Critical analysis of Dorothea Orem Theory

Critically analysis of Dorothea Orem Theory

 

Introduction

Nursing had been a profession pursued basis personal experiences of the nurses who practiced it. As the profession started progressing, various theories were developed that established a rationale for the nursing activities. This essay discusses about a leading theory in nursing by Dorothea Orem, Self-care deficit Nursing Theory.  The first section deals with the early life and works of the theorist, followed a discussion of the core components, followed by discussion on the metaparadigm, followed by discussion on origin and development, followed by critical analysis and application.  

Early life and works of Orem

Dorothea Elizabeth Orem was a leading American nursing theorist. Orem was born the 22nd. day of July, 1914 in Baltimore, in Maryland. Orem was certified as Diploma in Nursing by Province Hospital School of Nursing in Washington D.C in the year 1934. She completed Bachelor of Science in Nursing Education in 1939, followed by Master of Science in Nursing Education in 1945, both from Catholic University of America, Washington D.C. 
She had a notable career in nursing. In 1976, Georgetown University and in 1980, Incarnate Word College awarded her Honorary Doctorate degrees. From 1940 to 1949, she served important posts at the Providence Hospital, Detroit, like Director of nursing school and in the branch of nursing. Here, she had also served as a teacher for biological sciences and nursing from the year 1939 up to 1941. From 1959 to 1964, she served at Catholic University of America as Assistant Professor and later from the year 1964 up to 1970 served as Associate Professor and from 1965 to 1966, served as the Dean of the School of Nursing. From the year 1958 up to 1960, she offered service as a curriculum consultant at The Office of Education, United States Department of Health, Education and Welfare, Practical Nurse Section. As a curriculum consultant she also served at Division of Hospital and Institutional Services, The Indiana State Board of Health, Center for Experimentation and Development in Nursing, The Johns Hopkins Hospital and Director of Nursing, Wilmer Clinic, The Johns Hopkins Hospital from 1949 to 1957, 1969 to 1971 and 1975 to 1976, respectively.
She played an integral part in the group of nurse theorists and participated in the presentation of the Patterns of Unitary Man (Humans), the preliminary construction for the diagnosis process used in nursing, to the North American Nursing Diagnosis Association in 1982. Her first book, “Nursing: Concepts of Practice”, was published in the year 1971. On June 22, 2007, Orem passed away in Savannah, Georgia.

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The core components of Self-Care Deficit Theory

Phenomena

A term used for describing an idea or response or, responses about a situation or, a set of situations, is referred to as phenomena. Phenomena may ether be permanent or, temporary. We may consider a patient unable to walk owing to a fresh amputation as an example of a nursing phenomenon. Theory of Self-care deficit by Orem emphasizes on ensuring nurses work together with patients to deliver the best possible care and the patient are allowed to care for themselves. 

Concepts

When a patient is unable to take care of self due to limitations in meeting self-care requisites, it leads to Self-care deficits and hence, nursing care is needed. Nursing care helps in restoring a patient’s self-care abilities that are needed for leading a quality life. Orem documented five methods that could be applied in nursing to help patients in overcoming their deficits. The methods included Acting or serving to another, directing, offering physical and psychological support, offering an environment supportive of personal development and finally, educating the patient. Considering the example mentioned above, self-care actions are carried out both by the nurses and the patients to attain the self-care objectives. This will be achieved by not only the nurses assisting and educating the patients but also allowing them to complete their own task wherever possible. 

Assumptions

Assumptions have been made in Orem’s theory of nursing. Foremost is that Human beings need to be independent and accountable for the care of their own self as well as care of other family members. The second assumption considers the fact that all patients are different individuals as no two human beings can be the same, physically and mentally. Third assumption stresses on the fact that in a profession like interactions are involved between multiple individuals. The fourth assumption states that in order to prevent ill health, it is important to attain the care requisites. A patient’s knowledge on health problems plays a significant role in promoting self-care attitude. Self-care and dependence are an outcome of socio-cultural learning of an individual.  
Any individual person can be the recipient of nursing care. Each individual patient has unique needs which are varied and complex. These needs form the basis of nursing care. Therefore, nursing support needs to be customized as per the patient’s requirements. Health is a dynamic factor and is subjected to continuous changes.  The major challenge in nursing is to provide best possible care to the patients basis their health status. 
The environment comprises of the set of conditions that affect the patients’ health care needs. The environment can affect the patients’ health either positively or, negatively. Factors like home, occupation influence the patients’ level of needs. For example a patient undergoing dialysis needs resume treatment periodically and hence, demands to be engaged in a part time role. 
Irrespective of the type of setting, nursing involves independent and shared care of sick and well individuals, families and communities. The profession of nursing involves promotion of healthy living, avoidance of illnesses, care and concern for disabled and patients on their death bed (WHO, 2018). Nurses diagnose a patient’s conditions as per nursing diagnosis guidelines; they cannot diagnose a patient’s medical condition. Basis the nursing diagnosis, a care plan is then chalked out for the patient to be restored to self-care abilities.

The four elements of metaparadigm of nursing

 

Person

Human beings are considered to be an integrated whole. They act as a unit functioning biologically, symbolically and socially. Human beings are reliant on their own power and resources to take care of themselves and their dependents. They exercise rational powers and logical thinking to enact their various activities. The ability of human beings to reflect upon their own experiences and the environment and the usage of symbols, words and ideas differentiate them and place them ahead of other species. A patient is an individual who lacks knowledge, motivation, skill and orientation and hence, requires help to attain specific health-care demands.
 
 

Environment

It is considered that the environment, in which a human being lives, forms an integral part of his self-care system. Some environmental conditions that support improvement are like, opportunities when one can seek help, being in the company of other individuals who can offer care, opportunity for both solitude and companionship, condition to seek help for both self and group concerns without curbing the scope for individual choices and personal quests like shared admiration, faith, gratitude, belief and nurturing of potential for further development.

Health

Health of an individual refers to his state of wholeness including his integrity, the body parts and modes of operation. The core concept of nursing revolves around optimal wellness of the patients. Health of an individual is the responsibility of the entire society and its members. An individual is considered to be healthy when he has adequate abilities to attain his own and the universal requirements for self-care.

 Nursing

Actions are purposefully chosen by the nurses to aid an individual or, a set of people under their purview. Such nursing activities help to preserve or modify conditions existing in the patients’ environments. Actions chosen during nursing are done on the basis of patients’ perspective of health conditions, doctor’s diagnosis of the patients’ state and the nurses’ diagnosis. The objective of nursing is to restore the patients’ and his family’s abilities for self-care. In case of a disease or, injury, nursing helps in stabilizing, minimizing and controlling the effects of persistent poor health or, disability. This is turn helps the patients to regain normal or, nearly normal health status.

Origin and development 

Orem highlighted that nursing is needed owing to the inability of an individual to carry out one’s own care as a consequence of limitations. The Self-Care Deficit Nursing Theory (SCDNT) is a commonly used nursing theory (Im & Chang, 2012). The concept of self-care highlighted by Orem led to this nursing theory which is still relevant in the present context. The earliest progress of the theory was initiated in 1956 (Orem, 1985). The application of the theory was put into practice since the publication of the book Nursing: Concepts of Practice by Orem in the year 1971. The Nursing Development Conference Group (NDCG)  started using the theory since 1973. The concepts of the model were used in clinical teaching and with the evolvement of the concepts further; they were included into nursing practice. Soon, theory based nursing practice gained prominence (Allison, 1973; Backscheider, 1971). One of the preliminary locations for the growth of the theory in practice was The Center for Experimentation and Development in Nursing at Johns Hopkins Hospital. In 1976, SCDNT-based practice was implemented in the Mississippi Methodist Hospital and Rehabilitation Center by Allison (Allison, 1989).
Orem used both inductive and deductive reasoning to develop her theory. The fact that Orem used her personal and professional experiences to point out the factors owing to which individuals needed to take help from nursing and also fact that the theory is still relevant in nursing practice today indicate the usage of inductive reasoning. Orem used deductive reasoning when she collected evidence from other scholars and disciplines to classify nursing as a profession distinguished from other connected fields (Fawcett, 1995). As SCDNT has its origin from clinical practice where regular reassessment is needed owing to the fact that investigations in the field of nursing is regularly developing, Orem too has been updating her theory on a regular basis (Fawcett, 1995; George, 2002).

Critical analysis

Orem initially originated a generalized theory on nursing. She described it 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 or injury, or in coping with their effects. With children the condition is the inability of the parent (or guardian) associated with the child’s health state to maintain continuously for the child the amount and quality of care that is therapeutic” (George, 2002). The original theory can be segregated into associated theories namely, theory of caring for one’s own self, the theory of deficit in caring for one’s own self, and the theory of systems involved in nursing. They include the concepts of caring for own self, an agency for caring for own self, beneficial requirements to assist in caring for own self, shortfalls in caring for self, an agency for nursing, and a system supporting nursing activities (Fawcett, 1995; George, 2002; McQuiston & Webb, 1995). 
Caring for one’s own self calls for actions that an individual can perform independently to continue class of life, proper healthiness, and supportive of the general well-being. The fundamentals needed for caring for one’s own self answer the reason for participation in self-care. General, growth, and health variation requisites were thus, defined by Orem as the fundamentals needed for self-care (Fawcett, 1995; George, 2002). Examples were provided by George (2002) for each of the categories defined by Orem. The air that supports breathing, water for drinking, food for eating, a balance between exercise and rest, and avoidance of perils, are all a part of universal needs that assist in caring for self. The adjustments made during the lifetime like the process of aging, or getting over the loss of our loved ones are part of developmental needs for caring for self. Finally, fundamental needs for deviation in health consist of availing apt medical aid, adapting to live in pathological conditions, taking the outcomes of the healing processes in an affirmative way, and efficiently following healing and rehabilitative measures.
Agency supportive of caring for one’s own self is basically the individual’s enthusiasm or capability to get engaged in caring for one’s own self and they are also influenced by the basic habituation factors. The factors comprise of age, sexual category, growth status, fitness status, socio-cultural aspects, and conditions of the health care system, family aspects, living style, environmental aspects, accessibility and sufficiency of supplies (Fawcett, 1995; George, 2002). In addition, the demand for healing one’s own self involves measurement of abilities or inabilities to attain the fundamental needs for self-care. It is to be noted that the idea of nursing agency is engaged not only for the advantage of others but also needs a thoroughly trained quality which allows one to perform, recognize, and to help others attain their self-care requirements. The final proposal in nursing systems has been planned by the nurses and is an outcome of evaluation of an individual’s needs for caring for one’s own self along with their capabilities as an agent for self-care (Fawcett, 1995; George, 2002). 
Even since its initial publication, Orem’s theory could be distinguished from other nursing models. However, over a period of time nursing has evolved and further developments have in been incorporated into the SCDNT in order to integrate it into daily practice. While Orem initially proposed the application of the on individuals, Kathie McLaughin Renpenning and Susan Taylor have extended the application of the theory to sets of individuals like workgroups, families and social communities (George, 2002; Green, 2013). Being easy to comprehend and follow, the theory gained popularity amongst both trainee and experienced nurses who apply its philosophy in daily schedule, particularly in crafting nursing systems post-appraisal (George, 2002). This theory focuses more on physical parameters than on emotional aspects, with the final objective of attaining stability in healing self-care agency (Fawcett, 1995; George, 2002).  

Application of the theory

SCDNT has been applied internationally to a spectrum of patients in changeable clinical conditions (Fawcett, 1995; George, 2002). Multiple publications have documented the application of SCDNT in all fields, starting from newborn intensive care units to wards for surgery, and for application in treatment of different diseases like asthma and even lethal illnesses (Fawcett, 1995; McQuiston & Webb, 1995). An analysis was conducted in Norway on a team of nurses and patients to compare reports generated by patients and nurses in a self-care agency. The observation revealed that the scale for appraisal of self care agency was convincing and apt for use in evaluation of self-care applications (Lorensen, Holter, Evers, Isenberg, & van Achterberg, 1993). 
Experiences shared by Dale M. Wallker who served as nurse administrator in Vancouver, Canada regarding a trial run for executing SCDNT into the practices in the Vancouver Health Department. Post the trial run, decision was taken by the management for full-time implementation of the model. Impetus for full-time application of SCDNT was basis “continuing greyness of the nursing role, and difficulty in setting priorities for nursing actions and staff education programs” (Parker, 1993).

Conclusion

It needs to be remembered that application of SCDNT or any other theory need to be modified as per the associated factors. For example, inadequacies in a patient’s environment for a certain system, or ineffective systems for avoidance of perils, may call for adjustments in the theory prior to application on that individual (Fawcett, 1995; George, 2002). In 2014, factors were proposed by Wilkinson that influenced the implementation of the SCDNT. The factors proposed were like decrease in the level of motivation, environmental obstacles, and failure to recognize a body part, neuromuscular and musculoskeletal injury, ache, cognitive or, perceptual disability, acute anxiety, weakness and low energy, uneasiness, restricted mobility status, and impaired relocation ability.

Bibliography

Allison, S. (1973). A framework for nursing action in a nurse-conducted diabetic management clinic. Journal of Nursing Administration, 3(4), 53–60.
Allison, S. (1989). Patient outcomes identified through theory-based practice.Clinical and cultural dimensions around the world (pp. 147–156). Columbia, MO: Curators of the University of Missouri.
Backscheider, J. (1971). The use of self as the essence of clinical supervision in ambulatory patient care. Nursing Clinics of North America, 6, 53–60.
Fawcett, J. (1995). Analysis and evaluation of conceptual models of nursing. Philadelphia, PA: F. A. Davis Company.
George, J. (1990), Nursing Theories: The Base for Professional Nursing Practice, Norwalk, Connecticut: Appleton & Lange.
George, J. B. (2002). Nursing theories: The base of professional nursing practice. Upper Saddle River, NJ: Prentice Hall.
Green, R. (2013). Application of the self care deficit nursing theory: The community context. Self-Care, Dependent-Care & Nursing, 20(1), 5-15. Retrieved from http://0-search.ebscohost.com.library.svsu.edu/login.aspx?direct=true&db=ccm&AN=2012210950&site=ehost-live.
Im, E., & Chang, S. (2012). Current trends in nursing theories. Journal of Nursing Scholarship, 44(2), 156–164.
Nursing Development Conference Group (NDCG). (1973). Concept formalization in nursing: Process and product. Boston: Little, Brown.
Orem, D. (1971). Nursing: Concepts of practice. New York: McGraw-Hill
Orem, D. (1985). Nursing: Concepts of practice (3rd ed.). New York: McGraw-Hill.
Lorensen, M., Holter, I. M., Evers, G. C., Isenberg, M. A., & van Achterberg, T. (1993). Cross-cultural testing of the "appraisal of self-care agency: ASA scale" in Norway. International Journal of Nursing Studies, 30(1), 15-23. doi: 10.1016/0020-7489(93)90089-D.
McQuiston, C. M. & Webb, A. A. (1995). Foundations of nursing theory: Contributions of 12 key nursing theorists. Thousand Oaks, CA: Sage Publications, Inc.
Parker, M. E. (1993). Patterns of nursing theories in practice. New York, NY: National League for Nursing Practice.
Wilkinson, J. M. (2014). Nursing diagnosis handbook. Upper Saddle River, NJ: Pearson Education, Inc.


Annexure

 
Refer below for the mind map.
 

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