In this age of multitudinous "theories" of nursing, upon which various curricula models are based, it is helpful to be able to glean the essence of a theory without necessarily having to expend a great deal of time and energy doing so. Since time is a precious commodity, especially for those engaged in nursing education, it is often useful to read a paper which analyzes, evaluates and demonstrates application of a given nursing "theory." Such exposure might then provide faculty with at least an elementary familiarity with a given theory, which might subsequently be entertained as a model for a curriculum change.
This paper includes an analysis of Dorothea Orem's SelfCare Model, using the criteria for analysis suggested in the writings of such individuals as Stevens (1979, pp. 21-69), Riehl and Roy (1974, pp. 2-6), Ellis (1968), and Dickoff and James (1968). Following this analysis of the model, a clinical example of the application of the model is presented.
Philosophical Assumptions: Orem has presented the following assumptions about the nature of man, the nature of nursing, and the interactions between man and environment.
Regarding the nature of man, Orem sees man as responsible for his own self-care in relation to his health. She also sees man as responsible for others who are dependent upon him (children, the sick and the elderly). Thirdly, she believes man has the right to choose or not to choose in relation to his health (Orem, 1980, pp. 1-33).
For Orem, nursing is viewed as a human service which is valued in many social groups. Nursing is considered to be a mode of helping, wherein the focus of nursing is the individual's self-care action. Nursing intervention is necessary, within Orem's framework, in order to sustain life and health, to facilitate recovery from disease or injury and to help individuals cope with the effects of such threats to their self-care abilities. In order to perform in the role of nurse, an individual requires specialized knowledge, skills, and attitudes. Since the nurse engages in activities described as "a complex form of deliberate action," Orem believes that nurses must be familiar with the technological and moral aspects of decisions which affect lives, health and welfare (Orem, 1980, pp. 1-33).
In terms of the interactions between man and environment, man is viewed conceptually as an open-system, i.e., a biopsychosocial being who has universal self-care requisites which are affected by age, developmental factors and health deviation experiences. The self-care "theory" presents nurse-patient relationships in an ecological context in which "human systems are formed from the interpénétrations of psychosocial and technological human systems" (Orem, 1980, p. 33). Interactions between man and nursing are determined by the needs of the patient, whose experience of self-care deficits, serves to legitimize the mutual roles.
System Components: The goals of Orem's Self-Care "Theory" are: 1) the satisfaction of universal self-care requisites; 2) to help man meet his self-care needs; 3) to maintain the most healthy "health state"; or, in the presence of self-care deficits; 4) the "regulation" of therapeutic self-care demands. Values postulated by this "theory" include: 1) the assertion that people can benefit from nursing because they are subject to health related or derived limitations which play havoc with their ability to continue their own selfcare; 2) that man should be regarded as a "whole"; 3) that nurses engage in encounters with patients by fostering "Iyou" relationships; and 4) that man has the right to exercise his capacity for decision making (Bromley, 1980).
The boundaries of man in this theory are not clearly defined since man is viewed as an open system. "Being normal" as a concept is seen as flexible in the sense that a range of "normal" is ascribed to, rather than rigid boundaries applied. Nursing is acknowledged as having legal boundaries in terms of its definition. However, realistically and philosophically the boundaries of nursing are seen as fluid in the sense that nursing is only limited by the needs of the patient for nursing. The pattern and organization of the "theory" include three major constructs: self-care, selfcare deficits, and nursing systems. The dynamics of these constructs are viewed as in a continuous interacting state, in which the energy and flow of the system components are determined by alterations in the self-care abilities of the patient.
The question of the developmental direction of man, nursing and the model is answerable by recognizing that: 1) man is in the process of developing throughout life, and that developmental factors affect his universal self-care requisites; 2) nursing is evolving as a profession; and 3) the model is evolving as it is analyzed and applied to nursing practice. Regarding potentiality as a system component, one could say that, according to Orem, man has the potential to develop the skills and motivation necessary for selfcare and care of dependent family members (Orem, 1980, pp. 35-116).
Evaluation of the Model
General Criteria: Self-care theory is abstract to the degree that it is applicable to persons of all ages regardless of degree of wellness. An aspect of self-care is considered to be "dependent care" which expands the degree of application of the model. The concepts in the theory of self-care are delineated in terms of sub-components and recognizable attributes. The definitions of the major constructs and their interrelationships enable one to explain, within the boundaries of the model, the relationship between the patient's self-care abilities and level of wellness, the relationship between oiminished self-care abilities and the need for nursing support and the relationships among nursing agency, patient agency, therapeutic self-care demands and maximizing self-care abilities.
Probably, one of the attractions Orem's theory has for many nurses is its utility in practice. This is highly evident in the writings of Kinlein (1977, pp. 1-195) and Bromley (1980). Hypotheses, which consist of projected relationships between independent and dependent variables can be derived from the major constructs and sub-constructs of self-care. Examples of hypotheses include: 1) clients with juvenile onset diabetes whose power of agency (i.e., selfcare abilities) is assessed as high, will experience greater control over their diabetic condition than those whose power of agency is assessed as low; or 2) those clients who do not maintain positive self-care practices are more likely to experience illness than those who do maintain positive selfcare practices.
Research evidence supporting the concepts in the model exists empirically in the experiences of Kinlein (1977, pp. 1-195) and the Nursing Development Conference Group (1973, pp. 195-211). Additionally, studies using the self-care "theory" include: "A Self-Care Model for Nursing the Aged" by Dr. Toni Sullivan (cited by Garvin, et al, 1980, p. 34), and another by Sister Hartnett entitled, "Development of a Theoretical Model for the Identification of Nursing Requirements in a Selected Aspect of Self-Care (cited by Orem, 1980, p. 223).
According to Stevens, Orem presents her "theory" in a thought pattern which she terms "operational." In this method, the agent is viewed as part of the method itself. The self-care theory defines what the agent does, how determinations of needs are made, and what modes of care are appropriate in response to the needs identified (Stevens, 1979, pp. 35-48).
Internal Criticism: Utilizing the criteria of internal criticism, I see Orem's theory as possessing a high degree of clarity, i.e., it is easily understood and basic terms are defined. The terms are used in the same way throughout, satisfying the criterion of consistency. The development of the argument is in the cognitive mode termed "operational," so that the criterion of logical development is followed. The level of theory development is descriptive in terms of conceptualization of "self-care." Thus, this "theory" might be viewed more accurately as a "conceptual model" which is evolving, and has the potential to develop that deeper level of "reality" representation known as "theory." By this I mean that theory is accepted as that level of abstraction which serves to explain observed phenomena and predict the impact of nursing as a practice discipline (Stevens, 1979, pp. 49-60).
External Criticism: The way in which a theory relates to the real world, constitutes the essence of the criteria of "external criticism." In terms of adequacy, in Orem's SelfCare "Theory," nursing is self-care which fills a deficit when something fails to exist on the part of the patient. The utility factor is determined by the usefulness of the theory for practice, education, research, and administration in nursing. Orem provides a practice framework for the practitioner; a conceptual model for curriculum development for the educator; the potential for an array of investigative questions for the researchers; and a guide for organizing a nursing department for the administrator.
In terms of significance, Orem's theory does provide the foundation for exploring essential issues in nursing and has tremendous research potential. As far as the capacity to discriminate what nursing is and what it is not, Orem clearly established the focus of nursing practice. The scope of nursing, in Orem's theory, is broad and contextual, nursing knows no limits. The complexity of Orem is viewed as balanced between highly complex and parsimonious. The elements are identified but there is room for growth and inclusion of other elements in the model (Stevens, 1979, pp. 60-68).
Synthesis of Theory into Practice
Application of the Model to a Clinical Situation: I have selected a clinical situation involving an 84-year-old woman who resided in a long-term care facility. She was admitted to the agency in November 1979 following an accident, in which her daughter, who fell and fractured her hip, found she could no longer provide her mother with the assistance she required.
The client was born in 1896, in New York City. She grew up in a suburban New Jersey community where she attended school until eighth grade, and then remained at home to care for her mother, who had had a CVA. Her mother died at 60 years of age. Her father lived until he was 85. The client is one of seven children born to these parents. She is the only surviving sibling.
The client lost her husband in 1957 due to metastatic cancer. Her remaining family include a daughter, and a son and their respective families. Her primary support system has been her daughter's family, who live a short distance from the long-term care facility in which she now resides.
Until 1977, the client managed her own home in a lake community in northern New Jersey. She experienced episodes of syncope which were accompanied by falls. Though a pacemaker was inserted, and the episodes all but disappeared, both the daughter and client felt it was no longer safe for her to be alone.
She lived with her daughter for two years prior to being admitted to the long-term care facility. Medically, the client has chronic renal failure, anemia of chronic disease, a history of gout, degenerative arthritis, a hiatal hernia, hypertension, congestive heart failure, and has had multiple TIAs. She has compensated well for a flexion-contracture of her right arm which she has had since birth. On interview, she repeatedly expressed concern about incessant fatigue and expressed a desire to be home rather than in this long-term care faculty. Her affect suggests depression.
According to Orem's self-care model, the client's power of agency is impaired, in the sense that she is not able to manage all of her self-care needs because of multiple deviations in her health state. To compensate for the self-care deficits experienced by this client, the nurse enters into a collaborative relationship with the client to identify her assets and deficits, and determine the therapeutic self -care demands brought about by changes in her developmental needs as well as changes in her health state. The nurse operates through a process of deliberative action, which involves assessment, planning, prescribing, implementing, and evaluating care to be given.
As stated before, there is mutual interaction and responsibility in the process. Given the circumstances of this client's situation, the nursing agency would take the forms of "partly compensatory" and "supportive-educative." Within these systems, needs which the client is meeting are maintained by the client; needs not being met would be addressed by the nurse. Nursing intervention would involve guiding, directing, offering psychological support, doing for, and educating the client, as determined through the assessment process (Appendix).
- Bromley, B. (1980). Applying Orem's self-care theory in enterostomal therapy. American Journal of Nursing, 80(2), 245-250.
- Dickoff, J. & James, P. (1968). A theory of theories: A position paper. Nursing Research, 17, 26-39.
- Ellis, R. (1968). Characteristics of significant theories. Nursing Research, 17, 217-222.
- Garvin, P., et al. (1980, Jan.-Feb.). Self-care applied to the elderly New Jersey Nurse, pp. 3, 34.
- Kinlein, M. L. (1977). Independent nursing practice with clients. New York: J.B. Lippincott Company.
- Nursing Development Conference Group. (1973). Concept formalization in nursing: Process and product. Boston: Little, Brown and Company.
- Orem, D.E. (1980). Nursing: concepts of practice (2nd ed.). New York: McGraw-Hill Book Company.
- Riehl, JP, & Roy, C. (1974). Conceptual models for nursing practice. New York: Appleton-Century Crofts.
- Stevens, B.J. (1979). Nursing theory: Analysis, application, evaluation. Boston: Little, Brown, and Company.