Orem's Self Care Theory Diagnosis: A Comprehensive Guide for Nurses

Dorothea Elizabeth Orem, a prominent figure in nursing theory, is best known for developing the Self-Care Deficit Nursing Theory. This framework, also referred to as the Orem Model of Nursing, revolutionized the way nurses approach patient care by emphasizing the individual’s role in their own health and well-being. Understanding Orem’s theory is crucial for nurses, especially in the context of diagnosis and creating effective care plans. This article delves into Orem’s life, her influential theory, and its practical application in nursing diagnosis.

Biography of Dorothea E. Orem

Dorothea Elizabeth Orem (July 15, 1914 – June 22, 2007) stands as one of the most significant American nursing theorists. Her Self-Care Deficit Nursing Theory, or Orem Model of Nursing, has profoundly impacted nursing practice and education globally.

Orem defined nursing as “the act of assisting others in the provision and management of self-care to maintain or improve human functioning at the home level of effectiveness.” Her theory centers on the concept of self-care, which she described as “the practice of activities that individuals initiate and perform on their own behalf in maintaining life, health, and well-being.” This definition highlights the proactive role of individuals in managing their health, a cornerstone of her theoretical framework.

Early Life and Education

Born in Baltimore, Maryland, on July 15, 1914, Dorothea Orem was the youngest of two daughters. Her father was a construction worker, and her mother was a homemaker. Orem’s early life provided a foundation for her later dedication to care and service.

She began her nursing journey in the early 1930s, obtaining her nursing diploma from the Providence Hospital School of Nursing in Washington, D.C. Driven by a thirst for knowledge, she furthered her education at the Catholic University of America in Washington, D.C., earning a Bachelor of Science in Nursing in 1939 and a Master of Science in Nursing in 1945. These academic achievements equipped her with the intellectual tools to develop her groundbreaking theory.

Academic and Professional Appointments

Dorothea Orem’s commitment to nursing was evident throughout her distinguished career. She held several key positions, starting with her role as director of both the nursing school and the nursing department at Providence Hospital in Detroit from 1940 to 1949. During this time, she also imparted her knowledge as a teacher of biological sciences and nursing from 1939 to 1941.

Returning to the Catholic University of America, Orem served as Assistant Professor (1959-1964), Associate Professor (1964-1970), and Dean of the School of Nursing (1965-1966). Her leadership roles in academia demonstrated her influence in shaping nursing education.

Beyond academic institutions, Orem contributed her expertise to various organizations. She was a curriculum consultant for the U.S. Department of Health, Education and Welfare (1958-1960), the Indiana State Board of Health (1949-1957), and The Johns Hopkins Hospital (1969-1976). Her involvement with these institutions highlights her commitment to improving nursing practice and standards across different healthcare settings. In 1982, she was part of a group of nurse theorists who presented Patterns of Unitary Man (Humans), a foundational framework for nursing diagnosis, to the North American Nursing Diagnosis Association.

Contributions to Nursing Theory and Literature

Dorothea Orem’s most significant contribution is undoubtedly her Self-Care Deficit Theory. This theory posits that nursing is necessary when an individual is unable to meet their own self-care needs. It comprises three interconnected theories: the theory of self-care, the self-care deficit theory, and the theory of nursing systems.

Orem’s seminal work, Nursing: Concepts of Practice, first published in 1971, laid out the principles of her nursing theory. This publication established her as a leading voice in nursing theory and practice. She also chaired the Nursing Development Conference Group and edited their work, Concept Formalization in Nursing, in 1973. Throughout the 1970s and 1980s, Orem actively participated in numerous conferences and workshops, disseminating her ideas globally. The establishment of the International Orem Society further demonstrates the lasting impact of her work, fostering ongoing research and development of her theories.

Orem continuously refined her theory, publishing revised editions of Nursing: Concepts of Practice in 1980, 1985, 1991, and 2001, showcasing her dedication to evolving her framework and ensuring its continued relevance.

Awards, Honors, and Legacy

Dorothea Orem received widespread recognition for her contributions to nursing. She was awarded honorary doctorates from Georgetown University (1976), Incarnate Word College (1980), Illinois Wesleyan University (1988), and the University of Missouri-Columbia (1998). Other accolades include the Catholic University of America Alumni Achievement Award for Nursing Theory (1980), the Linda Richards Award from the National League for Nursing (1991), and honorary fellowship in the American Academy of Nursing (1992).

Death and Enduring Influence

Dorothea Orem passed away on June 22, 2007, in Savannah, Georgia, at the age of 92. Even in her later years, she remained active as a consultant and author. Her Self-Care Deficit Theory continues to be a cornerstone of nursing education and practice, guiding nurses in assessing patient needs and developing individualized care plans. Her work emphasizes patient autonomy and the nurse’s role in supporting individuals in meeting their self-care demands, making her legacy enduring and profoundly impactful on the nursing profession.

Dorothea Orem’s Self-Care Deficit Theory: A Framework for Diagnosis

Dorothea Orem’s Self-Care Deficit Theory provides a structured approach to understanding patient needs and formulating nursing diagnoses. It emphasizes the importance of self-care in maintaining health and well-being and identifies situations where nursing intervention is required due to self-care deficits.

Core Principles and Definition

Orem defined nursing as assisting individuals to maintain or improve their ability to care for themselves. Her theory is rooted in the idea that individuals have a natural desire to care for themselves and maintain their health. A central tenet is that a self-care deficit exists when an individual is unable to perform the self-care activities necessary to maintain life, health, and well-being. This deficit becomes the focal point for nursing intervention and diagnosis.

Orem (1991) stated, “The condition that validates the existence of a requirement for nursing in an adult is the absence of the ability to maintain continuously that amount and quality of self-care which is therapeutic in sustaining life and health, in recovering from disease or injury, or in coping with their effects. With children, the condition is the parent’s inability (or guardian) to maintain continuity for the child the amount and quality of care that is therapeutic.” This definition clearly links the need for nursing to the presence of a self-care deficit, making it directly relevant to nursing diagnosis.

Foundational Assumptions

Orem’s theory is built upon several key assumptions about human beings and their interaction with their environment:

Constant Interaction: Humans are constantly interacting with their environment and communicating with others to survive and function effectively.
Deliberate Action: Humans possess the capacity for deliberate action, enabling them to identify their needs and make informed decisions about their care.
Self-Care Needs: Mature individuals inevitably face situations where their ability to perform self-care is compromised, necessitating actions to sustain life and regulate bodily functions.
Agency and Transmission of Knowledge: Humans can discover, develop, and share methods for identifying and addressing self-care needs for themselves and others.
Shared Responsibility: Groups of individuals establish structured relationships to distribute tasks and responsibilities related to providing care for their members.

These assumptions underscore the active role of individuals in their health and the social context of care, providing a comprehensive backdrop for understanding self-care and its deficits.

Key Concepts in Orem’s Theory for Diagnosis

Understanding the major concepts within Orem’s Self-Care Deficit Theory is essential for its application in nursing diagnosis:

Nursing

In Orem’s view, nursing is an art where practitioners provide specialized assistance to individuals with limitations in their ability to meet their self-care needs. Nurses collaborate with physicians, contributing to the overall medical care while focusing on addressing self-care deficits.

Humans

Humans are the central focus of nursing care, viewed as individuals or social units (families, groups). They are the recipients of nursing actions aimed at meeting their self-care needs.

Environment

The environment encompasses physical, chemical, biological, and social aspects, including family, culture, and community. Environmental factors significantly influence an individual’s self-care abilities and needs.

Health

Orem defined health as structural and functional wholeness or soundness. It’s a state of being that includes both individual and group well-being, as well as the capacity for self-reflection, experiential learning, and communication.

Self-Care

Self-care refers to the activities individuals initiate and perform independently to maintain life, health, and well-being. These activities are goal-oriented and essential for human functioning.

Self-Care Agency

Self-care agency is an individual’s ability or power to engage in self-care. This capacity is influenced by basic conditioning factors, such as age, gender, developmental stage, health status, sociocultural factors, healthcare system factors, family factors, lifestyle patterns, environmental factors, and resource availability. Assessing self-care agency is crucial in diagnosing self-care deficits.

Basic Conditioning Factors

These factors are essential to consider when assessing an individual’s self-care agency and needs. They provide context and help explain variations in self-care abilities across individuals and situations.

Therapeutic Self-Care Demand

Therapeutic self-care demand represents the total self-care actions required to meet an individual’s known self-care requisites using effective methods. It’s the standard against which an individual’s self-care agency is measured to identify deficits.

Self-Care Deficit

The self-care deficit is the core concept for nursing diagnosis in Orem’s theory. It arises when an individual’s therapeutic self-care demand exceeds their self-care agency. This deficit signifies the need for nursing intervention to assist the individual in meeting their self-care needs.

Nursing Agency

Nursing agency is the specialized capability of nurses, developed through education and training, that enables them to assist others in meeting their therapeutic self-care demands. Nurses use their nursing agency to address patients’ self-care deficits.

Nursing System

A nursing system is formed through the relationship between a nurse and a patient when the patient’s therapeutic self-care demand surpasses their self-care agency. The nursing system is designed to address and overcome the identified self-care deficits.

The Interrelated Theories: A Diagnostic Structure

Orem’s Self-Care Deficit Theory is comprised of three interconnected theories that provide a comprehensive framework for nursing diagnosis and intervention:

1. Theory of Self-Care

This theory describes the practice of activities that individuals initiate and perform on their own behalf to maintain life, health, and well-being. It focuses on self-care requisites, which are the actions needed to achieve self-care.

Self-Care Requisites: Identifying Diagnostic Categories

Self-care requisites are categorized into three types, each providing a specific lens for nursing diagnosis:

Universal Self-Care Requisites

These are fundamental needs common to all individuals, essential for life processes and maintaining human structure and function. They include:

Maintaining sufficient intake of air
Maintaining sufficient intake of water
Maintaining sufficient intake of food
Providing care related to elimination processes and excrements
Maintaining a balance between activity and rest
Maintaining a balance between solitude and social interaction
Preventing hazards to life, functioning, and well-being
Promoting human functioning and development within social groups in accordance with human potential and limitations, and the desire for normalcy.

Diagnostic Relevance: Deficits in universal self-care requisites are often readily identifiable and form the basis for many basic nursing diagnoses, such as impaired gas exchange, deficient fluid volume, imbalanced nutrition, impaired bowel/urinary elimination, activity intolerance, social isolation, risk for injury, and ineffective health maintenance.

Developmental Self-Care Requisites

These requisites are specific to different stages of development or are related to developmental processes. They are either specialized expressions of universal self-care requisites or new needs arising from developmental changes or events.

Diagnostic Relevance: Developmental self-care requisites guide nurses in diagnosing needs specific to age groups or developmental stages. For example, delayed growth and development in children, or adjustment issues in adolescents or older adults, can be identified through this lens.

Health Deviation Self-Care Requisites

These arise in conditions of illness, injury, disease, or medical treatment. They include:

Seeking and securing appropriate medical assistance
Being aware of and attending to the effects and results of pathological conditions
Effectively carrying out medically prescribed diagnostic, therapeutic, and rehabilitative measures
Being aware of and managing the discomforting or adverse effects of medical treatments
Modifying self-concept and self-image to accept one’s health state and need for care
Learning to live with the effects of pathological conditions and medical treatments in a lifestyle that promotes ongoing personal development.

Diagnostic Relevance: Health deviation self-care requisites are crucial for diagnosing needs related to managing illness and treatment. Diagnoses such as ineffective self-health management, risk for complications, knowledge deficit (related to treatment regimen), and disturbed body image are directly linked to these requisites.

2. Theory of Self-Care Deficit

This theory specifies when nursing is needed. A self-care deficit exists when an individual’s ability to perform self-care is inadequate to meet their therapeutic self-care demand. Orem identified five methods of helping nurses use to address these deficits:

Acting for and doing for others: Performing self-care actions the patient cannot do themselves.
Guiding others: Providing direction and support.
Supporting another: Offering physical or psychological support.
Providing an environment promoting personal development: Creating a conducive setting for self-care.
Teaching another: Educating patients to perform self-care activities.

Diagnostic Relevance: This theory directly informs the nursing diagnosis process by identifying the type and extent of assistance needed. The chosen helping method becomes part of the nursing intervention strategy based on the diagnosed self-care deficit.

3. Theory of Nursing Systems

This theory describes how nurses can organize actions to meet patients’ self-care needs. Nursing systems are designed based on the patient’s self-care deficits and can be:

Wholly Compensatory System: The nurse performs all required self-care actions for the patient. This is used when the patient has minimal or no ability to participate in their care.
- Example: Care for a patient in a coma or a newborn infant.
Partially Compensatory System: Both the nurse and patient perform care measures. This system is used when the patient can perform some but not all self-care measures.
- Example: Assisting a postoperative patient with ambulation or hygiene.
Supportive-Educative System: The nurse’s role is to educate and support the patient in performing their own self-care. This is employed when the patient can and should learn to perform self-care with assistance.
- Example: Teaching a patient with diabetes how to manage their diet and medication.

Diagnostic Relevance: The selection of a nursing system is a direct outcome of the nursing diagnosis process. Based on the diagnosed self-care deficit and the patient’s self-care agency, nurses determine which system is most appropriate to deliver care effectively. The nursing diagnosis guides the design and implementation of one of these nursing systems.

Applying Orem’s Theory in the Nursing Process for Diagnosis

Orem’s theory aligns closely with the nursing process, providing a structured method for identifying self-care deficits and planning nursing care.

Nursing Process Steps in Orem’s Framework

1. Assessment: Identifying Self-Care Deficits

The assessment phase in Orem’s theory is crucial for diagnosis. It involves collecting data in six key areas:

The person’s health status: Current physical and psychological condition.
The physician’s perspective of the person’s health status: Medical diagnosis and prognosis.
The person’s perspective of their own health status: Patient’s subjective experience of their health.
Health goals within the context of life history, lifestyle, and health status: Patient’s personal health objectives and values.
The person’s requirements for self-care: Identification of universal, developmental, and health deviation self-care requisites.
The person’s capacity to perform self-care (Self-Care Agency): Assessment of the patient’s ability to meet their self-care requirements, considering basic conditioning factors.

Diagnostic Activity: Analyzing data from these six areas allows the nurse to identify discrepancies between the patient’s therapeutic self-care demand and their self-care agency, thus pinpointing self-care deficits.

2. Nursing Diagnosis & Care Planning: Designing the Nursing System

Based on the assessment, the nurse formulates nursing diagnoses that directly reflect the identified self-care deficits. The care plan is then designed, specifying the type of nursing system (wholly compensatory, partially compensatory, or supportive-educative) and the helping methods to be used.

Diagnostic Activity: Nursing diagnoses are stated in terms of self-care deficits. For example: “Self-care deficit: Bathing/Hygiene related to physical weakness as evidenced by inability to reach lower extremities.” The care plan outlines interventions to address this deficit, such as providing assistance with bathing (partially compensatory system) and teaching adaptive techniques.

3. Implementation & Evaluation: Managing and Adapting the System

Implementation involves putting the nursing system into action, using the selected helping methods. Evaluation focuses on assessing the effectiveness of the nursing system in meeting the patient’s self-care demands and reducing or eliminating self-care deficits.

Diagnostic Activity: Evaluation involves monitoring the patient’s progress in meeting their self-care needs. If the initial nursing diagnoses are not being adequately addressed, reassessment and modification of the nursing system and care plan are necessary. This iterative process ensures that the diagnoses and interventions remain relevant and effective.

Analysis of Orem’s Self-Care Deficit Theory for Diagnosis

Orem’s theory provides a clear and structured framework for nursing diagnosis, emphasizing patient autonomy and individualized care.

Strengths in Diagnostic Application

Comprehensive Framework: Orem’s theory offers a holistic approach to diagnosis, considering various aspects of the patient’s life and health status through basic conditioning factors and self-care requisites.
Clear Focus on Patient Needs: The theory directs nurses to focus on identifying and addressing specific self-care deficits, leading to patient-centered diagnoses.
Applicability Across Settings: Orem’s theory is versatile and can be applied in diverse nursing settings, from acute care to community health and rehabilitation, making it universally relevant for diagnosis.
Promotes Patient Independence: By focusing on self-care agency and deficits, the theory encourages nurses to empower patients to participate actively in their care, fostering independence and recovery.
Structured Nursing Process Integration: Orem’s framework seamlessly integrates with the nursing process, providing a step-by-step method for assessment, diagnosis, planning, implementation, and evaluation.

Limitations in Diagnostic Application

Complexity: While providing a structured approach, the numerous concepts and sub-theories within Orem’s model can be complex to grasp and apply, potentially making the diagnostic process seem intricate for novice nurses.
Limited Focus on Emotional Needs: Some critics argue that Orem’s theory primarily focuses on physical and functional self-care needs, with less emphasis on the emotional, psychosocial, and spiritual dimensions of patient care, which are also crucial in holistic diagnosis.
Static View of Health: Orem’s initial definition of health as structural and functional wholeness has been viewed as somewhat static. Modern perspectives on health emphasize its dynamic and ever-changing nature, which might require nurses to adapt Orem’s framework to incorporate these nuances in diagnosis.
Application to Dependent Individuals: While acknowledging the role of parents or guardians for dependents, the direct application of self-care concepts to individuals who require complete care, such as infants or severely debilitated individuals, can be challenging. Diagnosing self-care deficits in these populations may require a modified interpretation of self-care agency.

Conclusion: Orem’s Enduring Impact on Nursing Diagnosis

Dorothea Orem’s Self-Care Deficit Theory remains a foundational framework in nursing, particularly for guiding nursing diagnosis. Its emphasis on self-care requisites, self-care agency, and the identification of self-care deficits provides a robust structure for understanding patient needs and developing targeted interventions. By applying Orem’s theory, nurses can formulate precise, patient-centered diagnoses that drive effective, individualized care plans, ultimately promoting patient autonomy and optimal health outcomes. While some limitations exist, the strengths of Orem’s theory in enhancing diagnostic rigor and patient-focused care solidify its continued relevance in contemporary nursing practice.

Recommended Resources

Recommended books and resources to learn more about nursing theory:

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References

References and sources for this study guide about Dorothea Orem:

“Obituary: Dorothea Elizabeth Orem,” Savannah Morning News, June 24, 2007, retrieved June 17, 2014
Taylor, Carol R.; Lillis, Carol; LeMone, Priscilla; Lynn, Pamela (2011). Fundamentals of Nursing. Philadelphia: Wolters Kluwer Health. p. 74. ISBN 978-0-7817-9383-4.
Orem, D. (1991). Nursing: Concepts of practice. (4th ed.). In George, J. (Ed.). Nursing theories: the base for professional nursing practice. Norwalk, Connecticut: Appleton & Lange.
Orem, D. (1995). Nursing: Concepts of practice. (5th ed.). In McEwen, M. and Wills, E. (Ed.). Theoretical basis for nursing. USA: Lippincott Williams & Wilkins.
Orem, D. (2001). Nursing: Concepts of practice. (6th ed.). In McEwen, M. and Wills, E. (Ed.). Theoretical basis for nursing. USA: Lippincott Williams & Wilkins.
Taylor, S.G. (2006). Dorothea E. Orem: Self-care deficit theory of nursing.
Meleis Ibrahim Afaf (1997), Theoretical Nursing: Development & Progress 3rd ed. Philadelphia, Lippincott.