Dorothea Orem’s

Theory of

Self-CareFronk, BSN, RN

Orem’s Grand Theory of NursingComposed of three interwoven

Middle-Range Theories

Self-CareDeficit

NursingSystems

Occurs when the demand of self-care is greater than the individual’s

ability to satisfactorily

attain it. ---

A deficit in self-care brings about a need

for nursing care.

Self-Care

Activities that an individual completes

or assists with in order to maintain life

and/or a higher level of well-being.

---Humans have an

innate desire to care for themselves.

Identifies actions that the nurse and client can take to

reduce or eliminate the identified self-

care deficit. ---

Role of the nurse and client.

Concepts of Self-Care

Self-Care

“A human regulatory function that is a

deliberate action to supply or ensure the supply of necessary materials needed for continued life,

growth, and development

and maintenance of human integrity”

(McEwen & Wills, 2014, p. 144)

Self-CareRequisites

The requirements needed to bring about or maintain optimal functioning

---Universal

DevelopmentalHealth Deviation

Self-CareAgency

The ability to engage in and/or perform fulfilling self-care

activities ---

Influenced by conditioning factors

such as development, age, sociocultural factors, health and

education ---

Agent provides careDependent agent

receives care

Therapeutic Self-Care Demand

The combined actions necessary to meet the prescribed

self-care activities in a given period in time

---The agent utilizes appropriate and

validated measures identified by the self-care requisites

Conceptual Model

R=relationship; <=deficit relationship, current or projected(Alligood & Marriner-Tomey, 2002, p. 192)

Self-Care

Self-CareAgency

Self-CareDemands<

Nursing Agency

Sub-Concepts Nursing – Deliberate actions that assist clients and their families in

regaining and/or maintaining optimal health. Human being – Has developmental and universal health related needs. Is

capable of providing self-care. Is the object of nursing. Environment – Influences self-care knowledge and behaviors.

Includes family and sociocultural factors. Health – A dynamic state that may “impose new or different demands for

self-care on the person” (Fawcett, 2005, p. 250). Nursing Client – Has a health related deviation and is incapable of

providing adequate self-care. Requires assistance from nursing. Developmental self-care requisites – Occur due to a

health condition or life event. Includes disease processes, injury, effects related to aging, etc..

Universal self-care requisites – Are common to all human beings. Consists of basic life requirements such as air, food, elimination, activity, etc.

Health deviation requisites – Actions necessary to employ when a deficit in self-care exists. Procuring medical treatment and nursing interventions.

Assumptions

Based on the philosophy that “all patients wish to care for themselves”

(Paraska & Clark, 2012, p. 63).

Individuals can and should strive for optimal health and life through self-care Individuals should care for themselves as well as their dependents Each individual is distinct and separate from others and the environment Nursing is deliberate and requires action as well as interaction Achieving the universal and developmental requisites of self-care is integral

to attaining optimal health Knowledge and the environment influences self-care behaviors and activities The art of nursing is a therapeutic form of self-care that assists individuals in

recovery from disease and/or injury Nursing enhances self-care behaviors and activities

Relationships & Influences Nursing exists due to deficits in self-care. Humans are self-reliant and desire to take responsibility

for self-care. Health is a state of individual well-being that is influenced by the

nurse as well as the environment. When a deficit or need for maintenance in self-care exists the

nurse and the environment can be modified to restore and/or preserve the state of health.

Optimal performance of self-care requisites minimizes the therapeutic self-care demand.

Universal, developmental and other conditioning factors can alter the agent’s ability to complete self-care requisites.

The nursing system is developed based upon the self-care deficit identified by the nurse.  

Self-care needs can be met by the nurse, the client or both.

Theory Development 1914: Born in Baltimore, Maryland 1939: BSN, Catholic University of America 1959: Experienced in many areas of nursing, including:

staffing, private duty, education, administration, and consulting; Orem began developing her definition of nursing practice and the concept of self-care

1971: First formal publication of Orem’s Theory of Self-Care (Orem, 1971)

1976: Honorary Doctor of Science Degree 2001-2007: Orem refined and publish her theories

throughout the remainder of her life Considered a “pioneer” of nursing theory (McEwen

& Wills, 2014, p. 142)

Orem developed her theory in the late 1960’s when tasked with designing a national curriculum for practical nursing education.

Orem wished to revitalize nursing education in order to keep it current with the healthcare needs of modern society.

1960’sThe “scientific foundation

for healthcare” moved nursing toward a more professional role (Taylor &

McLaughlin Renpenning, 2003, p. 18)

The American Nurses Association recommended institutional education with the baccalaureate degree as the basic foundation for

nursing practice.

The U.S. Public Health Service recommended increasing the quality

of patient care.

The Nurse Training Act allocated millions of dollars

in government funds to improve and enhance nursing schools and

education.

Nursing scholars strived to build their own body of knowledge

Nurses were employed in a variety of settings.

This increased the number and complexity

of problems nurses encountered.

Passage of the Civil Rights Act

Medicaid and Medicare provided government-funded healthcare to millions of Americans.

Vietnam War

Women’s movement focused on equality in pay and employment

Theory Origin & Support Orem’s theory was developed and revised over the course of four decades. The combination of practice, experience, education and collegiate

collaboration influenced values and theory development. Orem’s Values: Optimal health for every individual, independence in caring

for the self, the art of nursing is valuable to society Orem refers to but has never directly credited an author or work as the

foundational basis for her theory. Significant influential nurses referred to by Orem include: Rogers, Roy,

Nightingale, Henderson, Abdullah & Orlando. Theoretical influences: Aristotle & Thomas Aquinas. Action Theory. An area of

philosophy concerned with “agent-causal” relationships. (O’Connor & Sandis, 2010, p. 7).

Motivation While employed as a nursing

consultant, Orem began to question the reality of nursing.

Orem was motivated by the ability to perform yet not communicate nursing services.

Orem wished to create a framework that organized nursing knowledge

What is Nursing?

“What is the human condition that occasions

requirements for nursing?” (Orem, 2001)

Why do some individual’s need nursing care and

others not?

What is the subject matter of the discipline

of nursing?

Orem asked…

Development StrategyIncorporates both inductive & Deductive reasoning processes

Concepts were identified and conceptualized based on

experience in practice

Worldview of reciprocal interaction

A Human Needs Theory

Orem utilized a developmental model to conceptualize her theory

The theory can also be regarded as an interaction model

Usefulness Useful in everyday practice settings Applicable across the lifespan Contributes to nursing’s body of knowledgeResearch findings can be applied to practice Can guide interventions to enhance outcomesGenerate research & research instrumentsUtilized by schools of nursing

as a base for curriculumGenerates testable hypothesis

for use in a multitude of settings Identifies the focus of nursing

Practicality in Practice Orem’s theory provides a practical means to guide and enhance

nursing practice.

The theory can be utilized to positively influence the motivation that drives the deliberate actions of self-care.

Patient outcomes can be enhanced through easily identifiable requisites and interventions.

The self-care requisites within the theory encompass practical concepts that can be developed to assist in daily practice. Universal requisites are common to all humans; Eliminative functions of self-

care can be addressed by encouraging the patient to bathe daily. Developmental requisites occur with growth and development; Proper growth

and development can be facilitated through skill and knowledge enhancement. Health Deviations occur due to internal and external forces; Primary, secondary

and tertiary interventions can be employed to maintain and/or restore function.

Contribution to Care Nurses make judgments for recommendations and adjustments in nurse-patient roles

and interventions. Theory that uncovers self-care needs, requisites and demands as well as the

interventions to meet these requirements contribute to nursing’s body of knowledge. Orem thoroughly describes each concept within the theory of self-care and predicts

relationships between them. This aids in determining outcomes. Identification of inadequacies in the self-care

agency and within self-care requisites aids in predicting the degree of disability and the need for nursing activities.

Determines the effect and outcomes of self-care activities

Identifies the needs of the patient Evaluates the success of interventions Identifies need for modification of interventions

Example in PracticeThe theory of self-care can provide a theory-based

approach to assist nurses and patients in hospital burn units

Burn units significantly lack theory in care interventions Wilson and Gramling suggest utilizing Orem’s Self-Care Model “as a valid basis for delivering care and increasing the level of professionalism in this specialty area” (Wilson & Gramling, 2009, p. 852). The authors also suggest that the application of the theory in the practice of burn care units will provide a unique way to view this phenomenon. Many theories present gaps in care due to lack of comprehensiveness. Additional theories such as Roy’s Adaptation Model can complement matters not addressed by Orem inthis specialty area of care. Orem’s theory however, “is the most applicable to burn care and provides a beginning point for theory usage in burn nursing care” (Wilson & Gramlin, 2009, p. 852).

Theory TestingDespite the popularity and feasibility of the theory of self-care, a 1993 review

noted only 4 of 31 related research studies met the criteria for making “‘adequate use’ of Orem’s theory” in testing (Spearman, Duldt & Brown, 1993, p. 1629).

Orem did not believe that “nursing research should be focused on testing her theory as much as on developing knowledge related to the different components” of her theories (Meleis, 2011, p. 220).

Theory Applications: Descriptive studies related to self-care practices Assesses needs of clients Development of interventions To generate research instruments To identify categories of self-care needs in specific

populations The self-care agency has been used to focus on the

development of research tools capable of measuring aspects of self-care

To form a basis for the testing of a hypothesis To identify relationships between the concept of the

self-care agent and other influencing concepts in a variety of populations

Usage: Easily tested with a variety of

methods and in various settings and populations.

Has generated numerous dialogues and stimulating thinking across disciplines

Broad clinical utility The theoretical concepts of the

grand theory has been applied as a whole and independently as well as in coordination with other theories to complement research studies

Research Examples Computer-assisted reinforcement of instruction: effects on adherence in adult atopic

asthmatics. A randomized pretest-posttest experimental design to determine effects of an intervention on adherence to dust mite avoidance in adults with atopic asthmatics (Huss, Salerno, Huss, R., 1991).

Health and illness self-care in adolescents with IDDM: a test of Orem's theory. Differentiates and proposes hypotheses related to adolescent diabetics and the various types of self-care identified by Orem (Frey & Denyes, 1989, p. 67-75).

Orem's model used for health promotion: directions from research. Utilized Orem's theory to test propositions associated to general health and health promotion (Denyes, 1988, p. 13-21).

Self-care agency as a function of patient-environmental factors among nursing home residents. Examined the relationships of environmental and personal factors on the ability of residents in nursing homes to provide self-care (Jirovec & Kasno, 1990, p. 303-309).

The effect of Orem's self-care model on nursing care in a nursing home setting. Determine patient perspectives and outcomes of nursing staff utilizing Orem’s theory of self-care compared to nursing staff employing other methods of assessments and goals (Faucett, Ellis, Underwood, Naqvi & Wilson, 1990, p. 659-666).

Influence of selected factors and self-care behavior on abdominal distention in patients with abdominal surgery. A descriptive and prospective study to explore self-care factors that influence abdominal distention in patients with recent abdominal surgery (Wattanawech, Srimoragot, Kasemkitwattana, Kimpee, 2003, p. 19-32).

Validity…Strengths Weaknesses

Provides a general foundation for the nursing discipline

Can be utilized to formulate nursing curriculum

Can enhance the development of nursing education, research and administration

Identifies when nursing is required Contemporary with nursing trends

in health promotion and maintenance

Promotes independence

Repetitive terms can be confusing (self-care agency/requisites/deficit, etc..)

Psychological/emotional needs not well developed within the theory

Assumes “all” are capable of self-care activities and does not address infants or the frail elderly

Oriented more toward illness than wellness

Example: Case StudyA case study was performed to identify “facilitators and inhibitors

to clinical application of Orem’s theory of self-care” (Clark, 1986, p. 127).

Facilitators were described as factors that aided the utilization of self-care theory while inhibitors deterred its use.

Subjects: Gerontological Patients Setting: Community health nursing Premise of theory: Individuals desire the ability and responsibility of self-care. The nurse’s role is to identify self-care deficits and provide assistance with self-care activities to enhance health and

well-being. Design: Following the nursing assessment, the individual’s ability to engage in identified self-care requisites was

evaluated. A nursing plan of care was implemented to achieve therapeutic self-care demands. Contributing and inhibiting factors to the outcomes were communicated and evaluated.

Findings: Facilitators:

Patient desire, attitude and beliefsPositive nurse-patient relationshipPatient education, values, collaboration, communicationNurse, knowledge, collaboration, advocacy, communicationNursing plan of care

Inhibitors:Managing large numbers of concepts within the theoryLack of additional case studies and research to guide the study

Considerations: The study revealed numerous areas with potential for furthering nursing research. (Clark, 1986, p. 127-135)

Research Methodologies

Descriptive studies - Focus on the comprehension, number and type of self-care behaviors. Proposition: The nurse must assess and identify the client’s ability and potential to complete self-care activities.

Correlational studies - Examine the relationships between self-care variables. Proposition: The ability to perform self-care activities is influenced by the self-care agency, requisites and demands.

Quasi-Experimental studies - Identifies causal relationships as well as the significance of those relationships. They are necessary to determine the effectiveness in fulfilling therapeutic self-care demands. Proposition: Self-care deficits are balanced between therapeutic self-care demands and the ability of the self-care agency to meet those demands. The inability to achieve optimal self-care indicates a degree of dependency.

Experimental studies – Explore client outcomes related to the application of interventions. Proposition: Nurses are tasked with identifying valid and reliable interventions required to meet self-care needs.

The intertwined concepts of self-care, self-care requisites, the self-care agency and therapeutic self-care demands must function

in harmony for optimal health and well-being to be realized.

Evaluation Orem’s generalized theory of nursing consists of three interrelated

theoretical constructs. Self-Care Self-Care Deficits Nursing Systems

The self-care component of the general theory is “common to the health professions and to all members of social groups.” (Basavanthappa, 2007, p. 85)

It identifies broad, comprehensive activities that are required by the individual to maintain health. It can be applied across the lifespan and within a variety of settings yet focus is on the ill.

The scope is more specific when applied to administration, education and research.

The concepts are simple and easy to understand.

Simple * Logical * Organized

Theory in Practice As a provider I will utilize this theory to identify

appropriate and validated measures required by self-care requisites.

Professional nursing practice is based on the assumption that patient’s desire and need the self-care agency. The ability to engage in self-care activities is innate as well as learned. As a provider, I will assist patients in learning as well as performing self-care activities.

My role is to facility the self-care agency of the patient. Utilizing the theory of self-care, along with the theories of self-care deficit and nursing systems, I will be able to identify self-care deficits and the degree and competency of the patient’s self-care requisites and abilities. With this data, the appropriate nursing system of action with interventions can be implemented.

This theory will assist me in identifying and encouraging appropriate self-care activities across the lifespan.

ThankYou

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Advanced Nursing, 18(10), 1626-1631. Taylor, S., & McLaughlin Renpenning, K. (2003). Self-Care Theory in Nursing: Selected Papers of Dorothea Orem (p. 18). New York: Springer

Pub. Wattanawech, T., Srimoragot, P., Kasemkitwattana, S., & Kimpee, S. (2003). Influence of selected factors and self-care behavior on abdominal

distention in patients with abdominal surgery. Self-Care, Dependent-Care & Nursing, 11(3), 19-32. Wilson, J., & Gramling, L. (2009). The application of Orem's Self-Care Model to burn care. Journal Of Burn Care & Research, 30(5), 852-858.