Dorothea E. Orem 1

Running Head: DOROTHEA E. OREM’S SELF-CARE DEFICIT THEORY

Dorothea E. Orem’s Theory

Elaine Martin

Troy University School of Nursing

Nursing 5504

December 2, 2005

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Dorothea E. Orem’s Theory

Orem presented a conceptual framework in 1959. Since then her work has

continued to evolve. Orem’s general theory of nursing was formulated and expressed in 1979-

1980. Orem (2001) states her general theory as the condition that validates the existence of a

requirement for nursing in an adult is the health-associated absence of the ability to maintain

continuously that amount and quality of self-care that is therapeutic in sustaining life and health,

in recovering from disease of injury, or in coping with their effects. With children, the condition

is the inability of the (or guardian) associated with the child’s health state to maintain

continuously for the child the amount and quality of care that is therapeutic (p.82). Orem’s Self-

Care Deficit Theory of Nursing is conceptual model, which is comprised of three related

theories: (1) the theory of self-care, (2) the theory of self-care deficit, and(3) the theory of

nursing systems. Included within these three theories are six central concepts and one peripheral

concept. You must understand these central concepts of self-care and dependent care, self-care

agency and dependent care agency, therapeutic self-care demand, self-care deficit, nursing

agency, and nursing systems in addition to the peripheral concept of basic conditioning factor, to

understanding her theory (George 2002).

The theory of self-care is the practice activities that individuals initiate and perform on

their own behalf in maintaining life, health, and well-being. The theory of self-care deficit is the

core of Orem’s general theory of nursing because it explains when nursing is needed. Nursing is

required when an adult (or in the case of dependent, the parent or guardian) is incapable or

limited in the provision of continuous effective self-care. The nursing system, designed by the

nurse, is based on the self-care needs and abilities of the patient to perform self-care activities.

In this theory, Orem states how the patient’s self-care needs will be met by the nurse, the patient,

or both.

Orem identified three classifications of nursing system to meet the self-care requisites of

the patient. These systems are: the wholly compensatory system, the partly compensatory system

and the supportive educative system (George, 2002). In the wholly compensatory system a nurse

provides complete universal and health care functions for the patient. This phase is when the

patient is most vulnerable and totally dependent upon the nurse to meet their self-care requisites.

When the patient is able to assist and perform some self-care needs, but must rely on someone

else to meet all self-care requisites in the partly compensatory system. Within the supportive/

educative system, the patient is able to perform their self-care requirements and the nurse simply

acts as a resource for guidance and support.

Orem’s theory is based on explicit and implicit assumptions. Meleis (1997) summarizes

the explicit assumptions as:

1) Nursing is a deliberate, purposeful helping service performed by

nurses for the sake others over a period of time,

2) Persons (human agency) are capable and

willing to perform self-care for self or for dependent members of the family,

3) Self-care is part

of life that is necessary for health, human development, and well-being,

4) Education and culture influence individuals,

5) Self-care is learned through human interaction and communication,

6) Self-care includes deliberate and systematic actions performed to meet known needs for care,

7) Human agency is exercised in discovering, developing and transmitting to others ways and

means to identify needs for and make inputs to self and others.

In brief, Meleis states the

implicit assumptions as:

1) People should be self-reliant and responsible for their own care needs

as well as for others in the family who are not able to care for themselves,

2) People are individuals with entities that are distinct from others and from their environment.

The metaparadigm is the most abstract component of the structural hierarchy of nursing

knowledge. Nursing’s metaparadigm consist of concepts and propositions that are global with

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phenomena which is limited to the discipline of nursing with no specific perspective.

The metaparadigm of nursing is composed of four concepts, which are person, environment, health

and nursing. These four concepts are reflected in Orem’s theory Self-Care Framework (Fawcett,

2000).

Orem defines person as human beings who are “distinguished from other living things by

their capacity (a) to reflect upon themselves and their environment, (b) to symbolize what they

experience, and (c) to use symbolic creations (ideas, words) in thinking, in communicating, and

in guiding efforts to do and to make things that are beneficial for themselves or others” (Orem,

2001, p 182). The functions of human beings are integrated to include physical, psychological,

interpersonal, and social aspects. A person’s self-care needs are met by a learned behavior.

Factors which may affect an individual learning include age, mental capacity, culture, society

and emotional state. When learning of self-care measures does not occur, others must learn the

care and provide it (George, 2002).

Orem’s (2001, p. 184) concept of health is defined as “a state of physical, mental and

social well-being and not only the absence of disease of infirmity” (p. 184) as well as speaking to

the relationship between health, well-being, and being whole or sound. Through a sense of

personalization well-being is a perception of contentment, happiness and pleasure. An individual

is an integrated whole composed of internal physical, psychologic and social nature with varying

degrees of self-care ability.

Orem (2001) speaks to nursing as a specific type of human service based on self-help and

help to others. Adults are expected to be self-reliant and responsible for themselves and for the

well-being of their dependents. Whenever the maintenance of continuous self-care requires the

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use of special techniques and the application of scientific knowledge then nursing is required in

providing the care or in designing it.

Orem (2001) further defines nursing as a human service. Nursing is distinguished from

other human services by its focus on persons with inabilities to maintain the continuous

provision of health care. Nursing is needed when the adult is unable “to maintain continuously

that amount and quality of [health-associated] self-care that is therapeutic in sustaining life and

health” (p. 82).

Environment as defined in the metaparadigm of nursing, refers to the person’s significant

others and physical surroundings, as well as the setting in which nursing occurs, which ranges

from the person’s home to clinical agencies, to society as a whole (Fawcett, 2000). According to

Orem, environment is tri-dimensional, encompassing the physical, socioeconomic, and

community features. The physical features involve maintaining the human structure, functioning,

and well being. Socioeconomic features focus on the family, including composition by roles and

ages, cultural prescriptions of authority, responsibilities and rights for the family unit.

Community features are inclusive of the population and its composition by family units, by other

function, collaborating social units, and by governmental voices (Fawcett, 2000).

The metaparadigm concept nursing is represented in the Self-Care Framework by the

concept Nursing Agency. Nursing Agency is the action of nurses in determining the needs for,

design of, and production of nursing for persons with a range of types of self-care deficits.

Nursing Agency includes three dimensions which are the social system, interpersonal system and

professional-technologic system. The social system includes the relationship between the nurse

and the patient forming an agreement for the purpose of obtaining nursing care when an actual or

potential self-care of dependent-care deficit has evolved. The interpersonal system involves the

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contact, association, and communication between the nurse and the patient. The professional

technological system is the system of action productive of nursing. The existence of the

professional-technological system is dependent on the existence of the interpersonal system,

which in turn, is dependent on the existence of the social system (Fawcett, 2000).

The Self-Care framework has been accepted by the nursing community to guide research

and practice throughout the U.S. and other countries. Before the use of the Self-Care framework,

it is vital to understand its focus and content. Nurses and nursing students have to learn the

particular “style of thinking and communicating nursing.” (Orem, 1995, p. 167)

Nurse administrators have found the theory adaptable to implementation in a number of

institutions and a great number of chief nurses of the Department of Veteran Affairs medical

centers reported using either Orem’s theory or a combination Orem with other theorists. Orem

herself proposed a framework for nursing administration. Miller (1980) challenged nursing

administrators to create a climate to enhance the use of theory, although she did not give much

guidance or exemplars for implementation on a large scale involving nursing administrators. She

offered a model for nursing practice based on Orem’s’ theory, demonstrating its utility for care in

acute illness, convalescence, and restored. The model was based more on a developmental,

health/illness continuum than on Orem’s theory.

The theory evolved from interest in curricula for diploma and baccalaureate programs and

the need to differentiate between technical and professional education. Therefore its utility to

nursing education is enhanced by theorist’s interests. It is no surprise that the theory has been

used as conceptual framework in associate degree programs. There has been documentation

published regarding the use of the framework as a curriculum guide for the diploma nursing

program at Methodist Medical Center of Illinois in Peoria, Illinois; the associate degree nursing

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program and the baccalaureate programs at George Mason University in Fairfax, Virginia,

Georgetown University in Washington, DC, just to name a few. Some of the uses of the

framework has been used in the administrative settings at the nurse-managed clinics at the Johns

Hopkins Hospital in Baltimore, Maryland, the basis for structuring nursing practice and roles and

functions of nurses at the Mississippi Methodist Hospital and Rehabilitation Center since 1976

and also structuring nursing practice a the Betty Bachrach Rehabilitation Center for Immunology

and Respiratory Medicine in Denver, Colorado.

In nursing research numerous master’s theses and doctoral dissertation have used the Self-

Care Framework as a guide. A literature review of the Self-Care Framework revealed that it

guided a wide range of research design, from psychometric studies of framework-based

instruments to experimental studies. Correlational studies have focused on the identification

of variables associated with the exercise of self-care agency. Moore(1993) found that basic

conditioning factors , self-care agency, and mothers’ dependent-care performance were related

to children’s self-care performance. Several Self-Care Framework –based experimental studies

have been conducted. The findings of some of those studies provide evidence that supports the

effectiveness of Self-Care Framework-based nursing interventions.

The utility of the Self-Care Framework for nursing practice is fully documented. The

Self-Care Framework has been used to guide the care of patients who seek care in different

inpatient and outpatient settings. Publications document the use of the framework as a guide to

patient care in such settings as: intensive care and critical care units, operating rooms, obstetrical

units, and nursing homes. Self-Care Framework –based nursing care is also documented in

outpatient settings such as: Ambulatory clinics, emergency departments industry and hospices.

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This framework has been used to design nursing care for patients of various ages and with a

variety of self-care requisites. The theory’s circle of contagiousness in research, education, and

administration is limited, but it has the widest circle of all theories in practice (Meleis, 1997).

The goal of nursing is to meet the self-care needs of individuals when they cannot. It is

the goal that nursing will help the client maintain, regain, or stabilize his or her state of health.

The major focus is the degree of therapeutic self-care demand as related to the capabilities one

may provide for a deficit relationship in which capabilities become necessary (Torres, 1986).

Therefore, the ultimate goal of Orem’s work is to allow the patient to achieve an optimal level of

self-care.

The application of Orem’s Self-Care Deficit Theory on Nursing can be utilized in Mr.

Jones case study within the nursing process. Orem (2001) defines, “Nursing process is a term

nurses use to refer to nurses’ performance of the professional-technologic operations of nursing

practice”. The first step is to investigate and collect data about the patients’ self-care agency and

their self-care demand and the existent or projected relationships between them. Mr. Jones was

able to meet all of his self-care needs prior to being diagnosed with a massive myocardial

infarction and CVA. Mr. Jones basic conditioning factors were listed as a 45 year old male,

accountant, and married with five children. His universal self-care demands were: stressful job,

little physical rest, did not take medicine, no annual checkup and only seeked medical attention

when he had chest pain. Mr. Jones worked 12-14 hours per work day, had a supportive family,

wife has never worked and no workable skill, with five children from age 1-17, and a 17 year old

son graduating from high school were developmental self –care requisites identified. His stage of

development is generativity, which he displayed a sense of accomplishment, providing for his

family, and giving loving care, rearing children as a contribution to humankind and the larger

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society. His family is very supportive and financially stable. Health –derived limitations, Mr.

Jones were characterized with non-functional on right side, limited mobility, barely speak

clearly, poor bilateral coordination, and family history of mother died of a stroke and father died

of a heart attack. These conditions diverted Mr. Jones from the theory of self-care to the theories

of self-care deficit and nursing systems. (Bufalin, 1991).

Nursing diagnosis based on self-care deficits are: Impaired verbal communication r/t

aphasia: Feeding self-care deficit r/t sensorimotor impairment, unilateral neglect, communication

difficulties; Body image disturbance r/t loss of body function, physical changes, role changes.

The plan of care to be provided for Mr. Jones, but not limited to: To establish/reestablish an

effective means of communication; Mr. Jones will perform basic ADLs with success and some

independence, and will be able to perform a schedule of activities appropriate to condition and

mental readiness; Mr. Jones and family will adapt effectively to altered lifestyle, and changes in

roles resulting from his altered health status. (Bufalin, 1991)

Measures implemented to improve self-care deficits: 1) assess patient’s ability to

communicate (express self, understand other, remain oriented),maintain eye contact wit patient

when communicating, address patient in a slow and unhurried manner, consult and coordinate

efforts with speech therapist; 2) determine patient’s ability to perform ADLs, obtain necessary

assistance devices to enable patient to function maximally, provide tasks that can be easily

accomplished, encourage patient to use affected extremity in as many tasks as possible, offer

positive feedback for gains in self-care activities, 3) assess patient’s/family previous lifestyle

roles and responsibilities, acknowledge patient’s frustration with limitations, reinforce abilities

and progress, encourage patient to dress in own clothes to focus positively on abilities and return

to a more normal lifestyle. (Bufalino, 1991)

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The following outcomes will enable Mr. Jones to become an effective self-care agent:

1) Mr. Jones communicates needs with verbal and/or nonverbal cues, 2) Mr. Jones can feed,

bathe, and dress self with increasing independence; verbalizes/demonstrates ability to care for

self at home, 3) Mr. Jones/family verbalize acceptance of necessary lifestyle change; interacts

positively with others. The designed nursing system for Mr. Jones would be the wholly

compensatory nursing system. Orem (2001) identifies this system as a situation in which the

individual is unable “to engage in those self-care actions requiring self-directed and controlled

ambulation and manipulative movement or the medical prescription to refrain from such activity

…Persons with these limitations are socially dependent on other for their continued existence

and well-being.”

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References

Bufalin, P.M., & Caine, R. M. (1991).

Williams & Wilkins.

Fawcett, J. (2000).

and theories.

Foster, P.C., & Bennett, A.M. (2002). Self-Care Deficit Nursing Theory: Dorothea E. Orem. In

J.B. George (5

125-149). Upper Saddle River, New Jersey: Prentice Hall.

Meleis, A.I. (1997).

Lippincott-Raven.

Orem, D. E. (2001).

Torres, G. (1986).