Dorothea Orem's Self-Care Deficit Theory (SCDT) has been proposed as a conceptual model for nursing practice. Because the immediate goal of a conceptual model is to guide practice (Riehl & Roy, 1974), evaluation of a model's usefulness in practice is a necessary and important step. Although a model may be potentially useful in a specific and well-defined setting, its ultimate usefulness depends on whether nurses are able to adapt it to their settings. Therefore, the purpose of this preliminary study was to determine if graduates from a baccalaureate nursing program with a curriculum based on Orem's SCDT, continued to use and were able to adapt the SCDT to their individual practices which included a variety of settings.
Review of the Literature
Orem's SCDT of nursing is based on the premise that all individuáis are capable of self-care. According to Orem, "self-care" consists of actions that individuals freely and deliberately initiate and perform on their own behalf in maintaining life, health, and weìl-being (Orem, 1985). The nurse's actions are directed toward assisting the patient to assume responsibility for self-care.
Orem identifies a two-step nursing process in achieving the goal of self-care. The first step includes identifying and prioritizing the client's unmet self-care needs (deficits). The second step consists of selecting methods of assisting the client to compensate for or overcome his self-care deficits.
The structure and content of Orem's SCDT has been developed and refined over the past two decades (Chang, 1980; Harrington, 1984; Porter, 1983). Examples for its use in a variety of settings have been suggested and described. For instance, Mullin (1980) implemented the SCDT in the acute care setting. Although hospital constraints were identified which limited its implementation, Mullin suggests that by "... internalizing the self-care concept and consciously translating it into practice, the nurse can modify the effects of the constraints." Neufeld and Hobbs (1985) established a health counseling service for senior citizens based on Orem's SCDT.
Using the self-care model, they developed a health assessment guide.
Woolery (1983) used Orem's SCDT with obstetrical patients. She found that the conceptual model allowed the nurse to operate ". . . within a client-centered system which encourages the individual to be responsible for her own care" (p.37). Eichelberger et al. (1980) used Orem's SCDT to create a self-care nursing plan for pediatrics which incorporated developmental concepts. The plan is appropriate for all settings and includes the child, parent and nurse as active participants in the care plan.
A research study by Anna et al. (1978) evaluated the applicability of the SCDT to a nursing home. The findings suggested that, although nurse subjects understood the concept of self-care, they did not understand the SCDT terminology. The nursing home residents resisted participating in self-care and chose instead to depend on the nurses. It was also found that nursing home employees resisted changing their established patterns of performing client care.
According to Mullin (1980), there are three general areas in which the nurse might encounter difficulties in implementing the SCDT. One is the nurse's lack of orientation to the self-care concepts. The other two are limitations imposed by the health care delivery system and the hospital setting which focus on patient dependency. Our present health care system encourages patient dependency which conflicts with the basic premise of Orem's SCOT which is self-care.
The use of Orem's SCDT has been studied in a variety of health care settings as described in the above examples. An unanswered question remains. Do nurses who have graduated from a curriculum based on the SCDT continue to use the model and adapt it to their individual practice settings?
The study asked four research questions:
1. Do subjects report using Orem's SCDT in practice?
2. What employment characteristics are related to subjects' reported use of the SCDT?
3. What factors enhanced the use of the SCDT in practice?
4. What factors inhibited the use of the SCDT in practice?
Sample: Subjects were 271 graduates from both the generic and RN programs at a liberal arts college in central Texas. Usable questionnaires were received from 95 subjects for a response rate of 36%. Of this total, 47 had graduated from the RN to BSN program and 48 had graduated from the generic program. Subjects' ages ranged from 22 to 64 years with a mean age of 34.
Of 95 subjects, 90 were employed at the time of the survey. Almost 30% were employed in medical/surgical areas and about 20% were employed in critical care areas. Employment areas were evenly distributed between generic and RN graduates with the exception of the critical care area; 14 generic graduates versus only six RN graduates were employed in this area. The majority of respondents were staff nurses while 19 of 90 held supervisory positions. The remaining 25% held a variety of positions including primary nurse, instructor, and researcher.
Instrument: A two-part questionnaire, developed by the investigators, was used to collect the data. An expert panel comprised of ten faculty members was asked to analyze the items to determine if the content area was adequately covered. After two revisions, a final instrument was designed and approved.
The first part, comprising nine items, requested education and employment information. The second part comprising ten items, requested information about the application of Orem's SCDT in practice.
In part two, the first eight items asked subjects to indicate the frequency with which they applied specific aspects of the SCDT. A four-point Likert scale was used and included the possible answers of never, seldom, frequently, and always. The last two open-ended items asked subjects to indicate if the practice setting in which they were employed inhibited or enhanced the use of the SCDT.
Data Collection: Questionnaires were mailed to all 271 graduates from 1980 through 1985. Each packet contained a cover letter, a copy of the questionnaire, and a stamped self-addressed envelope. Three weeks following the initial mail-out of questionnaires, postcards were sent to each subject urging nonrespondents to return their questionnaires and thanking respondents for their participation.
Research Question One: Do subjects report using Orem's SCDT in practice? More than 75% of all responses to these eight items was "frequently" or "always." In particular, 74 of 90 subjects (82%) reported that they found the SCDT useful in identifying the client's self-care deficits. Identifying client self-care actions was the least reported activity when using the SCDT (65 of 90 subjects or 72%).
Research Question Two: What employment characteristics are related to subjects' reported use of the SCDT? The majority of subjects reported that they used the SCDT. Only 20 of 90 employed subjects (22%) reported that the SCDT was not applicable to their practice setting or that they never or seldom used the SCDT.
Of the remaining 20 subjects who reported that they never or seldom used the SCDT, all previously mentioned practice settings were represented and there was an even distribution of generic and RN graduates. In other words, there were no employment characteristics that distinguished those who reported using the SCDT from those who did not other than roles of administration and instruction.
Research Question Three: What factors enhanced the use of the SCDT in practice? Fifty-nine subjects (66%) reported that their specific practice settings enhanced the use of the SCDT. Of these 59 subjects, 48 described specific factors which enhanced their use of the SCDT These 48 written responses were then classified into four categories in which practice settings: 1) encouraged self-care; 2) prioritized early discharge planning; 3) subscribed to "whole person" care concept; and 4) placed a high expectation on patient teaching.
Research Question Fbur: What factors inhibited the use of the SCDT in practice? Seventeen (18%) of the 90 employed respondents reported that their settings inhibited the use of the SCDT. Seventeen written responses were classified into the following four categories: 1) time constraints; 2) unable to adapt SCDT to practice setting; 3) SCDT terminology presented an obstacle in communicating with staff; and 4) patients were not interested in self-care and preferred dependence on the nurse.
A limitation of this study is that the sample was small and perhaps not representative of other graduates. The majority of this school's nursing graduates since 1980 may not have responded in the same way.
The results of this survey suggest that a majority of respondents frequently or always used the SCDT in practice. This positive response was evenly distributed between both RN and generic graduates.
Factors which enhanced the application of the SCDT in practice were identified. The most outstanding factor identified in 35 of 59 cases was that the setting itself encouraged clients to assume responsibility for their own care.
Seventeen of 90 respondents reported that their settings inhibited the use of the SCDT. The most outstanding factor in nine of these 17 cases was insufficient time to use the model. Respondents may have not understood this question and confused writing out an entire plan as they had in nursing school, with using the model as an internalized thinking process.
In conclusion, because the results of this study were consistent and evenly distributed, it appears that graduates did adapt the SCDT to their individual practice settings. This was true whether analyzing results for RN or generic graduates.
Based on the findings of this survey, three recommendations for further study have been proposed:
1. There is a need for follow-up studies on graduates from schools which use Orem's conceptual model in their curriculum. This is important for two reasons: nursing schools have a responsibility to evaluate the effectiveness of the conceptual model they are using; and, it is vital to the nursing profession to promote research related to the application of conceptual models in practice settings.
2. Factors which inhibit the use of the conceptual model in practice need to be further described. In doing so, changes can be made in teaching the SCDT which would assist students to adapt the model to all settings.
3. Practice settings which encourage active patient participation in self-care facilitate the application of the SCDT. In settings where this is not the case, studies are needed that will identify those factors which limit the application of the SCDT.
As a result of this study, a five-year follow-up plan has been adopted in which graduates from the nursing school in the present study will be asked to complete the questionnaire used in the current study one year following licensure to practice professional nursing. This information will provide direction for future curriculum revision and additional data for evaluating the application of the SCDT in practice.
- Christenaen, D., Hohon, S., Ord, L., & Welle, S. (1978). Implementing Orem's conceptual framework. Journal of Nursing Administration. 8 (November) 8-11.
- Chang, B. (1980). Evaluation of health care professionals in facilitating se If -care: Review of the literature and a conceptual model. Advances in Nursing Science, 3, (October, 43-58.
- Eichelberger, K,, Kaufman, D., Rundahl, M., & Schwartz, N. (1980). Self-care nursing plan: Helping children to help themselves. Pediatric Nursing, 6, (May-June), 9-13.
- Harrington, J., & Houston, S. (1984). Using Orem's theory: A plan for all seasons. Nursing and Health Care, 5, (1), 45-47.
- Kearney, B., & Fleischer, B. (1979). Development of an instrument to measure exercise of selfcare agency. Research in Nursing and Health, 2, (1), 25-34.
- Mullin, V. (1980). Implementing the self-care concept in the acute care setting. Nursing Clinics of North America, IS, (March), 177-189.
- Neufeld, A., and Hobbs, H. (1985). Self-care in a high-rise for seniors. Nursing Outlook, 33, (6), 298-301.
- Orem, D. (1985). Nursing: Concepts of practice (3rd ed.). New York: McGraw-Hill.
- Porter, D., & Shamian, J. (1983). Self care in theory and practice. Canadian Nurse, 79, (8X 21-23.
- Riehl, J., & Roy, C. (1974). Conceptual Models for Nursing Practice. New York: Appleton-Century-Crofts.
- Woolery, L. (1983). Self-care for the obstetrical patient. Journal of Obstetrical and Gynecologic Nursing, 12, (1), 33-37.