Self-Care Deficit Theory
Running head: SELF-CARE DEFICIT THEORY IN PRACTICE
Self-Care Deficit Theory of Nursing in Practice:
APN Expert Coaching and Guidance in Heart Failure
Emily Duke Koch
University of Virginia School of Nursing
On my honor as a student, I have neither given nor received aid on this assignment.
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Self-Care Deficit Theory
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Abstract
Heart failure is a chronic illness characterized by periods of exacerbation and remission,
and coping with heart failure greatly impacts self-care demands. As proposed in the selfcare deficit theory of nursing, heart failure patients enter periods of fluctuating illness and
health states that correspond with varying degrees of self-care deficit and agency. The
APN intervention of expert coaching and guidance creates a dynamic, collaborative
relationship with patients with the goal of restoring their self-care abilities and preventing
heart failure exacerbation and hospitalization. In the process of expert coaching and
guidance, the APN integrates self-reflection and clinical expertise with patients’
understandings, experiences and goals to accomplish therapeutic and educational goals.
The congruence between nursing theory and practice is realized in the relationship
between the self-care deficit theory of nursing and the APN intervention of expert
coaching and guidance. Heart failure patients experience a higher level of self-care
agency as a result of expert coaching and guidance from an APN.
Self-Care Deficit Theory
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Self-Care Deficit Theory of Nursing in Practice:
APN Expert Coaching and Guidance
Introduction
Heart failure is a chronic illness characterized by periods of exacerbation and
remission. Although severely decompensated heart failure may require hospitalization, it
is possible for patients to manage heart failure in the outpatient setting and learn to
identify the symptoms that indicate decompensation before emergency occurs. Coping
with heart failure greatly impacts self-care demands, and as proposed in the self-care
deficit theory of nursing, patients enter periods of fluctuating illness and health states that
correspond with varying degrees of self-care deficit and agency. The Advanced Practice
Nurse (APN) is uniquely prepared to assist patients with heart failure recover and
maintain self-care agency. The APN intervention of expert coaching and guidance creates
a dynamic, collaborative relationship with patients with the goal of restoring their selfcare abilities and preventing heart failure exacerbation and hospitalization.
This paper will discuss the relationship between the self-care deficit theory of
nursing and the APN intervention of expert coaching and guidance. It will begin with a
description of the clinical nursing problem of heart failure patients’ frequent
hospitalization when their self-care deficits outweigh their self-care abilities. Summary
of the self-care deficit theory of nursing and description of the expert coaching and
guidance intervention will follow. Finally, the paper will discuss the relationship between
the theory and the intervention. The congruence between nursing theory and practice is
realized in the relationship between the self-care deficit theory of nursing and the APN
intervention of expert coaching and guidance.
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Clinical Nursing Problem
Heart failure affects millions of Americans and is the most common reason for
hospital admissions among the elderly, accounting for over one million admissions and
costing $20 billion per year (Mueller, Vuckovic, Knox, & Williams, 2002; Stanley,
1997). Heart failure consumes copious health care resources, is the foremost
complication of heart disease, and is associated with high incidence of early and frequent
rehospitalization (Kegel, 1995). The majority of hospitalizations result from
decompensation of chronic heart failure, and data suggest about half of these
readmissions could be prevented (Artinian, Magnan, Sloan, & Lange, 2002; Mueller,
Vuckovic, Knox, & Williams, 2002).
Managing heart failure requires careful and frequent patient self-assessment for
signs and symptoms of exacerbation and prompt treatment to prevent hospitalization
(Kegel, 1995). Thus patients must be actively involved with their plan of care and need
access to ongoing education, assessment, and counseling (Kegel, 1995). The greatest
barriers to self-care are inadequate knowledge and understanding of disease process and
prescribed treatment, inadequate access to healthcare providers, and inadequate social
support (Davidson, Macdonald, Paull, Rees, Howes, Cockburn, & Brown, 2003; Mueller,
Vuckovic, Knox, & Williams, 2002; Stanley, 1997).
Following hospitalization for heart failure exacerbation, key clinical problems
leading to preventable rehospitalizations are inadequate patient and family education,
poor self-assessment skills, inadequate support systems, failure to seek medical attention
promptly when symptom reoccur, and noncompliance with diet and medication regimens
(Artinian, Magnan, Sloan, & Lange, 2002; Stanley, 1997). One way to prevent
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hospitalizations and to promote positive health outcomes in heart failure patients is to
ensure that the amount and quality of self-care used is appropriate for individual patients’
conditions (Artinian, Magnan, Sloan, & Lange, 2002). Substantial evidence suggests that
frequent hospitalizations for heart failure exacerbation can be prevented by Advanced
Practice Nurse (APN) intervention and coordinated disease management strategies
(Davidson, Macdonald, Paull, Rees, Howes, Cockburn, & Brown, 2003; Kegel, 1995;
McCauley, Bixby, & Naylor, 2006; Stanley, 1997).
APNs are particularly adept at facilitating self-management of heart failure by
collaborating with and coordinating care among care providers, providing education and
planning to prepare hospitalized patients for discharge, following up with discharged
patients, assessing access to resources, maintaining presence in the lives of heart failure
patients, and establishing therapeutic partnerships with patients and families (Davidson,
Macdonald, Paull, Rees, Howes, Cockburn, & Brown, 2003; Kegel 1995; McCauley,
Bixby, & Naylor, 2006). When heart failure patients’ self-care abilities overwhelm their
self-care deficits, it is possible to prevent hospitalization and manage heart failure in
outpatient setting.
Summary of the Theory
Purpose
This paper will use Chinn & Kramer’s (2008) guide to describe the self-care
deficit theory of nursing (Orem, 2001). Orem’s work on the self-care deficit theory of
nursing began in the 1950s when nursing curricula were based on conceptual models
from medicine, psychology, and sociology (Fawcett, 2001). She was motivated by the
desire to foster agreement about the proper focus of nursing and the need to clarify the
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domain and boundaries of nursing practice (Orem, 2001). Orem felt that nursing lacked
an organizing framework for its knowledge and hoped that formal articulation of the
foundations and essential elements of the self-care deficit theory of nursing would serve
to upgrade nursing education curriculums and enhance nursing’s disciplinary evolution
(Fawcett, 2001).
The self-care deficit theory of nursing asserts that human limitations in self-care
associated with states of illness give rise to the requirement for nursing care (Fawcett,
2001). Orem refined and formally described what nursing is and should be in the selfcare deficit theory of nursing, which has three constituent articulating theories: (a) the
theory of self-care, which describes why and how people care for themselves; (b) the
theory of self-care deficit, which explains why people require nursing; and (c) the theory
of nursing systems, which describes relationships that must be fostered and maintained
for effective nursing care (Fawcett, 2001; Orem, 2001). The self-care deficit theory of
nursing is a general theory, applicable across all nursing practice areas and situations in
which people require nursing care (Orem, 2001).
According to the self-care deficit theory of nursing, the special focus on human
beings is what distinguishes nursing from other human services (Orem, 2001). It follows
that the role of nursing in society is to assist individuals’ development and exercise of
their self-care abilities to the extent that they can adequately and completely provide for
their care requirements (Isenberg, 2001). According to the theory, individuals who cannot
adequately provide for their self-care requirements are experiencing a self-care deficit,
and it is this deficit that identifies individuals in need of nursing care. The theory’s
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purpose in formulating the self-care deficit theory of nursing is to describe when and why
nursing is needed (Isenberg, 2001).
Concepts
The self-care deficit theory of nursing implies two categories of human beings:
the agent of action and the object of action (Denyes, Orem, & SozWiss, 2001). The three
interrelated theories of the general self-care deficit theory of nursing identify and define
four concepts about individuals who require nursing care: self-care, self-care agency,
therapeutic self-care demand, and self-care deficit. The theory identifies and defines two
concepts about those who provide nursing service: nursing agency and nursing systems.
Orem proposes that human beings throughout the lifespan have self-care agency, which
she defines as the power to develop and exercise capabilities to know and meet self-care
requirements (Orem, 2001). According to the theory, self-care agency varies qualitatively
and quantitatively throughout the lifespan, and a self-care deficit exists when, for health
and health-care associated reasons, individuals’ self-care agency proves incapable of
meeting therapeutic self-care demands (Orem, 2001). The imbalance between a person’s
self-care agency and therapeutic self-care demand creates the need for nursing care.
Nursing agency is defined as the power of nurses to design and produce nursing care for
others. It follows that nursing agency extends to assist individuals with health-associated
self-care deficits to know and meet with assistance their self-care demands and to
exercise their powers of self-care agency (Orem, 2001).
In the latest edition of the self-care deficit theory of nursing, nursing is recognized
as a tripartite nursing system comprised of a professional-technical system dependent on
an interpersonal system and a societal system that provide the context for the nurse-
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patient relationship (Orem, 2001). The nursing system concept describes the evolution of
nursing to include details of the structure and process of providing nursing care to
individuals, families, and communities (Orem, 2001). Nurses make decisions about what
type of nursing system is appropriate to attend to a self-care deficit by asking who can
and should perform the self-care operations (Isenberg, 2001). The nurse then designs and
applies the appropriate system with the goal of empowering the person to meet their selfcare requirements. The continuum of nursing systems range from wholly compensatory if
the nurse provides for the self-care demand to supportive-educative if the nurse assists
the individual to develop agency, with a partly compensatory system falling in between
the two extremes when nurses both provide for and assist the patient to provide for selfcare demands (Isenberg, 2001).
Relationships, Structure, and Assumptions
The self-care deficit theory of nursing describes and explains the relationship
between self-care agency and therapeutic self-care demand, identifying a self-care deficit
when capabilities to engage in self-care are less than the demand for self-care (Isenberg,
2001). The theory states that nurses provide a therapeutic system when individuals are
identified with an existing or potential self-care deficit. The theory’s conceptual
framework treats the concept of the whole person as greater than the sum of the parts. For
Orem, the individual is an integrated whole person with varying degrees of self-care
capabilities informed by the individual’s internal physical, psychological, and social
nature (Chinn & Kramer, 2008). The theory assumes that restoration of self-care agency
is the desired goal and purpose of nursing. Additionally, the theory assumes individuals
are motivated by self-preservation to participate in the restoration of self-care agency.
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Application of the Theory: Nursing Care of Patients with Heart Failure
The theory implies that nursing actions are required to restore self-care ability and
provides comprehensive development of the self-care concepts, rendering the theory
applicable and useful as a guide to nursing practice areas involving individuals across the
lifespan experiencing health or illness, as well as to nursing interventions designed for
health promotion, health restoration, and health maintenance (Isenberg, 2001). The
theory’s application to nursing practice is well documented in the literature across a wide
range of age groups, practice settings, and nursing systems of care (Isenberg, 2001). This
paper will consider the theory’s relevance to the heart failure patient population, which is
also well documented in the literature.
Description of the APN Intervention: Expert Coaching & Guidance
Coping with heart failure greatly impacts self-care demands, and as proposed in
the self-care deficit theory of nursing, patients enter periods of fluctuating illness and
health states that correspond with varying degrees of self-care deficit and agency. The
Advanced Practice Nurse (APN) is uniquely prepared to assist patients with heart failure
recover and maintain self-care agency. Expert coaching and guidance is an APN core
competency and describes a complex, invisible process wherein the APN provides
education, surveillance, and reassurance to equip patients with the tools to manage their
health and illness transitions (Spross, 2009). Spross defines APN coaching as “a
complex, dynamic, collaborative and holistic interpersonal process that is mediated by
the APN-patient relationship and the APN’s self-reflective skills” (Spross, 2009, p. 167).
In the process of expert coaching and guidance, the APN integrates self-reflection and
clinical expertise with patients’ understandings, experiences and goals to accomplish
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therapeutic and educational goals (Spross, 2009). The interaction of self-reflection with
technical, clinical, and interpersonal competence (Figure 1) drives the expansion and
refinement of the APN’s expertise in this process (Spross, 2009).
The intervention is termed coaching and guidance because these terms imply the
existence of a relationship that is fundamental to effective patient education and teaching
(Spross, 2009). A coach facilitates safe passage through transition, and the work of
coaching is complex and requires interpersonal confidence and competence. In the model
of APN expert coaching and guidance, the APN integrates physical examination,
interviewing, and intuition to acquire the patient’s perspective and reflect or translate this
understanding back to the patient (Spross, 2009). The APN involves the patient’s
significant other as appropriate. As coach, the APN helps patients uncover opportunities
for personal growth and assists them to clarify goals, decide what matters most to them,
acknowledge trade-offs and losses, and develop coping strategies (Spross, 2009). The
term coaching applied to the nurse-patient relationship permits both parties to experience
intense emotion and it simultaneously connotes the one-sided aspect and mutuality in the
relationship (Spross, 2009). Coaching is multidimensional involving cognitive, spiritual,
behavioral, physical, and social aspects of the human experience, and competence in its
administration requires a tailored approach to meet each individual patient’s needs
(Spross, 2009).
In the setting of heart failure, the APN can provide expert coaching and guidance
to address patient self-assessment, adherence to medication and diet regimen, knowledge
of disease maintenance, social support, and resource utilization (Kegel, 1995; McCauley,
Bixby, & Naylor, 2006). The APN is uniquely equipped with advanced communication
Self-Care Deficit Theory
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skills to build therapeutic relationships with patients. The APN can elicit the patient’s
thoughts, perspectives, expectations, values, and goals; provide patients with self-care
information to enable participation in health decisions; and develop disease management
plans collaboratively with patients (Spross, 2009).
The APN can conduct individualized patient assessment to identify signs and
symptoms of heart failure exacerbation and teach the patient how to problem solve and
identify emergency (McCauley, 2006). The education plan in the expert coaching and
guidance model considers the patient’s knowledge base, learning style, and capabilities. It
is important for patients to understand the importance of adhering to disease maintenance
regimen even when symptoms subside (McCauley, 2006). APNs use multiple strategies
to improve patients’ self-management including education about the chronic nature of
heart failure, practical solutions such as pill organizers and patient-specific prompts to
remember to take them, detailed nutrition counseling sessions (McCauley, 2006). The
APN uses patient-centered communication to learn the patient’s beliefs about their illness
and treatment, perceptions of severity of the condition because studies have shown that
the patient’s subjective interpretation of the severity of disease is often more influential
than objective reality (Davidson, Macdonald, Paull, Rees, Howes, Cockburn, & Brown,
2003; Spross, 2009).
The effectiveness of telemanagement as a component of the expert coaching and
guidance intervention is well-documented in the literature (Kegel, 1995; Mueller,
Vuckovic, Knox, & Williams, 2002; Ryder, 2005). This is a particularly effective
strategy for reinforcing and clarifying how to take and follow medication regimen and
disease management strategies that a patient may have received at time of discharge from
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the hospital or during a physician visit. Patients experiencing heart failure
decompensation are under duress and typically forget two thirds of diagnosis and
treatment explanations and half of instructional statements immediately after physician
visit (Davidson, Macdonald, Paull, Rees, Howes, Cockburn, & Brown, 2003).
Discussion of the Theory as Supportive of the Intervention
Since heart failure is a chronic disease characterized by exacerbations and disease
maintenance, self-care is important to optimize outcomes. Self-care behaviors include
adherence to medication and diet regimen, seeking assistance when symptoms indicate
exacerbation, and performing daily weights (Kegel, 1995; McCauley, 2006). The selfcare deficit theory of nursing identifies three sets of limitations for self-care: limitations
of knowing, limitations of judgment, and limitations on result-achieving courses of action
(Orem, 1995). All three sets of limitations are present to varying degrees in heart failure
patients. The nursing system that seems to be most applicable for addressing these
limitations for maintenance of heart failure is the supportive-educative system. The selfcare deficit theory of nursing describes general methods of nursing action in the
supportive-educative system, including support, guidance, provision of developmental
environment, and teaching (Orem, 1995). Several articles documented Orem’s general
theory as a framework for studying, describing, and developing supportive-educative
nursing interventions to prevent potential self-care deficits and enhance self-care agency
for heart failure patients in the outpatient setting (Artinian, Magnan, Sloan, & Lange,
2002; Jaarsma, Abu-Saad, Dracup, & Halfens, 2000; Jaarsma, Halfens, Senten, Saad, &
Dracup, 1998).
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Coping with heart failure greatly impacts self-care demands (Davidson,
Macdonald, Paull, Rees, Howes, Cockburn, & Brown, 2003). Phases of adjusting to heart
failure include acceptance, adjustment to crisis and diagnosis, and decision to resume
living with new knowledge of the condition (Davidson, Macdonald, Paull, Rees, Howes,
Cockburn, & Brown, 2003). APNs can promote self-care by providing information within
a supportive-educative framework that is consistent with the individual’s phase of
adjustment. In particular, an Orem-inspired supportive-educative nursing system has
facilitated several programs designed to enhance patients’ abilities to perform self-care
operations to maintain a prescribed medication regimen and to monitor and manage
symptoms (Artinian, Magnan, Sloan, & Lange, 2002; Fujita & Dungan, 1994; Schneider,
Hornberger, Booker, Davis, Kralicek, 1993). One example is the utilization of a diuretic
treatment algorithm, in which APNs and patients agree on a set of signs and symptoms of
decompensation for the patient to use to determine when to take an extra dose of diuretic
and when to see a physician (Meuller, Vuckovic, Knox, & Williams, 2002).
During periods of exacerbation and in the instance of end stage heart failure
patients who are under consideration for heart transplant, the wholly compensatory and
partly compensatory nursing systems become more applicable, but these scenarios are
less documented in the literature. Casida, Peters, & Magnan (2009) eloquently propose
the use of self-care deficit theory of nursing as a framework to identify and organize
nursing care for hospitalized heart failure patients on left-ventricular assist devices and to
assess readiness for discharge.
In the expert coaching and guidance intervention, the APN individualizes
strategies for changing health behaviors, fosters initiative, encompasses an unambiguous
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treatment plan, and incorporates patients’ significant others (Davidson, Macdonald, Paull,
Rees, Howes, Cockburn, & Brown, 2003). Evidence suggests that APN expert coaching
and guidance, in conjunction with coordinated care and collaboration among providers
can decrease hospital readmission in heart failure patients by as much as 50% (Mueller,
Vuckovic, Knox, & Williams, 2002). Through expert coaching and guidance, the APN
uses multiple strategies to simultaneously address heart failure patients’ limitations of
knowing, limitations of judgment, and limitations of result-achieving courses of action
(McCauley, 2006). Significant increases in self-care agency occur when education and
support are provided and when patients perceive themselves to be a partner in the
development of their treatment plans (Artinian, Magnan, Sloan, & Lange, 2002).
Concluding Summary of the Relationship Between the Theory and the Intervention
The congruence between nursing theory and practice is realized in the relationship
between the self-care deficit theory of nursing and the APN intervention of expert
coaching and guidance. The expert coaching and guidance APN intervention is a perfect
practical application of the self-care deficit theory of nursing. The goal of the expert
coaching and guidance intervention is to restore patients’ ability to provide for their selfcare needs. As coach, the APN helps patients discover opportunities for personal growth
and assists them to clarify goals, decide what matters most to them, acknowledge tradeoffs and losses, and develop coping strategies (Spross, 2009). The APN coach can equip
heart failure patients with the knowledge and tools to recognize their self-care agency and
self-care deficits.
Heart failure is characterized by exacerbations and remissions (Stanley 1997).
Coping with heart failure greatly impacts self-care demands, and as proposed in the self-
Self-Care Deficit Theory
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care deficit theory of nursing, patients enter periods of fluctuating illness and health states
that correspond with varying degrees of self-care deficit and agency. The Advanced
Practice Nurse (APN) is uniquely prepared to assist patients with heart failure recover
and maintain self-care agency. By maintaining the commitment to the coaching and
guidance process, the APN establishes a supportive and therapeutic partnership with heart
failure patients that allows for fluctuations in the patient’s ability to self-manage a labile
chronic disease in the outpatient setting (Ryder, 2005). The APN coach can expertly
individualize strategies in accordance with patients’ varying degrees of confidence, fear,
knowledge, abilities, and resources within a supportive-educative nursing framework
(Orem, 1995; Spross, 2009).
Increases in self-care behaviors as a result of expert coaching and guidance from
an APN are well-documented in the literature (Artinian, Magnan, Sloan, & Lange, 2002;
Davidson, Macdonald, Paull, Rees, Howes, Cockburn, & Brown, 2003; McCauley, 2006;
Ryder, 2005). Specifically, after APNs addressed self-care limitations, heart failure
patients demonstrated improved and effective self-care decision making in response to
signs and symptoms of heart failure exacerbation, promptly and appropriately seeking
medical care (Artinian, Magnan, Sloan, & Lange, 2002; Davidson, Macdonald, Paull,
Rees, Howes, Cockburn, & Brown, 2003). Additionally, heart failure patients
demonstrated improved understanding of their disease process and better selfmanagement relative to medication compliance and weight monitoring in response to
APN expert coaching and guidance interventions (Artinian, Magnan, Sloan, & Lange,
2002).
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The relationship between knowledge and self-care behavior is significant and
documented throughout the literature without exception, revealing the practical
application of the self-care deficit theory of nursing. The theory proposes that knowledge
is a power that enables self-care and that strategies to address knowledge limitations must
be specific and organized around known self-care requisites (Artinian, Magnan, Sloan, &
Lange, 2002). The APN intervention of expert coaching and guidance is uniquely suited
to apply the self-care deficit theory in practice. Through the intervention of expert
coaching and guidance, the APN considers the patient’s knowledge base, learning style,
and capabilities to develop disease management plans collaboratively with patients
(McCauley, 2006; Spross, 2009). Heart failure patients experience a higher level of selfcare agency as a result of expert coaching and guidance from an APN.
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References
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Figure 1. Model of the APN intervention of expert coaching and guidance.
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