in a subsystem, based on nursingassessment of the individuals drive, set behavior, repertoire, and observable behavior. The plan may include protection, nurturance or stimulation of the identified subsystem.
Evaluation
Evaluation is based on the attainment of a goal of balance in the identified subsystems. If the baseline data are available for an individual, thenurse may have goal for the individual to return to the baseline behavior. If the alterations in the behavior that are planned do occur, the nurseshould be able to observe the return to the previous behavior patterns. Johnson's behavioral model with the nursing process is a nurse
centered activity, with the nurse determining the clients needs and state behavior appropriate for that need.
Assessment
y Affiliative subsystem between mother and John.
y Dependency subsystem between mother and John
y Affiliative subsystem between Mrs.Kim and her mother.
y Insufficiency ingestion subsystem.
Diagnosis
y Insufficient development of the affiliative subsystem.
y Insufficient development of the dependency subsystem
Planning and implementation
y Increasing mother¶s awareness of the baby¶s clues.
y Assisting her to talk with the baby.
y Teach her to bring a bond between her and the baby by touch, pat and cuddles etc.
Evaluation
y Johnny's weight gain or weight loss will be carefully assessed.
y The ±infant interaction could be reassessed, using the nursing child assessment feeding scale.
y The interaction of Mrs. Kim with her mother.
Johnson¶s and Characteristics of a theory
y Interrelate concepts to create a different way of viewing a phenomenon.
y Theories must be logical in nature.
y Theories must be simple yet generalizable
y Theories can be bases of hypothesis that can be tested.
y Theories contribute to and assist in increasing the body of knowledge within the discipline through the research implemented tovalidate them
y Theories can be utilized by practitioners to guide and improve their practice.
y Theories must be consistent with other validated theories, laws and principles but will leave unanswered questions that need to beinvestigated.
Limitation
y Johnson does not clearly interrelate her concepts of subsystems comprising the behavioral system model.
y The definition of concept is so abstract that they are difficult to use.
y It is difficult to test Johnson's model by development of hypothesis.
y The focus on the behavioral system makes it difficult for nurses to work with physically impaired individual to use this theory.
y The model is very individual oriented so the nurses working with the group have difficulty in its implementation.
y The model is very individual oriented so the family of the client is only considered as an environment.
y Johnson does not define the expected outcomes when one of the system is affected by the nursing implementation an implicitexpectation is made that all human in all cultures will attain same outcome ±homeostasis.
y Johnson¶s behavioral system model is not flexible.
Summary
Johnson¶s Behavioral system model is a model of nursing care that advocates the fostering of efficient and effective behavioral functioning inthe patient to prevent illness. The patient is defined as behavioral system composed of 7 behavioral subsystems. Each subsystem composed of
four structural characteristics i.e. drives, set, choices and observable behavior.
Three functional requirement of each subsystem includes
y (1) Protection from noxious influences,
y (2) Provision for the nurturing environment, and
y (3) stimulation for growth.
Any imbalance in each system results in disequilibrium .it is nursing role to assist the client to return to the state of equilibrium.
y Faye Glenn Abdellah, pioneer nursing researcher, helped transform nursing theory, nursing care and nursing education
y Birth:1919
y Dr Abdellah worked as Deputy Surgeon General in US and Chief Nurse Officer for the US Public Health Service , Department of Health and human services, Washington, D.C.
y She was a leader in nursing research and has over one hundred publications related to nursing care, education for advanced practicein nursing and nursing research.
y According to her, nursing is based on an art and science that mould the attitudes, intellectual competencies, and technical skills of theindividual nurse into the desire and ability to help people , sick or well, cope with their health needs.
As per Abdellah, nursing as a comprehensive service includes:
1. Recognizing the nursing problems of the patient2. Deciding the appropriate course of action to take in terms of relevant nursing principles3. Providing continuous care of the individuals total needs4. Providing continuous care to relieve pain and discomfort and provide immediate security for the individual5. Adjusting the total nursing care plan to meet the patient¶s individual needs6. Helping the individual to become more self directing in attaining or maintaining a healthy state of mind & body7. Instructing nursing personnel and family to help the individual do for himself that which he can within his limitations8. Helping the individual to adjust to his limitations and emotional problems9. Working with allied health professions in planning for optimum health on local, state, national and international levels10. Carrying out continuous evaluation and research to improve nursing techniques and to develop new techniques to meet the health
needs of people
(In 1973, the item 3, - ³providing continuous care of the individual¶s total health needs´ was eliminated.)
P H I L O S O P H I C A L U N D E R P I N N I N G S O F T H E T H E O R Y
y Abdellah¶s patient-centred approach to nursing was developed inductively from her practice and is considered a human needs theory.
y The theory was created to assist with nursing education and is most applicable to the education of nurses.
y Although it was intended to guide care of those in the hospital, it also has relevance for nursing care in community settings.
M A J O R A S S U M P T I O N S , C O N C E P T S & R E L A T I O N S H I P S
y The language of Abdellah¶s framework is readable and clear.
y She uses the term µshe¶ for nurses, µhe¶ for doctors and patients, and refers to the object of nursing as µpatient¶ rather than client or consumer.
y She referred to Nursing diagnosis during a time when nurses were taught that diagnosis was not a nurses¶ prerogative.
Assumptions were related to
y change and anticipated changes that affect nursing;
y the need to appreciate the interconnectedness of social enterprises and social problems;
y
the impact of problems such as poverty, racism, pollution, education, and so forth on health care delivery;y changing nursing education
y continuing education for professional nurses
y development of nursing leaders from under reserved groups
Abdellah and colleagues developed a list of 21 nursing problems.They also identified 10 steps to identify the client¶s problems. 11 nursing skills
y To accept the optimum possible goals in the light of limitations, physical and emotional
y To use community resources as an aid in resolving problems arising from illness
y To understand the role of social problems as influencing factors in the case of illness
A B D E L L A H ¶ S T H E O R Y A N D T H E F O U R M A J O R C O N C E P T S
NURSING
y Nursing is a helping profession.
y In Abdellah¶s model, nursing care is doing something to or for the person or providing information to the person with the goals of meeting needs, increasing or restoring self-help ability, or alleviating impairment.
y Nursing is broadly grouped into the 21 problem areas to guide care and promote use of nursing judgment.
y She considers nursing to be comprehensive service that is based on art and science and aims to help people, sick or well, cope withtheir health needs.
PERSON
y Abdellah describes people as having physical, emotional, and sociological needs. These needs may overt, consisting of largelyphysical needs, or covert, such as emotional and social needs.
y Patient is described as the only justification for the existence of nursing.
y Individuals (and families) are the recipients of nursing
y Health, or achieving of it, is the purpose of nursing services.
HEALTH
y In Patient±Centered Approaches to Nursing, Abdellah describes health as a state mutually exclusive of illness.
y Although Abdellah does not give a definition of health, she speaks to ³total health needs´ and ³a healthy state of mind and body´ in herdescription of nursing as a comprehensive service.
SOCIETY AND ENVIRONMENT
y Society is included in ³planning for optimum health on local, state, national, and international levels´. However, as she further delineated her ideas, the focus of nursing service is clearly the individual.
y The environment is the home or community from which patient comes.
A B D E L L A H ¶ S W O R K A N D C H A R A C T E R I S T I C S O F A T H E O R Y
Characteristic 1
y Abdellah¶s theory has interrelated the concepts of health, nursing problems, and problem solving as she attempts to create a differentway of viewing nursing phenomenon
y Nursing is the use of problem solving approach with key nursing problems related to health needs of people.
Characteristic 2
y Problem solving is an activity that is inherently logical in nature.
Characteristic 3
y Framework focus on nursing practice and individuals.
y The results of testing such hypothesis would contribute to the general body of nursing knowledge
Characteristic 6
y Abdellah¶s problem solving approach can easily be used by practitioners to guide various activities within their practice that deals withclients who have specific needs and specific nursing problems.
Characteristic 7
y Although consistency with other theories exist, many questions remain unanswered
U S E O F 2 1 P R O B L E M S I N T H E N U R S I N G P R O C E S S
ASSESSMENT PHASE
y
Nursing problems provide guidelines for the collection of data.y A principle underlying the problem solving approach is that for each identified problem, pertinent data are collected.
y The overt or covert nature of the problems necessitates a direct or indirect approach, respectively.
NURSING DIAGNOSIS
y The results of data collection would determine the client¶s specific overt or covert problems.
y These specific problems would be grouped under one or more of the broader nursing problems.
y This step is consistent with that involved in nursing diagnosis
PLANNING PHASE
y The statements of nursing problems most closely resemble goal statements. Once the problem has been diagnosed, the nursinggoals have been established.
IMPLEMENTATION
y Using the goals as the framework, a plan is developed and appropriate nursing interventions are determined.
EVALUATION
y The most appropriate evaluation would be the nurse progress or lack of progress toward the achievement of the stated goals
C O N C E P T O F P R O G R E S S I V E P A T I E N T C A R E
y PPC is defined as better patient care through the organization of hospital facilities, services and staff around the changing medical
and nursing needs of the patient
y PPC is tailoring of hospital services to meet patients needs
y PPC is caring for the right patient in the right bed with the right services at the right time
y PPC is systematic classification of patients based on their medical needs
y Critically and seriously ill patients requiring highly skilled nursing care, close and frequent if not constant, nursing observation are
assigned to the ICU. One patient in an ICU requires at least three nurses to observe him in 24 hrs
y Intermediate care Patients assigned to this unit are both the moderately ill and those for whom the treatment can only be palliative
y Self care Ambulatory patients who are convalescencing or require diagnosis or therapy may be cared for in this unit
y Long term care unit This unit will provide services to certain patients now cared for in the general hospital, in nursing homes, or in
their own homes and who would benefit by care in a hospital environment to achieve its maximum potentialy Home care This programme makes it possible to extend needed services to the patient after he leaves the hospital and returns to his
home in the community
BENEFITS OF PPC
PATIENT
y better attention
y better adjustment
y minimized problems
y life saving care
y constant medical and nursing care
PHYSICIAN
y assuring best nursing care
y drugs and equipments at hand
y orders carried out effectively
y better clinical an team service
HOSPITAL
y effective and efficient use of staff
y improved public image
NURSING PERSONNEL
y individual skills can be used
y more time with patient
y helping pt. and family to solve problems
y job satisfaction
y in-service education
COMMUNITY
y continuity with hospital services
y minimize the need of hospitalization
IMPLICATIONS OF PPC FOR NURSING EDUCATION
y Many nurse educators feel that the PPC hospital where all five phases of care are available can provide clinical experience in which
the nurse can learn to solve basic nursing problems in meeting patients¶ needs.
y The three month assignment of professional nurses may no longer be realistic in such a setting.
y Organization of hospital and community services based on patients needs
y In the intensive care unit, the critically ill patients are concentrated regardless of diagnosis.
y These patients are under the constant audio-visual observation of the nurse, with life saving techniques and equipment immediately
available
y In the intermediate care unit are concentrated patients requiring a moderate amount of nursing care, not of an emergency nature, who
are ambulatory for short periods, and who are beginning to participate in he planning of their own care
y The self-care unit provides for patients who are physically self-sufficient and require diagnostic and convalescent care in hotel-type
accommodations. This unit serves as a link between the hospital and the home.y In the long-term care unit are concentrated patients requiring prolonged care. The grouping of such patients will permit staffing
patterns that are less costly
y Home care, the fifth element of progressive patient care, extends hospital services into the home to assist the physician in the care of
his patients
USEFULNESS
y The patient centered approach was constructed to be useful to nursing practice, with impetus for it being nursing education.
y Abdellah¶s publications on nursing education began with her dissertation; her interest in education for nurses continues into the
present.
y Abdellah has also published on nursing, nursing research, and public policy related to nursing in several international publications.
She has been a strong advocate for improving nursing practice through nursing research
VALUE IN EXTENDING NURSING SCIENCE
y It helped to bring structure and organization to what was often a disorganized collection of lectures and experiences.
y She categorized nursing problems based on the individual¶s needs and developed developed a typology of nursing treatment and
nursing skills..
NURSING RESEARCH
y She has been a leader in nursing research and has over one hundred publications related to nursing care, education for advanced
practice in nursing and nursing research.
LIMITATIONS
y Very strong nursing centered orientation
y Little emphasis on what the client is to achieve
y Her framework is inconsistent with the concept of holism
Potential problems might be overlooked
C O N C L U S I O N S
y Using Abdellah¶s concepts of health, nursing problems, and problem solving, the theoretical statement of nursing that can be derived
is the use of the problem solving approach with key nursing problems related to health needs of people.
y From this framework, 21 nursing problems were developed
y Abdellah¶s theory provides a basis for determining and organizing nursing care. The problems also provide a basis for organizing
appropriate nursing strategies.
y It is anticipated that by solving the nursing problems, the client would be moved toward health. The nurse¶s philosophical frame of
reference would determine whether this theory and the 21 nursing problems could be implemented in practice.
y Any observation shared and explored with the patient is immediately useful in
ascertaining and meeting his need or finding out that he is not in need at that
time
y
The nurse does not assume that any aspect of her reaction to the patient iscorrect, helpful or appropriate until she checks the validity of it in exploration with
the patient
y The nurse initiates a process of exploration to ascertain how the patient is
affected by what she says or does
y Automatic reactions are not effective because the nurses action is decided upon
for reasons other than the meaning of the patients behavior or the patients
immediate need for help
y When the nurse does not explore with the patient her reaction it seems
reasonably certain that clear communication between them stops
PROVEMENT - RESOLUTION
y It is not the nurses activity that is evaluated but rather its result : whether the
activity serves to help the patient communicate her or his need for help and how
it is met
y In each contact the nurse repeats a process of learning how to help the individual
patient.
y Her own individuality and that of the patient requires that she go through this
each time she is called upon to render service to those who need her.
SUMPTIONS
y When patients cannot cope with their needs without help, they become
distressed with feelings of helplessness
y Nursing , in its professional character , does add to the distress of the patient
y Patients are unique and individual in their responses
y Nursing offers mothering and nursing analogous to an adult mothering and
nurturing of a child
y Nursing deals with people, environment and health
y Patient need help in communicating needs, they are uncomfortable and
ambivalent about dependency needs
y Human beings are able to be secretive or explicit about their needs, perceptions,
thoughts and feelings
y The nurse ± patient situation is dynamic, actions and reactions are influenced by
both nurse and patient
y Human beings attach meanings to situations and actions that are not apparent to
others
y Patients entry into nursing care is through medicine
y The patient cannot state the nature and meaning of his distress for his need
without the nurses help or without her first having established a helpful