Orems self care deficit nursing theory

Presented by
Prof. Dorothy Deena Theodore
Principal
Narayana Hrudayalaya College of Nursing
Bangalore

Introduction
Dorothea Orem has described nursing as working in life situations to bring about conditions that
are beneficial to the person being nursed. Therefore nursing needs both the speculative and
practical intelligence. As nurses are constantly with the client they are in the position of being
aware of the current circumstance and condition of the client. This knowledge acts as a concrete
base for development of creative practical insights and what can be done to bring about a
beneficial relationship with the client.

Profile of the proposer

Dorothea Elizabeth Orem is one of Americas foremost nursing theorists. Was born in Baltimore,
Maryland in 1914.she was the younger of 2 daughters who began her nursing career at
Providence Hospital SON in Washington DC. She received her B.Sc. & M.Sc. at The Catholic
university of America in 1939 and 1946.
Initial nursing experience included OT nursing, home and hospital nursing in the pediatric and
adult medical and surgical units.
Later she held the director post for both the nursing school and department of nursing at
providence hospital till 1949.
She then worked in the division of the hospital and institutional services of the Indiana state
board of health with the goal to upgrade the quality of nursing in general hospitals throughout the
state. During this time she developed her definition of nursing practice.
In 1957 Orem took a position at the office of education, department of health, education and
welfare as a curriculum consultant. She also worked on a project to upgrade practical nurse
training. She also developed guides for developing curricula for the education of practical
nurses.
In 1970 began her own consulting firm and published her first book in 1971entitiled Nursing:
Concepts of Practice she was also the editor for the Nursing Development Conference Group.
Her text book was revised many times the last being in the year 2001.
Georgetown University conferred on her the honorary doctorate in the year 1976.

Background & history

The earliest development of the theory occurred in 1956 when Orem tried to define nursing
goal and nursing concern. She defined nursing goal as overcoming human limitations and
nursing concern as mans need for self-care action and the provision and management of it on a
continuous basis in order to sustain life and health, recover from disease or injury, and cope with
their effects.
This model supported and continues to support the following central theories they are as follows;

Nursing is required because of the inability of the client to perform self care as a result of
limitations.(self care deficit)
Mature or maturing adults deliberately learn and perform actions to direct their survival,
quality of life, and wellbeing.(theory of self care)
The product of nursing is nursing systems by which nurses use the nursing process to
help individuals meet their self care requisites and build their self care or dependence
care capabilities.(theory of nursing systems)

In 1971 this model was published in the 1st edition of nursing concepts of practice.
The utilization of this theory in practice began with the work of the Nursing Development
conference group(NDCG).this group was able to address the reality of the theory based
nursing practice from their leadership position that enabled control over the nursing systems.
Gradually the theory began to be put into practice in a variety of practice settings.
In 1990s literature features this theory guided practice in a variety of settings & situations.
The international Orem Society was founded in 1993, for the purpose of scholarships and
nursing science. This is also a forum for the exchange of this model application. These
models were also presented at the international conferences.
The twenty first century brought with it the development of additional self care deficit
nursing theories.

Major concepts and definitions

Self care
The practice of activities that maturing and mature persons initiate and perform, within the time
frames, on their own behalf in the interest of maintaining life, healthful functioning, continuing
personal development, and wellbeing through meeting known requisites for functional and
developmental regulations.
Self care requisites

A self care requisite is a formulated and expressed insight about actions to be performed that are
known or hypothesized to be necessary in the regulation of an aspect of human functioning and
development, continuously or under specified conditions and circumstances. It has two elements
they are;

The factor that needs to be controlled or managed to keep an aspect of human

functioning and development within the norms compatible with life, health and personal
wellbeing
The nature of the required action.

Universal self care requisites

Universally required goals are to be met through self care or dependent care and have their
origins in what is known and what is validated or what is in the process of being validated about
human structural and functional integrity at various stages of the life cycle. There are 8 self care
requisites they are as follows:

Maintenance of sufficient intake of air

Maintenance of sufficient intake of food.
Maintenance of sufficient intake of water
The provision of care associated with elimination processes.
Maintenance of balance between rest and activity
Maintenance of balance between solitude and social interaction
The prevention of human hazards to human life, human functioning, and human
wellbeing.
The promotion of human functioning and development within social groups in
accordance with human potential, known human limitations, and the human desire to be
normal.

Developmental self care requisites

They consist of three sets which are as follows:

Provision of conditions that promote development

Engagement in self development
Prevention of or overcoming effects of human conditions and life situations that can
adversely affect human development

Health deviation self care requisites

These requisites exist due to illness or injury, caused due to specific forms of pathological
conditions or disorders, including defects and disabilities, and who have a medical diagnosis and
are under treatment. The type of health deviation determines the kind of care demanded. Care

needs to meet the existent health deviation self care requisites must be made action components
of individuals system of self care or dependent care.
Therapeutic self care demand
This consists of the summation of care measures necessary at specific times over duration of
time for meeting all of the individuals known self care requisites. They are of two types:

Controlling or managing factors regulatory of human functions like sufficiency of air,

water, and food.
Fulfilling - activities that promote maintenance, promotion of health, prevention of
illness, and provision.

Self care agency

Is a complex acquired ability of mature and maturing persons to know and meet their continuing
requirements for deliberate, purposive action to regulate their own human functioning and
development.
Agent
One who engages in a course of action or has the power to do so.
Dependent care agent
Is a maturing adolescent or adult who accepts and fulfills the responsibility to know and meet the
therapeutic self care demand of relevant others who are socially dependent on them or to regulate
the development or exercise of the persons self care agency.
Self care deficit
Is the relation between the persons therapeutic self care demands and their powers of self care
agency in which constituent developed self care capabilities within self care agency are not
operable or not adequate for knowing and meeting some or all components of the existent or
projected therapeutic self care demand.
Nursing agency
Comprises of developed capabilities of persons educated as nurses that empower them to
represent themselves as nurses and within the frame of legitimate interpersonal relationship to
act, know and to help persons in such relationships to meet the therapeutic self care demands and
to regulate the development or exercise of their self care agency.
Nursing design

Is a professional function performed both before and after nursing diagnosis and prescription,
allow s nurses, on the basis of reflective practical judgment about existent conditions , to
synthesize concrete situational elements into orderly relations to structural operational units. The
purpose of nursing designs is to provide guides for achieving needed and foreseen results in the
production of nursing toward the achievement of nursing goals.
Nursing systems
Are series and sequences of deliberate practical actions of nurses performed at times in
coordination with actions of their patients to know and meet components of their patients
therapeutic self care demands and to protect and regulate the exercise or development of patients
self care agency.
Helping methods
Is a sequential series of actions which f performed, will overcome or compensate for the health
associated limitations of persons to engage in actions to regulate their own functioning and
development or that of their dependents. The types of helping methods used include:

Acting for or doing for another

Guiding and directing
Providing physical and psychological support
Providing and maintaining an environment that supports personal development.
Teaching

Major assumptions.
The assumptions identified by Orem that underlie the general theory of nursing are:

Human beings require continuous, deliberate inputs to themselves and their environments
to remain alive and function in accordance with the natural human endowments.
Human agency, the power to act deliberately, is exercised in the form of care for self and
others in identifying needs and making needed inputs.
Mature human beings experience privations in the form of limitations for action in care
for self and others involving and making of life sustaining and function regulating inputs.
Human agency is exercised in discovering, developing, and transmitting ways and means
to identify needs and make inputs to self and others.
Groups of human beings with structured relationships cluster tasks and allocate
responsibilities for providing care to group members who experience privations for
making required, deliberate input to self and others.

Over view of the model

This model represents a caring approach that uses experiential and specialized knowledge
(science) to design and produce nursing care (art). This incorporates empirical & antecedent
knowledge.

Empirical knowledge experience oriented and addresses specific events and related
conditions that have relevance to health and wellbeing. This type of knowledge supports
observations, interpretations of the meaning of that which is observed and correlates the
meaning with potential courses of action.
Antecedent knowledge previously mastered knowledge& identified fields of
knowledge, conditions, and situations.

Orem identified 8 fields of knowledge essential for understanding nursing practice. Seven of
these fields are from previously developed fields such as sociology, profession, jurisprudence,
history, ethics, economics and administration. The last one was from nursing science which has
been developed through scientific investigations that provide an understanding of the field of
nursing and provide foundations for nursing practice. This practical science establishes essential
content for courses focused on nursing practice. Her philosophical view was identified as
moderate realism.
This theory views human being as dynamic, unitary being who exist in their environments, who
are in the process of becoming and who possess a free will as well as other human qualities. Her
view of nursing science was as human practical science. This practical science includes
speculative practical, practically practical and applied sciences. Nursing practice science
included science of wholly compensatory nursing, partly compensatory nursing and supportive
educative or developmental nursing. Foundational nursing science includes the science of self
care, self care agency, and human assistance.
Personal knowledge of elf and others provides a screen through which input about the other is
objectified. Insights gained facilitate a reality orientation to self and the other and contribute to
giving characteristics of nursing care, responsibility, and respect.
The practice knowledge is systematized, validated, and conducive to dynamic processes.
Dynamic knowledge leads the user to acceptance and owning of the theory. This theory is
dynamic in quality as it always keeps the nurse in the action mode. Todays nursing scholars
must be scholars with in the developing theory.
This theorys critical thinking emanates from four structural cognitive operations. They are:
diagnostic, prescriptive, and regulatory and control.ach operation fulfills a distinctive phase in
the use of theory. The sequencing of the phase may vary throughout the process in order to
reassess and continue to prescribe and regulate the nursing system for the best interest of self
care.

The operations are intended to be collaborative and to provide the self care agent input into the
decision making.

Diagnostic operations

This phase begins with the establishment of the nurse client relationship and proceeds to
contracting to work toward identifying and discussing current and potential therapeutic
self care demands. Basic conditioning factors are noted and considered in relationship to
a thorough review of universal, developmental and health deviation self care requisites
and related self care actions, the projected value of the requisites is estimated. The
analysis of the assessment data results in the diagnosis concerning the type of self care
demands. The self care agency is addressed through an assessment of self care practices
and the effects of related limitations and abilities. Personal characteristics such as
intellect, skill performance, and willingness are evaluated. From these data, inferences
about the adequacy and potential of self care agency are made, validated, and treated as
diagnostic of self care agency. Finally self care deficits are diagnosed reflecting on the
adequacy of the agency to meet the specific requisites. This phase in short consists of 2
main steps

o Establish therapeutic relationship this involves the following actions;

Enter into and maintain the relationship
Contract to collaborate in identifying and analyzing existing &
potential therapeutic health care demands.
Assess for basic conditioning factors.
Review existing and projected universal, developmental, and health
deviation requisites.
Estimate value and expected changes in value of each requisite
Consider interaction between basic conditioning factors and requisites
Identify and describe self care practices.
State specific limitations and abilities related to practices.
Make inferences about effect of limitations and abilities on engaging
in self care activities
Validate inferences through continuous observation.
Determine adequacy of knowledge, skills, and willingness to meet
therapeutic care demands.
Estimate potential for development of self care agency.
o Diagnose self care deficits (existing & projected)
Make judgments about degree of ability to provide care.
Inform client of presence or absence of self care deficit.
Prescriptive operations

Here the ideal therapeutic self care requisite for each self care requisites are determined
by reviewing possible helping methods , considering related basic conditioning factors

and identifying the most appropriate helping methods. This phase consists of four main
steps which are as follows:

o Calculate the ideal therapeutic self care demand this in turn involves the
following steps;
Review possible helping methods
Consider the validity & reliability of each method in relation to the
basic conditioning factors.
Identify the most appropriate method
Review identified methods with the client and the family
Explain to the client and the family the sequence of action for the
selected method.
o Design therapeutic self care demands this involves the following aspects;
Consider the time specific relationship between requisites, economy of
time & effort, and compatibility with family and personal life.
Plan for adjustment in the design as requisites change or new
requisites emerge.
o Prioritize therapeutic self care demands
Prioritize in this order- 1st those essential for life processes, 2nd those
that prevent personal harm or health deterioration, 3rd those that
maintain or promote health, 4th those that contribute to well being
o Prescribe client role and nurses role.
Identify what the client should do, should not do, and is willing to do.
Determine potential for continued development of self care agency.
Regulatory operations

The prescriptions that evolve are used in the regulatory phase to design, plan and produce
the regulatory nursing system. Factors to be considered for decisions regarding the design
include basic conditioning factors. Effective regulation of health and development state,
timing, assignment of action, and degree of cooperation. Further planning specifies the
conditions for the regulatory operations such as frequency, equipment/supplies, and
personnel needed.
For easy understanding it may be classified into 3 phases which are as follows;

Design regulatory nursing system for prescribed therapeutic self care

demands.
o Assess the basic conditioning factors such as age, developmental state,
health state and the health care system.
o Provide for effective regulation of health and developmental state by
setting forth relationships among components of therapeutic self care
demands.

o Specify timing, amount of nurse patient contact, and reason for

contact.
o Identify actions of nurse, client, and others
o Take into consideration positive or negative cooperation.
Plan for regulatory operations
o Set forth the organization and timing of essential tasks/roles
responsibilities.
o Specify time, place, environmental conditions, equipment/supplies and
type and number of personnel necessary.
Production of regulatory care
o Perform and regulate self care tasks, or assist client in performing self
care tasks.
o Coordinate self care task performance.
o Bring about accomplishment of self care that is satisfying to the client.
o Guide, direct, and support client in exercise of self care agency
o Stimulate client interest in self care.
o Support and guide client learning.
o Support and guide client through experiences in meeting ongoing self
care requisites.
o Monitor and assist client to monitor self in self care measures.
Control operations

This is the last phase which involves evaluation of the effectiveness of the regulatory
operation and the client outcome. The steps involved in this phase are;
o Observe and appraise regulatory operations
Evaluate the quality & quantity of self care, development of the self
care agency, and nursing assistance.
Measure the wellbeing of the client.
Make or recommend adjustment or modification of the nursing care
system.
Assess whether the care is implemented according to the plan and
design.
Assess whether the operations were in accord with the clients
condition and environment for which they were prescribed.
Assess whether the operations are still valid.
Assess whether regulation of the clients functioning has been
achieved.
Assess whether the developmental change is in progress and is
adequate.
Assess whether the client is adjusting to any decline in the self care
ability.

Theoretical assertions
The self care deficit nursing model is expressed in the following three theories

Theory of nursing systems proposes that nursing is human action; nursing systems
are action systems formed/ designed/ produced by nurses through the exercise of their
nursing agency for persons with health derived or health associated limitations in self
care or dependent care. Nursing agency includes concepts of deliberate action,
including intentionality, and operations of diagnosis, prescription, and regulation
The figure shows the basic nursing systems categorized according to the relationship
between patient and nurse action.
Accomplishes patients therapeutic self care
Compensates for patients inability to engage
in self care
Supports and protects patient
Wholly compensatory system
Performs some self care measures for client
Compensates for self care limitations of the
client
Assists care and assistance from nurse

Performs some self care measures

Regulates self care agency
Accepts care assistance from nurse
Partly compensatory system
Accomplishes self care
Regulates the exercise and development of
self care agency
Supportive educative system

Theory of self care deficit the central idea is that the requirements of the individual
for nursing are associated with the subjectivity of mature and maturing persons to
health related or health care related action limitations. These limitations render them
completely or partially unable to know existent and emerging requisites for regulatory
care for themselves or their dependents. They also limit the ability engage in the

continuing performance of care measures to control or in some way manage factors

that are regulatory of their own or their dependents functioning and development.
Theory of self care is a human regulatory function that individuals must, with
deliberation, perform themselves or have performed for them to maintain life, health,
development, and wellbeing. Self care is an action system. The elaboration of the
concepts of self care, self care demand and self care agency provide a foundation for
understanding the action requirement and action limitations of persons who may
benefit from nursing. Self care must be learned and it must be performed deliberately
and continuously in time and in conformity with the regulatory requirements of the
individuals. These requirements are associated with their stages of growth and
development, states of health, specific features of health or development states, level
of energy expenditure, and environmental factors.

Application of the theory

Practice

Used extensively in the practice setup in a variety of settings across cultures, clinical
groups and age groups.
Used in all specialties
From acute to chronic illnesses
Also used in occupational health nursing health hazards, and job related risk factors
Used in specific nursing focus like patient education, primary care, health promotion, and
rehabilitation

Education

Lays down foundation for structure of nursing knowledge.

Structures theory
Provides a guide for developing curriculum for education and practical nurses.
Provides basis for developing curriculum
Theory is used at all levels of the curriculum

Research

Development of research instruments for measuring the conceptual elements of the

theory.
o Assessment of self care agency scale (ASA)
o Self as-carer inventory (SCI)
o Exercise of self care agency (ESCA)
o Danyes and Hanson And Bickels Perception of Self Care Agency (DSCAI)
Studies that test elements of the theory in specific populations.
Development of new models or middle range theory.

Critique

Clarity terms used are defined precisely with consistency in the language used in both
action and theory. Terminologies are congruent through out.
Simplicity uses limited number of terms in a nutshell constitutes only 3 theories;
o Self care
o Self care deficit
o Nursing systems
Generality the theory is the expression of a singular combination of conceptualized
properties or features common to all instances of nursing.
Empirical precision used for both qualitative and quantitative studies. Empirical
precision is dependent on the operational design.
Derivable consequences it gives direction to nursing specific outcomes related to
knowing and meeting the therapeutic self care demands, regulating development and
exercise of the self care agency, and establishing self care and self management systems.