Orems Final

INTRODUCT ION: -

The systematic accumulation of knowledge is essential to progress in any profession. However, theory and practice must be constantly interactive. Theory without practice is empty and practice without theory is blind (Cross,1981).

Among the client-centered theory available to the nursing profession and students, Dorothea Orem’s Theory of Self-Care Deficit is probably one of the best known, easily understood and most applied in the clinical setting. While most of us would recognize the Self-Care Deficit Theory as Orem’s sole contribution to the development of nursing, she is in fact the author of three, namely: the Self-Care Theory, the Theory of Self-Care Deficit and the Theory of Nursing Systems. All three theories are related to one another .

Nursing profession and practice wouldn't be the same now, as it was yesterday, who's in their initiative and deep concern to the profession richly contributed to the development of its standard of practice, and that a nurse is equally regarded and recognized together with other medical profession with its own unique functions and contributions to patient recovery. In turn the society itself is benefiting from it. Dorothea Orem's great contribution in conceptualizing a model or framework of nursing, is when she headed a nursing committee in creating a model that will guide research in nursing as it is now.

BACKGROUND OF THEORIST (DOROTHEA OREM 1914-2007) :-

One of foremost nursing theorists. Born 1914 in Baltimore.

Earned her diploma at Providence Hospital – Washington, DC

1939 – B.Sc . Nsg Ed., Catholic University of America

1945 – M .Sc .Nsg Ed., Catholic University of America

Involved in nursing practice, nursing service, and nursing education

During her professional career, she worked as a staff nurse, private duty nurse, nurse educator and administrator and nurse consultant

Received honorary Doctor of Science degree in 1976

Published first formal articulation of her ideas in Nursing: Concepts of Practice in 1971, second in 1980, and in 1995 & 2001 .

DEVELOPMENT OF THEORY : -

1949-1957 Orem worked for the Division of Hospital and Institutional Services of the Indiana State Board of Health.

Her goal was to upgrade the quality of nursing in general hospitals throughout the state. During this time she developed her definition of nursing practice.

1959 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.

Orem’s Nursing: Concept of Practice was first published in 1971 and subsequently in 1980, 1985, 1991, 1995, and 2001 .

PARADIGM OF OREMS THEORY / DOMAINS : -

Nursing – is art, a helping service, and a technology

Actions deliberately selected and performed by nurses to help individuals or groups under their care to maintain or change conditions in themselves or their environments

Encompasses the patient’s perspective of health condition ,the physician’s perspective , and the nursing perspective

Goal of nursing – to render the patient or members of his family capable of meeting the patient’s self care needs

To maintain a state of health

To regain normal or near normal state of health in the event of disease or injury

To stabilize ,control ,or minimize the effects of chronic poor health or disability

Health – health and healthy are terms used to describe living things …

It is when they are structurally and functionally whole or sound … wholeness or integrity. .includes that which makes a person human,…operating in conjunction with physiological and psychophysiological mechanisms and a material structure and in relation to and interacting with other human beings

Environment

environment components are enthronement factors, enthronement elements, conditions, and developed environment .

Person

A human being who has "health related /health derived limitations that render him incapable of continuous self care or dependent care or limitations that result in ineffective / incomplete care.

A human being is the focus of nursing only when a self –care requisites exceeds self care capabilities

MAJOR ASSUMPT IONS: -

People should be self-reliant and responsible for their own care and others in their family needing care

People are distinct individuals

Nursing is a form of action – interaction between two or more persons

Successfully meeting universal and development self-care requisites is an important component of primary care prevention and ill health

A person’s knowledge of potential health problems is necessary for promoting self-care behaviors

Self care and dependent care are behaviors learned within a socio-cultural context

OREM’S GENERAL THEORY OF NURS ING: -

Orem’s general theory of nursing in three related parts:-

Theory of self care Theory of self care deficit

Theory of nursing system

A . T h e o r y o f S e l f C a r e

This theory Includes:

Self care – practice of activities that individual initiates and perform on their own behalf in maintaining life ,health and well being

Self care agency – is a human ability which is "the ability for engaging in self care" -conditioned by age developmental state, life experience socio-cultural orientation health and available resources

Therapeutic self care demand – "totality of self care actions to be performed for some duration in order to meet self care requisites by using valid methods and related sets of operations and actions"

Self care requisites - action directed towards provision of self care. 3 categories of self care requisites are-

o Universal self care requisites

o Developmental self care requisites

o Health deviation self care requisites

1. Universal self care requisites Associated with life processes and the maintenance of the integrity

of human structure and functioning Common to all , ADL

Identifies these requisites as:

o Maintenance of sufficient intake of air ,water, food

o Provision of care assoc with elimination process

o Balance between activity and rest, between solitude and social interaction

o Prevention of hazards to human life well being and

o Promotion of human functioning

2. Developmental self care requisites

Associated with developmental processes/ derived from a condition…. Or associated with an event

E.g. adjusting to a new job

adjusting to body changes

3. Health deviation self care

Required in conditions of illness, injury, or disease .these include:-- Seeking and securing appropriate medical assistance

Being aware of and attending to the effects and results of pathologic conditions

Supporting another

Providing an environment promoting personal development in relation to meet future demands

Teaching another

B .Theory of self care deficit

  Five Methods of Assistance

- is the central focus of Orem’s Grand Theory of Nursing- explains when nursing is needed- describes and explains how people can be helped through nursing- results when the Self-care Agency (patient) can’t meet her/his self-care needs or administer self-care- nursing meets these self-care needs through five methods of help

Five Methods of Nursing Help

-Acting or doing for-Guiding-Teaching-Supporting-Providing an environment to promote the patient’s ability to meet current or future demands

Orems has identified five areas of activity for nursing practices

Entering into & maintaining nurse – patient relationship with individuals , families & groups until patient can legitimately be discharged from nursing .

Determining if & how patients can be helped through nursing

Responding to patients requests , desires , & need for nurse contacts & assistance

Prescribing , providing & regulating direct help to patients (& their significant others) in the form of nursing .

Coordinating & integrating nursing with the patients daily living , other health care needed or being received , & social & educational services needed or being received .

C . T h e o r y o f N u r s i n g S y s t e m s

Describes how the patient’s self care needs will be met by the nurse , the patient, or both

Identifies 3 classifications of nursing system to meet the self care requisites of the patient:-

Wholly compensatory system

Partly compensatory system

Supportive – educative system

Refers to a series of actions a nurse undertakes to aid in meeting a person’s self-care needs. Describes nursing responsibilities; roles of the nurse & patient. Rationales for the nurse should be patient relationship. The essential organizing component of the Self-Care Deficit theory of Nursing because of it establishes the form of nursing and the relationship

between patient and nurse properties. Focused on person There are three support modalities identified in theory: wholly compensatory; partly compensatory; supportive-educative

Three Support Modalities: The client’s ability for self-care involvement will determine under which support modality they would be considered. A person may fluctuate between support modalities at any given time

wholly compensatory system The patient has no active role in the performance of his care. The nurse acts for the patient An individual requires total nursing care to full-fill self-care needs A patient’s self-care agency is so limited that she or he depends on others for well-being The nurse accomplishes patient’s therapeutic self-care; compensates for patient’s inability to engage in self-care; supports and protects patients

Partly compensatory system Both nurse and patient work together to perform activities to achieve desired self-care goals. A patient can do some self-care measures but needs a nurse to assist her to meet others It has a give and take relationship between the nurse and the patient The nurse compensates for self-care limitations of patient

Supportive-educative system:

Requires uses of resources and educational tools to teach the person & family to perform their own self-care . Indicates that the patient contributes mostly in his/her self-care and the nurse’s role is merely to monitor & regulate the patient’s self-care. The patient accomplishes self-care & regulates the exercise & development of self-care agency. The patient is able to perform, or can learn to perform, required measures of therapeutic self-care but cannot do so without assistance A patient can meet self-care requisites but needs help in decision-making, behaviour control, or knowledge acquisition

Basic Nursing system

Wholly compensatory system

NURSES

ACTION

Accomplishes patient therapeutic care

Compensates for pt’s inability to engage in self care

Supports & protects patients

Partly compensatory system

NURSES

ACTION

Performs some self care measures for the patients

Compensates some self care limitations of the pts.

Assists pt’s – as required

Performs some self care measures PATIENT

ACTION

Regulates self care

Accepts care & assistance from nurse

Supportive educative system

Accomplishes self care PATIENT

ACTIONRegulates exercise and development of self care agency

OREM’S THEORY AND NURS ING PROCESS : -

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.

The steps within the approach are considered to be the technical component of the nursing process.

Orem emphasizes that the technological component "must be coordinated with interpersonal and social processes within nursing situations.

PATIENT PROFILE

Areas Patient details

Name Age Sex Education

Mrs. X 56 years Female No formal education

Occupation Marital status Religion Diagnosis Theory applied 

House hold Married Hindu Rheumatoid arthritis Orem’s theory of self care deficit.

Medical Diagnosis:- Rheumatoid arthritis

Medical Treatment: -Medication and physical therapy

NURS ING CARE PLAN ACCORDING TO OREM’S THEORY OF SELF CARE DEF IC IT : -

Nursing diagnosis  (diagnostic operations)

Outcome and plan (Prescriptive operations)

Implementation (control operations)

Evaluation (regulatory operations)

Based on self care deficits

Outcome Nursing goal and objectives

Design of nursing system Appropriate method of helping

Nurse- patient actions to -   Promote patient as self care agent -   Meet self care needs -   Decrease the self care deficit.

1. Effectiveness of the nurse patient action to -Promote patient as self care agent -    Meet self care needs -   Decrease the self care deficit. 2. Effectiveness of the selected nursing system to meet the needs.

A. NURSING DIAGNOSIS

Self-care deficit: dressing, toileting related to restricted joint movement, secondary to the inflammatory process in the joints.

Plan

improved self-care  maintain the ability to perform the toileting and dressing with

modification as required. 

Goal: to achieve optimal levels of ability for self care.  

Objectives: Mrs. X will:

perform the dressing activities within limitations  utilize the alternative measures available for improving the toileting

perform the other activities of daily living with minimal assistance.

Design of the nursing system:- Partly compensatory 

Method of helping:

1. Guidance:  

Assess the various hindering factors for self care and how to tackle them.

2. Support:

Provide all the articles needed for self care, near to the patient and ask the family members also to give the articles near to her.

Provide passive exercises and make to perform active exercises so as to promote the mobility of the joint.

Make the patient use commodes or stools to perform toileting and insist on avoidance of squatting position

Provide assistance whenever needed for the self care activities

Provide encouragement and positive reinforcement for minor improvement in the activity level.

Initiate the pain relieving measures always before the patient go for any of the activities of daily living

Make the patient to use loose fitting clothes which will be easy to wear and remove.

3. Teaching:

Teach the family members the limitation in the activity level the patient has and the cooperation required

4. Promoting a developmental environment:

Teach the family and help them to practice how to help the patient according to her needs

Implementation

Mutually planned and identified the objectives and the patient was made to understand about the required changes in the behaviour to have the requisites met.

Evaluation

Patient was performing some of the activities and she practiced toileting using a commode in the hospital.  

She verbalized an improved comfort and self care ability. 

She performed the dressing activities with minimal assistance  

Patient verbalized that she will perform the activities as instructed to get her ADL done.

The partly compensatory system was useful for Mrs. X

B . NURSING DIAGNOSIS :- Inability to maintain the ideal nutrition related to inadequate intake and knowledge deficit

Plan

Improved nutrition

Maintenance of a balanced diet with adequate iron supplementation.

Goal: to achieve optimal levels of nutrition.

Objectives: Mrs. X will:  

state the importance of maintaining a balanced diet.   List the food items rich in iron , that are available in the locality.

Design of the nursing system: - supportive educative

Method of helping:

guidance support

Teaching

Providing developmental environment

Implementation

Mutually planned and identified the objectives and the patient were made to understand about the required changes in the behaviour to have the requisites met.

Evaluation

Mrs. X understood the importance of maintaining an optimum nutrition.  

She told that she will select the iron rich diet for her food. 

She listed the foods that are rich in iron and that are locally available.  

The self care deficit in terms of food will be decreased with the initiation of the nutritional intake.

The supportive educative system was useful for Mrs. X

C .NURSING DIAGNOSIS :-Ineffective pain control related to lack of utilization of pain relief measures 

Plan

improved pain self control  achieve and maintain a reduction in the pain.  

Goal: to achieve reduction in the pain.  

Objectives: Mrs. X will:

describe  the total plan of pharmacological and non pharmacological pain relief 

demonstrate a reduction in the pain behaviours 

verbalize a reduction in the pain scale score from 7 – 4

Design of the nursing system: supportive educative  

Method of helping:

Guidance:

Explore the past experience of pain and methods used to manage them.

Ask the client to report the intensity, location, severity, associated and aggravating factors.

Support:

Provide rest to the joints and avoid excessive manipulations provide hot and cold application to have better mobility.  

Encourage exercises to the joints by immersing in the warm water.

Administer T. Ultracet and Tab Diclofecac as prescribed.  

Provide diversion and psychological support to the patient

Teaching:

Teach the non – pharmacological method to the patient once the pain is a little reduced.  

Providing the developmental environment:

Discuss with the patient the necessity to maintain a pain diary with all information regarding episodes of pain and refer to that periodically  

Enquire from the health team, the need for opioid analgesics or other analgesics and get a prescription for the patient.

Implementation

-Non pharmachological measure are adopted ,encouraged for exercise

Evaluation

Patient still has pain over the joints and she agreed that she will use the measures for pain relief that is told to her. 

The pain scale score was 6 after the measures were provided to the patient. 

She demonstrated slight reduction in the pain behaviours.

The supportive educative system was useful for Mrs. X

S T R E N G T H S O F O R E M S T H E O R Y : -

Provides a comprehensive base to nursing practice It has utility for professional nursing in the areas of nursing practice

nursing curricula ,nursing education administration ,and nursing research

Specifies when nursing is needed

Also includes continuing education as part of the professional component of nursing education

Her self care approach is contemporary with the concepts of health promotion and health maintenance

Expanded her focus of individual self care to include multi person units

L I M I T A T I O N S O F O R E M S T H E O R Y : -

In general system theory a system is viewed as a single whole thing while Orem defines a system as a single , whole thing

Health is often viewed as dynamic and ever changing .Orem’s nursing systems implies three static conditions of health

Appears that the theory is illness oriented rather with no indication of its use in wellness settings

One of the most obvious limitations of Orem’s theory is that throughout her work, it can be said that a limited recognition of an individual’s emotional needs is present within the theory (George JB., 1995). It focuses more on physical care and gives lesser emphasis to psychological care.

Orem’s self care deficit theory may not encompass all aspects of care and needs of a specific client

The ambiguity of applying theory to nursing practice may lie in the fact that one theory does not always specifically support all aspects of nursing care.

CRITIQUE OF OREM ‘S SELF CARE DEFICIT THEORY :

Clarity Despite the comprehensiveness and the wide applications of Orem’s theory, there still some issues regarding its clarity. Orem’s theory is known for its multiple terms that can make the learner confused. According to Mendoza, et al (2004), most of the students who are studying Orem’s work are perplexed on the different terminologies with

similar meanings. For example, Orem both defined self care and self care

agency as learned behaviors/abilities that deliberately regulate human structural integrity, functioning and development. A similar definition is also noted on Self care action. Another is the difference between Therapeutic, Practical and Health deviation self care need/demand. All of these terms are defined as self care needs or demands that arises when an illness or disease affect the self care agent. These terminologies can cause uncertainty to the learner. Abdul (2002) also stated that Orem’s theory is redundant in some way.

SimplicityDorothea Orem’s work is simple as it is, a person must have the ability to take care for himself. And if the person cannot do so, the nurse will do it for him. However, once you studied her theory more closely, you will see how complex it is.According to Alshamsi (1995), Orem’s work is like a simple wall clock. From the outside, it seems as plain as it can be but once you look inside it, you will be surprised to see the intricacy of its work. This is the reason why most undergraduate students volunteered to report Orem’s theory not knowing how tricky it is to differentiate all the terminologies and how to apply this in a hospital/community setting. Mendoza, et al (2004) also noted that students find Orem’s work “easy to explain but difficult to define”. This means that generally, the concepts of Orem are easy enough to explain but once you go deeper to her theory, they find it hard to define and differentiate her numerous terminologies and hypothesis.

GeneralityThe Self care deficit theory is one of the Grand Theories of our generation. This means that it is one of the most complex and has the broadest scope of all the nursing theories present. Grand theories are usually difficult to test in a study or apply in a healthcare setting because it is too complex (dela Cruz, et al, 1991). Wide range theories are effective in an academic environment as its concepts are the building blocks of our practice. Almost all of our current practices are somehow developed from the grand theories. But applying a grand theory, like Orem’s, in a study exclusively will be extremely difficult to prove. Because of the complexity and the broadness of the theory, it gives the study a lot of variables to look at and a very wide scope to apply the study.

SELF CARE DEFICIT NURSING THEORY AS APPLIED IN NURSING PRACTICE: -

By Nica-Ann Galang Santos

”Nurses work in life situations with others to bring about the conditions that are beneficial to persons nursed. Nursing demands the exercise of both the speculative and practical intelligence of nurses. In nursing practice situations, nurses must have accurate information and be knowing about existent conditions and circumstances of patients and about emerging changes in them. This knowledge is the concrete base for nurses’ development of creative practical insights of what can be done to bring about beneficial relationships or conditions that do not presently exist. Asking and answering the questions, ‘what is?’ and ‘what can be?’ are nurse’s point of departure in nursing practice situation.” (Orem, 1995, p. 155)

The significance of the utilization of the Orem’s model in practice has been explicit since the publication of the first edition of Nursing: Concepts of Practice (Orem, 1971). Early use of the theory in nursing practice began with the work of the Nursing Development Conference Group (NDCG) (1973). The group initiated their adventure into theory-based nursing practice by integrating the developing concepts of the model into their clinical teaching of students. As the conceptualizations evolved, they were incorporated into nursing care.

APPLICATION OF OREMS SELF CARE DEFICIT THEORY IN NURSING PROFESSION :

By Rosinee Rosales

As a staff nurse in a medical ward in Riyadh Military Hospital, many of our patients have respiratory and heart problems. All of them present different health problems and needs, some of them are intubated and some of them are in comatose condition after cerebrovascular accident or cardiac arrest. These patients will not be able to verbalize their concerns and feelings. Orem’s concept of self-care specified different self-care requisites, being acquainted in these concepts, it’s easier for me to assess and recognize the needs of my patients and it will facilitate me in selecting particular nursing interventions based on their needs. Orem’s theory of nursing systems is also evident in my current practice. The concepts of wholly compensatory, partly compensatory, and supportive-educative systems are relevant to various interventions that I perform

based on different needs and abilities of my patients thus it creates individualized nursing care. In the case of bedridden patients, wholly compensatory nursing system is appropriate to them, “the nurse is their hands and their feet”. Patients who had liver biopsy are not allowed to ambulate 24 hours after the procedure. In this event, partly compensatory nursing system can be applied. Supportive-educative nursing system is appropriate to patients who have diabetes mellitus, they should be taught to correct their diet and lifestyle and how to check their blood sugar and to administer insulin if needed.

APPLICATION OF OREMS SELF CARE DEFICIT THEORY IN NURSING EDUCATION :

By Vonnalin A. Del Rio

Orem's theory is useful in designing curricula for preservice, graduate, and continuing nursing education. It can also give direction to nursing administration, and be used for guiding practice and research. It precisely indicates most of the skills, techniques and methods that an individual must learn to become a nurse practitioner. It "gives direction to nurse-specific outcomes related to knowing and meeting the therapeutic self-care demands, and establishing self-care and self-management systems" .

APPLICATION OF OREMS SELF CARE DEFICIT THEORY IN NURSING RESEARCH :

By Jenzer Mae Ambrocio

The research related to or derived from Orem's theory can be classified as relating to: (1) the development of research instruments for measuring the conceptual elements of the theory and (2) studies the test element of theory in specific populations.

SIGNIFICANCE OF OREM ‘S SELF CARE DEFICIT THEORY :

For a Surgical NurseBy: Vonnalin Del Rio

Orem’s theory serves as a guide in my daily practice at the Surgery Ward where majority of the patients are experiencing changes in their physical structure for instance those who have undergone surgeries like BKA, ORIF, etc. most of them lack the ability, strength, and motivation to perform their daily self care activities, so as a nurse committed in their care I must

understand how they feel, and provide them with therapeutic interventions by giving them proper assistance or guiding them in meeting their essential needs throughout their care until they recover.

For a Dialysis NurseBy: Allan Andan

In line with Orem’s concept regarding fostering self-reliance and her insight that man is responsible for his/her self-care and well-being of his/her dependents, we educate patients or their relatives about the condition they are in and how to do peritoneal dialysis exchange and PD care themselves during their hospital stay.

For an Obstetric NurseBy: Nica-Ann Santos

An obstetric nurse, functions to render assistance, whether wholly compensatory, partly compensatory or supportive educative nursing system to the client through the different pregnancy stages, from the initiation of pregnancy, to the stages of labor and delivery and up to the involution stage, wherein there may be inability or decreased ability to perform activities of daily living (ADLs).

For an Opthalmology/Surgical NurseBy: Monaliza M. Pineda

Visually impaired patients have high demand when it comes to caring and dependence. At early stage, they have no capacity to function in their environment alone. They need someone to assist them and teach them to become familiar of their environment. As an ophthalmology nurse, Dorothea Orem’s theory plays an important role in my field of specialization. This is where we help our patient to become as independent as possible despite of the impairment. We teach them and involve their family to our teaching to help them function just like a normal individual. At early stage, we help them accept the disability by letting them express their sentiment and feeling. Afterwards, we give them the necessary options like surgery. In an operating room setting, patient has no control over their environment. As an operating room nurse, we ensure that the area and all the members of the team that will do the operation are kept sterile. To facilitate a good outcome of the operation, the nurse will do his/her part by maintaining the sterility of the area.

For an Ambulance Nurse By: Wally Guevarra

On my everyday encounters at work and during my eight years span as an ambulance nurse here in Dubai. I should say it is a lot of learning experience for me by handling variety of cases of medical and trauma cases. From a very simple minor injury of abrasion to a multiple injuries of long bone fractures, head injury and up to the extent of scattered brain tissues on the scene or what we called dead on spot.The TLC or the tender, love and care approach that we know, which really helps the patient. Because they know that they are well taken care of and you will gain the confidence of your patient. Then the health teachings that we are sharing to patient and family. Dorothea Orem's theory states that when there is self-care deficit on the part of the patient, which is the potential risk for injury or complication due to knowledge deficit about his condition. Educating the patient will give information of what he has and avoid possible complications thus,the client self-care needs of necessary strength and knowledge is met.

For an Emergency Room NurseBy: Russel de Lara

An everyday walk in the mill within the confines of the Emergency Department, never has there been a day that people walking in would mind how they look, talk or present themselves. What others would think about them is none of their worries when suffering acute and severe complaints.

Most of the time, during the acute stage, can we find ER or ED clients mostly if not unconscious, has altered levels of consciousness. It is during this time that they need wholly compensatory support. When they start to become more responsive, and like anyone of us, demand independence but after careful assessment, all that they may need is partly compensatory assistance. It is only when the physician deems them to be stable, and able for ward transfer, that we may provide supportive-educative support.Provision and assistance of the client’s satisfaction of self-care requisites is very fundamental and that sometimes, we nurses forget that the smallest things we do sometimes are manifestations of the application of these theories, that we have spent years trying to comprehend. Some, if not most, remember these, but just to remind us all, sometimes knowing that we are doing the most basic of things just makes the bigger picture look right.

CONCLUSION :- If we consider the strength of orems theory & apply in nursing research ( by keeping the limitation of theory in mind ) then it will be very much effective . Limitation also is there till it is used by nurse in their practice .

INTRODUCTION

By Rosenald Sen

She was born in Baltimore, Maryland on 1914. Her father was a construction worker and her mother is a home maker. She was the youngest among two daughters. She died in June 22, 2007Education:She studied Diploma in Nursing in early 1930’s at the Providence Hospital School og Nursing In Washington D.C., In 139 and 1945 she finished B.S. Nursing Education ( BSN Ed.) and MSN Ed successively in Catholic University of America, Washington D.C.1976 She become Honorary Doctorates: Doctors of Science from Georgetown University and Incarnate word college in San Antonio in Texas in 1980.In 1988 she finished Doctor of Humane Letters from Illinois Wesleyan University in Bloomington, Illinois.1988 She Graduated from University of Missouri in Columbia, Doctor Honoris Causae.

Historical PerspectivesBy Russel de Lara

- born in Baltimore, Maryland and the younger of two daughters- began her nursing career at Providence Hospital School of Nursing in Washington, D.C.; received a diploma certificate of nursing (1930)- pursued her education further and received a BSN and MS in nursing education from the Catholic University of America in 1939 and 1945, respectively; had varied nursing experiences which included private duty nursing, hospital staff nursing and teaching- occupied important nursing positions, like the directorship of both the nursing school and the department of nursing at Providence Hospital, Detroit (1940 to 1949)- spent seven years at the Division of Hospital and Institutional Services of

the Indiana State Board of Health (1949-1957), developed her definition of nursing practice- moved to Washington D.C. where she was employed by the Office of Education, U.S. Department of Health, Education and Welfare as a curriculum consultant( 1958 to 1960); became more aware of deficiencies in the training of practical nurses so she worked on a project to upgrade practical nursing. Consequently she published her book Guidelines for Developing Curricula for the Education of Practical Nurses.- joined the Catholic University of America first as Assistant Professor, then later became Assistant Dean and Associate Professor of the School of Nursing. - continued to develop her theory and later wrote “The Hope of Nursing,” published in the Journal of Nursing Education (1962).- was the leader of the Nursing Model Committee of the School of Nursing Faculty of the Catholic University of America whose task was to develop a model that would express the foundations for, and characteristics of, research in nursing. This committee developed, reviewed, and tested several tentative generalizations about nursing and submitted its final report to the School of Nursing (May 1968) - published her second book, Nursing Concepts of Practice in 1971, after completing her work on the Nursing Model Committee.- left the university and started her own consulting firm called Orem and Shield’s Inc. at Chevy Chase, Maryland- Georgetown University conferred on her the honorary degree of Doctor of Science (1976)- work began by the Nursing Model Committee was continued in 1968 by a group of 11 nurses with different backgrounds and areas of practice who formed the Nursing Development Conference Group (NDCG); formed because of their dissatisfaction with the lack of an organizing framework for nursing knowledge; believed that a concept of nursing would help develop that framework; held a series of meetings and developed an approach to the structuring of nursing knowledge within a nursing framework (model)- concept of nursing as formalized by the NDCG was published (1973) in Concept Formalization: Process and Product; outlined the basic assumptions of the model concerning nursing and self-care- received the Catholic University of America Alumni Association Award for Nursing Theory in 1980. The second edition of Nursing: Concept of Practice was published (1980) - retired (1984) but she continued to work on the third edition which was published (1985); fourth edition of her book was completed (1991); continues to work on the conceptual development of Self-Care Deficit Nursing Theory.

OREMS NURSING PARADIGM :By Allan Andan

Man

Orem viewed man as an integrated whole composed of an internal physical, psychologic, and social nature with varying degrees of self-care ability. He/she has the potential for learning and development as he/she is gifted with rational ability and capacity to reflect on his/her experience and use symbols (ideas and words). Under normal conditions, man is self-reliant, responsible and capable continuous self-care, not only of himself/herself, but also oh his/her dependents.

Orem viewed a patient as an individual with health related limitations that make him/her incapable of continuous self care or dependent care. His/ her self-care requisites or demands are beyond his/her self-care abilities which can be attributed to his/her lack of knowledge, skills, motivation or orientation.

Health

Orem defined health as a state of wholeness or integrity of a human being: a state where one is structurally and functionally whole or sound. She further added that a healthy being is one who has the necessary self-care ability to meet his/her changing self-care demands. She supported the concepts of health promotion and health maintenance and claimed that it is not just the individual’s responsibility, but also the society as a whole, including its members.

Environment

Orem viewed the environment as not just the elements external to man. She viewed man and environment as an integrated system. It includes conditions that can positively or negatively affect a person’s ability to provide self-care. She enumerated certain conditions which are conducive for one’s development and includes the following: opportunities to be helped; being with other persons or group where care is offered; opportunities for solitude and companionship; provision of help for personal and group concerns without limiting individual decisions and personal pursuits; shared respect and trust; recognition and fostering of developmental potential.

Nursing

According to Orem, nursing consists of actions deliberately selected and performed by nurses to help individuals or groups under their care to maintain or change conditions in themselves or their environment. She further viewed nursing as an art, community service and a technology. As an art, it has a theoretical base which serves as the basis in providing self-care towards improvement of one’s functioning and development. As a community service, it is geared towards deliberative actions of assisting

another in maintaining or reestablishing balance between self-care abilities and demands also leading to improvement in one’s functioning and development. As a technology, it has specialized methods or practice of delivering self-care.

When there is demand to care for oneself and the individual is able to meet that demand, self-care is possible. If, on the other hand, the demand is greater than the individual’s capacity or ability to meet it, an imbalance occurs and this is called a self care deficit.

The theory of self-care deficit is the core of Orem's grand theory of nursing because it delineates when nursing is needed. Nursing is required when an adult (or in the case of a dependent, the parent or guardian) is incapable of or limited in the provision of continuous effective self-care (George 1995). The term "deficit" refers to a particular relationship between self-care agency and self-care demand that is said to exist when capabilities for engaging in self-care are less than the demand for self-care (Parker, 2005, p. 149).

The self-care deficit may be actual or potential. For example:1. In the case of premature birth, the actual infant-care deficit may be the parent’s lack of knowledge of how to provide care for the preterm infant.2. The potential infant-care deficit could result in increased risk of infant abuse or neglect.

Orem identifies 6 methods of helping:--1. Doing for or acting for another2. Guiding or directing another3. Providing physical support4. Providing psychological support5. Providing an environment supportive of development6. Teaching another

By Therese A. Baulita

Theory of Nursing Systems Refers to a series of actions a nurse undertakes to aid in meeting a person’s self-care needs. Describes nursing responsibilities; roles of the nurse & patient Rationales for the nurse-patient relationship The essential organizing component of the Self-Care Deficit Theory of Nursing because it establishes the form of nursing and the relationship between patient and nurse properties. Focused on person

There are three support modalities identified in theory: wholly compensatory; partly compensatory; supportive-educative

Three Support Modalities: The client’s ability for self-care involvement will determine under which support modality they would be considered A person may fluctuate between support modalities at any given time

Wholly compensatory system The patient has no active role in the performance of his care The nurse acts for the patient An individual requires total nursing care to fulfill self-care needs A patient’s self-care agency is so limited that she or he depends on others for well-being The nurse accomplishes patient’s therapeutic self-care; compensates for patient’s inability to engage in self-care; supports and protects patients

Partly compensatory system Both nurse and patient work together to perform activities to achieve desired self-care goals A patient can do some self-care measures but needs a nurse to assist her to meet others It has a give and take relationship between the nurse and the patient The nurse compensates for self-care limitations of patient

Supportive-educative system Requires uses of resources and educational tools to teach the person & family to perform their own self-care Indicates that the patient contributes mostly in his/her self-care and the nurse’s role is merely to monitor & regulate the patient’s self-care The patient accomplishes self-care & regulates the exercise & development of self-care agency The patient is able to perform, or can learn to perform, required measures of therapeutic self-care but cannot do so without assistance A patient can meet self-care requisites but needs help in decision-making, behavior control, or knowledge acquisition

By Rachelle Dogao

Dorothea Orem's Self Care Deficit Theory encompasses all aspect relating to the patient's health, nursing and all the factors that affect which.

The concepts discussed revolve mainly around self care. It is the patient's ability to care for himself and his dependents as well as others as dictated by the environment he lives in that determines health or the need for assistance in maintaining health. On the other hand, the society plays the

major role into regulating the nursing care process as to when nursing care is needed and when and how the nursing system is implemented. It is also the environment and the society that directly affect the nurse-patient relationship and self care agency, which are all interconnected into achieving, restoring, and maintaining health.

As shown in the figure below, health can be achieved if the person has knowledge and resources to perform self care activities to meet self care deficits. On the other side, self care deficit results when self care agency (ability to perform self-care) is not adequate to meet the known self care demand and/or the failure to meet the health care requisites (Kozier et.al, 2002) This then warrants the need for nursing intervention through the nursing system, which in turn is empowered by the nurse-patient relationship. The end result of all of this is the maintenance, restoration, or preservation of health.

Strengths of OREM’S THEORY :

Orem’s theory provide a comprehensive base to nursing practice. It is functional in the different fields of nursing. May it be in clinical setting, education, research or administration. Moreover, this theory is as applicable for nursing by the beginning practitioner as much as the advanced clinician(George JB., 1995). Another major strength of Orem’s theory is it’s advocacy for the use of the Nursing Process (Balabagno, et.al, 2006). Orem specifically identified the steps of this process. She also mentioned that the nursing process involves intellectual and practical phases.

Limitations

The ambiguity of applying theory to nursing practice may lie in the fact that one theory does not always specifically support all aspects of nursing care. Orem’s self care deficit theory may not encompass all aspects of care and needs of a specific client. For instance, some dilemma with Orem’s theory include having an unclear definition of family, the nurse-society relationship and public education areas are weak. These issues are essential in the management and treatment plan in caring for patients. Although the family, community and environment are considered in self care action, the focus is primarily on the individual (Balabagno, et.al, 2006). Another limitation is the definition of health as being dynamic and ever changing with states ranging from health or non health, wellness or illness (Fitzpatrick JJ, 2005). This definition of health directly contradicts the experience of some patients with varying needs and levels of care requirements. One of the most obvious limitations of Orem’s theory is that throughout her work, it can be said that a limited recognition of an individual’s emotional needs is present within the theory (George JB., 1995). It focuses more on physical care and gives lesser emphasis to

psychological care. Other theories address this limitation quite adequately such as Jean Watson’s Theory of Caring.

CRITIQUE OF OREM ‘S SELF CARE DEFICIT THEORY :Clarity:-Despite the comprehensiveness and the wide applications of Orem’s theory, there still some issues regarding its clarity. Orem’s theory is known for its multiple terms that can make the learner confused. According to Mendoza, et al (2004), most of the students who are studying Orem’s work are perplexed on the different terminologies with similar meanings. For example, Orem both defined self care and self care agency as learned behaviors/abilities that deliberately regulate human structural integrity, functioning and development. A similar definition is also noted on Self care action. Another is the difference between Therapeutic, Practical and Health deviation self care need/demand. All of these terms are defined as self care needs or demands that arises when an illness or disease affect the self care agent. These terminologies can cause uncertainty to the learner. Abdul (2002) also stated that Orem’s theory is redundant in some way. As you have known, Orem’s work was divided into three theories: the theory of self care, theory of self care deficit, and theory of nursing system. Each of these theories is defined separately on their own. However, as it grew more detailed, the redundancy of the concepts occurs. For example, in the theory of self care, Orem defined what are self care, self care agency, and self care requisites. Self care requisites itself can define the theory of self care deficit. And it can also define the theory of the nursing systems if you will view it on a different angle. We think that Orem created her theory this way to have a broader scope and better explain her concepts no matter how redundant it is.We all have been through in studying Orem’s theory in our college days and we can safely say that we agree on some of the things that the noted researchers said. But we can also say that without Orem’s multiple terminologies and highly detailed theories, applying it to hospital/community setting will be far more difficult because of its generality.

Simplicity :-Dorothea Orem’s work is simple as it is, a person must have the ability to take care for himself. And if the person cannot do so, the nurse will do it for him. However, once you studied her theory more closely, you will see how complex it is.According to Alshamsi (1995), Orem’s work is like a simple wall clock. From the outside, it seems as plain as it can be but once you look inside it, you will be surprised to see the intricacy of its work. This is the reason why most undergraduate students volunteered to report Orem’s theory not knowing how tricky it is to differentiate all the terminologies and how to apply this in a hospital/community setting. Mendoza, et al (2004) also noted that students find Orem’s work “easy to explain but difficult to define”. This means that generally, the concepts of

Orem are easy enough to explain but once you go deeper to her theory, they find it hard to define and differentiate her numerous terminologies and hypothesis.

Generality :-The Self care deficit theory is one of the Grand Theories of our generation. This means that it is one of the most complex and has the broadest scope of all the nursing theories present. Grand theories are usually difficult to test in a study or apply in a healthcare setting because it is too complex (dela Cruz, et al, 1991). Wide range theories are effective in an academic environment as its concepts are the building blocks of our practice. Almost all of our current practices are somehow developed from the grand theories. But applying a grand theory, like Orem’s, in a study exclusively will be extremely difficult to prove. Because of the complexity and the broadness of the theory, it gives the study a lot of variables to look at and a very wide scope to apply the study.Moustafa (1999) also noted that Orem’s theory is generally accorded to the physiological and sociological wellbeing of the person, undermining the importance of mental health. According to him, as general as it may look, Orem’s work is lacking some concepts which are vital to nursing care. He greatly stressed the lack mental health on this theory and the possible problems that may happen once Orem’s theory is applied in a healthcare setting. For example, a person who is a paranoid schizophrenic will not admit that he needs help regarding his self care demands. And without acceptance of the self care deficit, it will be difficult to care for the person if we are using Orem’s concepts. .