Dorothea Orem Nursing Theory

Courtney Sack, George Shepherd, Rachael Nitz, Hannah Schnelle

SUMMARY

Dorothea Orem was a nursing theorist, recognized for her self-care deficit nursing theory.
The foundation of her theory was built on her educational background as well as the variety of
areas that she specialized in. When her theory was developed it consisted of a multitude of
concepts and propositions to clearly articulate her main focus of a patient being able to perform
self-care and live independently with the care of a nurse. The paradigms person, health,
environment/situation, and nursing in Orems theory clearly demonstrate her holistic approach to
nursing care. When put into practice, the self-care deficit theory has huge implications on
nursing practice, education, and research. Orems self-care deficit theory has become a
foundational theory used in nursing practice and continues to impact nursing care today.
EDUCATION AND SPECIALTIES
Dorothea Elizabeth Orem (1914 June 22, 2007) received her nursing education in
Washington, D.C. at the Providence Hospital School of Nursing. Orem had earned her diploma
of nursing in the 1930s. She pursued further education and "completed her Bachelor of Science
in Nursing in the Catholic University of America in 1939 and in 1946, she received her Master of
Science degree in Nursing Education" ("Biography of Dorothea Orem", n.d., para.1) . After
receiving her advanced degrees, she worked at a few hospitals and universities. Her practice
background included working as a staff nurse, private duty nurse, nurse educator and
administrator and nurse consultant ("Name of Theorist", 2011). Orem had "primarily focused on
teaching, research, and administration" ("Dorothea Orem Collection," n.d.).
Orem began working in the hospital as an operating room nurse, private duty nursing, medical-
surgical units, hospital staff nursing on the pediatric floor, as a supervisor in the emergency
room, and as a teacher of biological science (Biography of Dorothea Orem, 2014). The variety
of work she dealt with allowed her to be well rounded when she began her work on the self-care
deficit theory. Before pursuing work on her theory, she practiced administration by holding
directorship of the nursing school and department of nursing in Detroit at Providence Hospital
from 1940 to 1949. From there she moved to Indiana working at Indiana State Board of Health in
the Division of Hospital and Institutional Services. It was during this time that Dorothea Orem
began to develop her definition of nursing practice through having the goal to improve the
quality of nursing practice (Biography of Dorothea Orem, 2014).
After moving to Washington D.C. in 1957, Orem took a position as a curriculum
consultant for the Office of Education, US Department of Health, Education, and Welfare. Here
she further developed her definition of nursing practice by working on projects to upgrade the
current practical nurse training. From this work came the development in 1959 of the Guides for
Developing Curricula for the Education of Practical Nurses (Biography of Dorothea Orem,
2014). This was her introduction to her self-care framework describing its basic ideas. During
that year Orem went back to the Catholic University of America, but this time as an assistant
professor of nursing education. Later this turned into an associate professor of nursing education
and serving as a dean at their School of Nursing (Biography of Dorothea Orem, 2014).
After leaving CUA, Orem started her own consulting firm in 1970. As Orems experience
nursing had furthered, her theory of self-care had also advanced. In 1971 she published her first
book Nursing: Concepts of Practice. In 1985, Orem expanded on her self-care framework
establishing the three theories within the overall structure. Because of her work and contribution
to nursing, Orem received a multitude of Honorary Doctorates from various colleges beginning
in 1976 and ending in 1998(Biography of Dorothea Orem, 2014).
Dorothea Orem served in a multitude of capacities over her nursing career. Throughout
her years as a nurse there was never a point where she stopped learning or specializing her care.
This well roundedness enabled her to develop the self-care deficit theory of nursing that is
commonly used in the healthcare practice setting today.
NURSING THEORY, CONCEPTS, AND PROPOSITIONS
The main point of Dorothea Orems theory is to nurse the patient until he or she is able
to perform self-care and live independently. She believed that individuals "should be self-reliant
and responsible for their own care and others in their family needing care" ("Dorothea Orem's
Self-Care Theory", 2012). Orems theory is divided into three constituents: self-care, nursing
system, and self-care deficit. The self-care factor stresses the need for the individual to perform
life-sustaining activities on his or her own. The individual must develop the ability to perform
those activities. In performing self-care, the individual encounters three categories regarding
self-care: universal, developmental, and health deviation. Universal self-care involves all "life
processes and the maintenance of the integrity of human structure and functioning" ("Dorothea
Orem's Self-Care Theory", 2012). Developmental self-care involves transitions in ones life.
Such transitions include: moving to a new state or country, adjusting to a new culture, and aging.
Health deviation involves performing self-care actions in response to abnormal conditions such
as injury, illness, and disabilities.
The concepts of Orems theory include: nursing, health, the human being, the nursing
client, environment, the nursing problem, nursing therapeutics, and the nursing process. To
Orem, nursing is an art that is practiced to promote the patients health and therefore, the
patients capability to carry out self-care. Health is the condition of optimal psychosocial and
physiological integrity. The human being is "conceptualized as a total being with universal,
developmental needs and [is] capable of continuous self-care" ("Dorothea Orem's Self-Care
Theory", 2012). Through Orem's theory, human beings are distinguished "in terms of their
capacity to: reflect upon themselves and their environment, symbolize what they experience,
[and] use symbolize creations in thinking, communicating, and guiding efforts to" produce
benefits for themselves and others ("Dorothea Orem: Self Care Deficit Nursing Theory", n.d.,
para.3). The nursing client is the patient; he or she is affected by a health problem that results in
limited self-care being performed. When self-care abilities are compromised, the nursing client is
the main focus of the nurse. The environment is the totality of the outside factors that can affect
the human being and the nursing client. The nursing problem is described as self-care deficits
that are rooted in universal, health deviation, and developmental factors. Nursing therapeutics
comprise of "deliberate, systematic, [sic] and purposeful action" ("Dorothea Orem's Self-Care
Theory", 2012). Lastly, the nursing process is expressed as a standardized system that is utilized
by nurses to determine the health needs of the patient, the plan of care to meet those needs, the
implementation of nursing interventions, and the success of those interventions.
The nursing systems factor explains "how the patient's self-care needs will met by the
nurse, the patient, or both" ("Dorothea Orem's Self-Care Theory", 2012). Depending on the
needs of the individual patient, the nurse can completely (wholly compensatory system) or
partially (partially compensatory system) assist the patient. Moreover, another important part of
the nursing systems factor is the supportive educative system, in which the nurse supports the
patient by educating him or her about positive health behaviors and potential health risks. The
self-care deficit factor explains when nursing care is required. When the patient is fully or
partially unable to carry out adequate self-care, the nurse must intervene through nursing acts,
guidance, positive environmental manipulation, dissemination of knowledge, and support.
Her theory proposes that people, as individuals, are to be responsible for their own
care and that people should assume a self-reliant lifestyle. Orem assumed that nursing revolves
around the interaction between two or more individuals. If an individual is to prevent illness, he
or she must meet the demands of self-care. To meet those demands, the individual must obtain
"knowledge of potential health problems" ("Dorothea Orem's Self-Care Theory", 2012).
Additionally, knowledge of dependent and self-regulated behaviors is ascertained within the
context of sociocultural context.
METAPARADIGM
Each nursing theory has four paradigms that include: person, health,
environment/situation, and nursing. In Dorothea Orems Self Care Deficit Theory, the person is
the individual patient that a nurse is caring for. She states that each persons ability to function
does not include just the physical aspect but also the psychological, interpersonal, and social as
well. She defines a human as a being that has the ability to "reflect, symbolize, and use
symbols" (currentnursing.com). Orem also states that self-care is not a born instinct in humans
but that it is influenced by many factors in a persons life. In this way, she believes that humans
are set apart from other species because we have the ability to learn and adapt and develop.
While going through the different developmental stages a persons beliefs about health are also
apt to change and develop, she says. Health can have various definitions from person to
person. According to Dorothea Orem, health does not only mean not being sick, but health is the
ability to completely care for oneself. She considers health to be when self-care demands are not
more than the resources or abilities a person has to meet those demands. Self-care is defined by
Orem as the performance or practice of activities that individuals initiate and perform on their
own behalf to maintain life, health, and well-being (George, pg. 115). This theorist also agrees
that health includes preventative care. Orem says that the environment includes conditioning
factors. These conditioning factors are defined as factors that can influence the self-care demand
and the self-care agency. Dorothea Orem states that there are many important components of
nursing. The most important to her included the art and prudence of nursing, nursing as a
service, role theory related to nursing, and technologies in nursing (George, pg. 121). Since she
defines health as the ability to care for oneself, nursing is defined by Orem as the care that is
needed when there is a self-care deficit or a person can no longer provide self- care. Nursing is
provided for children when their caregiver cannot provide adequate care. Nursing is provided if
the capacity to provide care is less than that what is needed for an identified self-care demand
(George, pg. 117). Nursing may also be needed even when the ability to care for one self is
sufficient if new teaching is needed or it is predicted that soon self-care demands will be larger
than self-care abilities. According to Orem, a nurse can help in five ways: Doing for another,
guiding and directing, providing physical or psychological support, providing/maintaining an
environment that supports personal development, and teaching (George, pg. 117). The goal of
all of these types of helping is to get the patient to be able to perform self-care according to
Orem.
THEORY'S IMPLICATION TO NURSING PRACTICE, EDUCATION, AND
RESEARCH
Orems Self-care deficit nursing theory is used in structuring the nursing process,
education, and research. Instead of the usual nursing process that consists of assessment, nursing
diagnosis, planning, implementation, and evaluation, Orem uses characteristics of her theory for
a nursing process that consists of diagnosis and prescription, designs for regulatory operation,
and production and management of nursing systems (George, p. 123).
In the first step, nursing diagnosis and prescription, a nurse collects assessment data and
determines the clients self-care agency and the therapeutic self-care demand. This step is
important in order to determine why nursing care is needed. Assessment data has six areas it is
written down in, the first being the persons health status, then the physicians perspective of the
persons health, the patients perspective of his or her own health, the health goals, the patients
requirements for self-care, and last his/her ability to perform self-care (George, p. 127-
128). While completing this first step in Orems nursing process, the nurse needs to answer
certain questions related to the theory such as What is the patients therapeutic care demand?
Does the patient have a deficit for engaging in self-care to meet the therapeutic self-care
demand? If so, what is its nature and the reasons for its existence? Should the patient be helped
to refrain from engagement in self-care or to protect already developed self-care capabilities for
therapeutic purposes? What is the patients potential for engaging in self-care at a future time
period? (George, p. 128). An example that is given in Nursing Theories: The Base for
Professional Nursing Practice is that assessment includes basic conditioning factors such as age,
race, gender, height, universal self-care factors such as smoking 1.5 packs of cigarettes a day, not
exercising, and frequently eating fast food, developmental self-care factors such as working 12
hour days, health deviation factors such as vital signs, family history, and potential for disease,
medical problem and plan such as a diagnosis of obesity, decreasing or stopping smoking, and
decrease cholesterol intake, and self-care deficits such as difference in a healthy lifestyle and the
lifestyle that the patient is living (George, p. 126).
In Orems second step of her nursing process, designs for regulatory operation, a nurse
designs a nursing system that is used in planning ways to help a patient. The system that the
nurse designs can either be wholly compensatory, partly compensatory, or supportive-educative
(George, p. 128) and includes nurse and patient roles in relation to which self-care tasks will be
performed when modifying the therapeutic self-care demands, controlling the implementation of
self-care agency, shielding the already developed powers of self-care agency, and assisting with
new developments in self-care agency, (George, p. 123). This section includes the outcomes
and plans for the given diagnosis related to self-care.
The third step, production/management of nursing systems, is about nurses helping his
or her patient to meet unmet and prescribed goals of therapeutic self-care and to then help the
patient carry out these self-care goals (George, p. 123). During this stage, the nurse has ten tasks
that s/he must do including assisting the client with their self-care tasks, coordinating the task
performance with other components of health care, helping the patient, the family, and others to
use daily living activities that are satisfying to the patients interests, guide, direct, and support
patients with their self-care, stimulate patients interests in self-care activities and abilities,
support and guide patients in learning self-care activities, support and guide the patient if s/he
gets sick and needs to adapt ways of self-care activities, monitor patients and assist the patient to
monitor him/herself to see if the self-care performance was effective, to make judgments about
the sufficiency and efficiency of self-care, and lastly, to make judgments on whether the nurses
plan helped with self-care ability or hindered (George, p. 124). The nurse can modify goals if
needed or continue the goal to ensure self-care activities are carried out. Not only does the nurse
need to help the patient be able to perform self-care tasks, but the nurse needs to teach the patient
on how to be able to identify the ability to effectively carry out a self-care tasks and ability. This
step includes evaluation in which the nurse and patient work together to determine if
implementation of the goals have worked or not.
A purpose of Orems self-care theory in nursing practice is to encourage a nurses
patients to perform self-care activities. A nurse needs to educate his or her patient on ways to be
able to do activities of daily living, going to therapy, doing exercises, and gaining strength. This
theory is used in practice to determine a patient's self-care abilities and if there are more demands
than abilities, nursing care and practice is necessary (George, p. 117). If the patient is not able to
care for him/herself biologically, psychologically developmentally, or socially, then nursing care
is necessary (Potter, Perry, Stockert, Hall, p. 45).When nursing practice is necessary for a
patient, self-care needs need to be supported by a nurse through systems. There are three systems
as stated before, wholly compensatory, partly compensatory, and supportive-educative. A system
is considered wholly compensatory when the nurse performs self-care operations because the
patient has a total lack of ability to perform self-care activities. A system is partial compensatory
if a patient can perform some self-care activities, and a system is supportive-educative when the
patient can perform all self-care activities and is working on developing self-care (The
University of Tennessee at Chattanooga, p. 21). According to Nursing Theories: The Base for
Professional Nursing Practice, in the wholly compensatory system, the nurse "accomplishes
patient's therapeutic self-care, compensates for patient's ability to engage in self-care, and
supports and protects the patient" (George, p. 119.) In partly compensatory, the nurse "performs
some self-care mesasures for patient, compensates for self-care limitations of patient, assists
patient as required, and regulates self-care agency," while the patient "performs some self-care
measures, regulates self-care agency, and accepts care and assistance from nurse," (George, p.
119). In supportive-educative, the patient "accomplishes self-care and regulates the exercise and
development of self-care agency," while the nurse also "regulates the exercise and development
of self-care agency," (George, p. 119). The nurse and patient work together in all of the systems
to ensure that self-care activities are performed successfully.
Dorothea Orem's theory of self-care deficit can be applied in research. According to Nursing
Theories: The Base for Professional Nursing Practice, "Orem's theory is the most readily applied
theories," (George, p. 132). George also writes that out of 143 journal articles found on the
internet about Orem's theory, 66 tested the relationships found in her theory. The rest of the
articles used Orem's definition of self-care or her self-care framework (George, p. 132). Orem's
theory is used by other agencies to make Self-as-Carer Inventory, Community Care Deficit
Nursing Model, Assessment of Self-Care Agency, and Self-Care Agency Instrument (George, p.
132). Not only is this theory used in research, but it is used every day by nurses when taking care
of his/her patient. It is used in education in nursing schools when learning about caring for a
patient and looking at the different ways of nursing.
REFERENCES
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