Nursing Theorist:
Dorothea Orem
Self-Care Deficit Theory
Presented by MSN Students:
Cheryl L Holz RN, BSN
Anna Marshall RN, BSN
Dorothea Orem
1914- June 22,2007
Born in Baltimore, Maryland
Died at home in Skidaway Island
Education:
Diploma (early 1930's) Providence Hospital School of
Nursing, Washington, DC
BSN Ed. (1939) and MSN Ed. (1945) from the Catholic
University of America, Washington, DC.
Credentials & Background
Honorary Doctorates:
Doctor of Science from Georgetown University
(1976) and Incarnate Word College in San Antonio,
Texas (1980)
Doctor of Humane Letters from Illinois Wesleyan
University, Bloomington, Illinois (1988)
Doctor Honoris Causae, University of MissouriColumbia (1998).
Credentials & Background
Special Awards:
Catholic University of America Alumni Achievement
Award for Nursing Theory (1980)
Linda Richards Award, National League for Nursing
(1991)
Honorary Fellow of the American Academy of Nursing
(1992).
Early Nursing Experiences
 Clinical
 OR
 Private Duty Nursing (home & hospital)
 Staff nursing (pediatric & adult medical and surgical units)
 Evening supervisor-ER
 Education:
 Biological science teacher
 Assistant Director of School of Nursing
 Consulting:
 Indiana St. Board of Health (1949-1957)
 Office of Education, US Department of Health, Education,
and Welfare (1957-1959)
Theoretical Sources & Influences
 Eugenia K. Spaulding-great friend & teacher only
 Cites no particular nursing leader as a direct influence on
her work.
 Does cite many other nurses’ works in terms of their
contributions to nursing:
 Abdullah, Henderson, Johnson, King, Levine, Nightingale,
Orlando, Peplau, Riehl, Rogers, Roy, Travelbee, and Weidenbach,
et al
 Cites numerous other authors from other disciplines:
 Chester Barnard, Rene’ Dubos, Robert Katz, Ernest Nagel, Hans
Selye, Ludwig von Bertalanffy, et al
Theoretical Sources & Influences-cont’d
Human organization, action theory
An area of philosophy concerned with theories
about the processes causing intentional/willful
human bodily movements of more or less complex
kind
http://en.wikipedia.org/wiki/Philosophy_of_action, retrieved 10/10/08
Theoretical Sources & Influences-cont’d
 The works of:
Aristotle
Thomas Aquinas
Barnard (1962)
Kotarbinski (1965)
Macmurray (1957)
Parson, Bales, and Shils (1953)
B.J.F Lonergan’s Insight(1958) [on reflective thinking],
Assays by Wallace (1979, 1983) [for recent
clarifications].
Orem, D.E (1987). Orem’s general theory of nursing. (p.73)
Origins
1949-1959
Began to develop ideas regarding
the uniqueness of nursing
In effort to formalize a framework by which to
organize nursing knowledge, she asked the
following questions…
Origins
“What is nursing?”
“How was it different from other disciplines?
“How was it similar?”
“What is the domain and what are the
boundaries of nursing as a field of practice
and a field of knowledge?”
“What condition exists when judgments are
made that people need nursing?”
Ideas evolved from:
 Unique experiences of her personal nursing career
 Observations in practice
 Study of formal logic and metaphysics
 Use of resources from many fields
 Abilities in methods of reflect and questioning
 Collaborations with students, practitioners,
researchers, educators, administrators and scholars
Formalization
1960-1980
 through extensive reading and self-reflection
collaborations with students, practitioners,
researchers, educators, administrators and
scholars
Publications
 1971-Nursing: Concepts of Practice
 Editor for Nursing Development Conference Group
(NDCG)-prepared & later revised Concept
Formalization in Nursing: Process and Product
 1980, 1985, 1991, 1995, and 2001- subsequent
editions of Nursing Concepts of Practice
 1984: Orem retired
Practice
First documented use:
1973-John Hopkins Hospital
In nurse-managed clinics
Various clinical populations & age groups
Neonates to the elderly
Health promotion practices & care of the sick
(The nursing management of pertussis was
described from the SCDNT perspective).
Practice-cont’d
 Ethnically & culturally diverse populations
Orem’s SCDNT: translated into Italian, French,
Spanish, Dutch, and Japanese
Currently, translations of some or all of her most
recent work in Germany, Thailand, and Norway, et
al.
Used throughout the world
Great Britain, Taiwan, Thailand, Japan, Korea, Canada,
Australia, New Zealand, South Africa, Israel, Germany,
Spain, Italy, France, Belgium, the Netherlands, Bolivia,
Colombia, Uruguay, and Mexico
Central Philosophy
The philosophy of Orem’s SCDNT is based
upon:
“patients wish to care for themselves”
“moderate realism”
Conceptual Theoretical Model
R=relationship; <=deficit relationship, current or projected
(Tomey & Alligood, 5th Ed., 2002, pg 192)
R
Conditioning
Factors
Self-Care
R
R
Self-Care
Agency
<
Self-Care
Demands
Deficit
R
R
Conditioning
Factors
Nursing
Agency
Conditioning
Factors
Internal/External Stimuli
SCDNT: A General Theory Composed of
Three Related Theories
 THEORY OF SELF-CARE:
How and why people care for themselves.
 THEORY OF SELF-CARE DEFICIT:
Describes and explains why people can be helped
through nursing.
 THEORY OF NURSING SYSTEMS:
Describes and explains relationships that must be
brought about and maintained for nursing to be
produced.
Three Types of Nursing Systems
 Wholly Compensatory
 Doing for the patient
 Partially Compensatory
 Helping the patient do for him/herself
 Supportive-Educative
 Helping the patient learn to do for him/herself
Concepts & Principles
SELF-CARE:
Activities individuals do on a daily basis within
time frames, on their own behalf
In the interest of maintaining life & healthful
functioning
To continue personal development & well being
Concepts & Principles-cont’d
 SELF-CARE REQUISITES (SCRs):
 Groups of needs or requirements
 Classified as:
UNIVERSAL SELF-CARE REQUISITES
 those needs all individuals have (six SCR common to men,
women, and children)
DEVELOPMENTAL SELF-CARE REQUISITES
 those needs that relate to the development of the individual
HEALTH DEVIATION REQUISITIES
 those needs that arise as a result of an individual’s condition
Concepts & Principles-cont’d
 THERAPEUTIC SELF-CARE DEMAND:
 Controlling or managing factors identified in the requisites;
the values of which are regulatory of human functioning
(air, water, and food)
 Fulfilling the activity element of the requisite
(maintenance, promotion, prevention, and provision)
Concepts & Principles-cont’d
SELF-CARE AGENCY:
“Complex acquired ability to meet one’s
continuing requirements for care that regulates
life processes, maintains or promotes integrity of
human structure and functioning and human
development, and promotes well-being.”
(Marriner-Tomey, 1994, pg. 184)
Concepts & Principles-cont’d
AGENT:
“The person taking action”
SELF-CARE AGENT:
“The provider of self-care”
DEPENDENT-CARE AGENT:
“The provider of infant care, child care, or
dependent adult care”
Concepts & Principles-cont’d
 SELF-CARE DEFICIT:
When a patient is very unable to meet their own
self-care requisites (refer to slide 21)
NURSING AGENCY:
Educated nurses
Ability to act, know, & help patients
Concepts & Principles-cont’d
NURSING DESIGN:
Professional function (done before and after
nursing diagnosis and prescription)Basis of reflective practical judgments
PurposeProvide guides for achieving needed and foreseen
results in production of nursing toward the
achievement of nursing goals
Concepts & Principles-cont’d
NURSING SYSTEMS:
Constructed through actions of nurses and nursespatients.
Deliberate practical actions of nurses
Performed at times in coordination with actions of
their patients to know & meet components of
their patient’s therapeutic self-care demands.
To protect and regulate the exercise or
development of patient’s self-care agency
Conceptual Theoretical Model
R=relationship; <=deficit relationship, current or projected
(Tomey & Alligood, 5th Ed., 2002, pg 192)
R
Conditioning
Factors
Self-Care
R
R
Self-Care
Agency
<
Self-Care
Demands
Deficit
R
R
Conditioning
Factors
Nursing
Agency
Conditioning
Factors
Fawcett’s Criteria & Pertinent
Questions for Evaluation of
Nursing Theories
Explication of Origins
Are the philosophical claims on which the
nursing model is based explicit?
 Yes, Orem’s Self-Care Framework is based on philosophical,
theoretical, and scientific knowledge about human
behavior
 Philosophical claims stated in the form of: assumptions,
presuppositions, and premises
 Orem: “Philosophy will help you think about things, but
will not tell you your subject matter”
Explication of Origins
 Are the scholars who influenced the model author’s
thinking acknowledged and are bibliographic citation
given?
 YES; scholars from a variety of disciplines cited
Bibliographical citations provided.
 Aristotle, Thomas Aquinas, T. Parsons et al (1953), J. Macmurray
(1957), B.J.F Lonergan (1958), M.B. Arnold (1960), M. Black
(1962), T. Kotarbinski (1965), R. Harre (1970), Paul Weiss (1980),
William A. Wallace (1983, 1996)
 The Nursing Development Conference Group
 Orem Study Group
Comprehensiveness of Content
Does the nursing model provide adequate
descriptions of all four concepts of nursing’s
metaparadigm?
 Yes, the descriptions of all four of nursing’s metaparadigm
concepts are adequate.
 Nursing-Person Emphasis
Comprehensiveness of Content
Do the relational propositions of the nursing
model completely link the four metaparadigm
concepts?
 Yes, linkages are specified between concepts throughout
the editions
 However, only ONE statement links all 4 concepts- in the
2nd edition of Orem’s book (1980)
“Nursing is made or produced by nurses. It is a
service, a mode of helping human beings…Nursing’s
form or structure is derived from actions deliberately
selected and performed by nurses to help individuals
or groups under their care to maintain or change
conditions in themselves or their environments. This
may be done by individuals or groups through their
own actions under the guidance of a nurse or
through the actions of nurses when persons have
health-derived or health-related limitations that
cannot be immediately overcome”
(Orem, 1980, p.5)
Comprehensiveness of Content
Is the researcher given sufficient direction about
what questions to ask and what methodology to
use?
 Purpose: to develop knowledge for the practical sciences
of nursing…
 Methods associated with: Empiricist research paradigm,
Interpretive research paradigm –
most consistent with Orem’s Framework
 See Fawcett Table 8-2, Table 8-3 for examples
Comprehensiveness of Content
Does the educator have sufficient guidelines to
construct a curriculum?
 The framework has been used as a conceptual guide to
nursing curriculums in a number of programs:
associate degree,
diploma,
baccalaureate,
masters and doctorate levels.
Comprehensiveness of Content
Does the administrator have sufficient guidelines
to organize and deliver nursing services?
 Yes, the Self-Care Framework provides ideas to guide:
1. The focus of nursing in the health-care institution
2. The purpose of nursing services
3. Characteristics of personnel
4. Settings for nursing services
5. Management strategies and administrative policies
Comprehensiveness of Content
 Is the practitioner given sufficient direction to be
able to make pertinent observations, decide that an
actual or potential need for nursing exists, and
prescribe and execute a course of action that
achieves the goal specified in a variety of practice
situations?
 Purpose: to help people with health-related self-care deficits
 Concepts encompass people across the lifespan and in a
variety of diverse settings
 Nursing Process: Professional-Technological Operations of
Nursing Practice (see Fawcett Table 8-1)
Logical Congruence
 Does the model reflect more than one world view?
 No, only that of ‘reciprocal interaction’ is noted
 Does the model reflect characteristics of more than
one category of nursing knowledge?
 Characteristics are congruent with classification as a
developmental model.
Logical Congruence
 Do the components of the model reflect logical
translation or reformulation of diverse
perspectives?
 Yes, the content of Orem’s Framework is logically
congruent with her philosophical claims
 Orem’s thinking was influenced by a variety of
perspectives and resources from a range of disciplines
Generation of Theory
 What theories have been generated from the
nursing model?
 Orem’s Self-Care Deficit Theory of Nursing
 Middle-Range Theory of relating factors & concepts of selfcare agency & dependent-care agency of school-aged
children & their mothers. (Gaffney & Moore, 1996).
 Middle-Range Theory of Testicular Self-Examination
(Fessenden, 2003).
Credibility of the Nursing Model:
social utility, social congruence, social
significance
 Are education and special skill training required
before applying the nursing model in nursing
practice?
 Yes, it is a rather unique framework in: focus, content, style
and vocabulary.
 Need to learn specific “style of thinking and
communicating nursing” (Orem, 2001, p.137)
 Familiarity with language of the theories of deliberate
human action enhances understanding of Orem’s work.
Credibility of the Nursing Model:
social utility, social congruence, social
significance
 Is it feasible to implement practice protocols
derived from the nursing model and related
theories?
 Despite the need for special training and education, the
implementation of Self-Care Framework-based practice
protocols is feasible.
 Patients of all ages, across diverse practice settings
Credibility of the Nursing Model:
social utility, social congruence, social
significance
 To what extent is the nursing model actually used to
guide nursing research, education, administration,
and practice?
 Actual application of Orem’s model takes many forms in all
of the above arenas.
 World-wide use: clinics, hospitals, home-health, health
promotion practices & screenings
Credibility of the Nursing Model:
social utility, social congruence, social
significance
 Does the nursing model lead to nursing activities
that meet the expectations of the public and health
professionals of various cultures and in diverse
geographic regions?
 Yes, it does; however, the emphasis on self-care may not
be completely congruent with some people’s expectations
of nursing practice
Credibility of the Nursing Model:
social utility, social congruence, social
significance
 Does the application of the nursing model, when
linked with relevant theories and appropriate
empirical indicators, make important and positive
differences in the health conditions of the public?
 Yes, much empirical evidence supports Orem’s claim that
nurses contribute to “maintaining health, preventing
disease, and disability and restoring or maintaining life
processes” by overcoming “health-associated human
limitations for engagement in self-care or dependent-care”
(Orem, 2001, p. 81).
Contributions to the Discipline of Nursing
 What is the overall contribution of the nursing
model to the discipline of nursing?
 Orem’s framework presents an optimistic view of patients’
contributions to their health care and an explicit focus on
what matters to nurses.
 Orem has identified the domain and boundaries of nursing
as a science and an art as well as nursing’s unique
contribution to health-care.
Contrast of Theories
Conceptual Model
Person
Environment
Health
Nursing
Orem’s
Self-Care
Framework
Self-care agent
Therapeutic self-care demand
made up of:
1-universal SCRs
2-developmental SCRs
3-Health deviation SCRs
The person’s external
environment
Soundness or wholeness of
developed human structures &
of bodily & mental functioning
Definition: a helping service,
creative effort to help people
Goal: help people to meet their
own therapeutic self-care
demand
Actions: wholly/partly,
compensatory, supportiveeducative nursing systems.
Assist by acting for or doing,
guiding, physical &/or
psychological support, providing
a developmental environment,
teaching.
Roger’s Science of
Unitary Human
Beings
A unitary human being, a
patterned, open, pandimensional
energy field
A patterned, open,
pandimensional energy field
An expression of the life process
Definition: A learned profession
that is both a science and an art.
Goal: Help people achieve
maximum well-being
Action: Deliberative mutual
patterning that involves
environmental patterning to
promote helicy, integrality, and
resonancy.
King’s
Interacting Systems
Framework
Personal system: Focus on
perception, self, growth &
development, body image, time,
space, learning
Interpersonal system:
Focus on interaction,
communication, transaction,
role, stress, coping.
Social system:
Focus on organization,
authority, power, status,
decision-making, and control.
Internal/external
Dynamic life experiences of a
human being.
Ability to function in social roles
Definition: Perceiving, thinking,
relating, judging, and acting vis-àvis the behavior of individuals
who come to a nursing situation.
Goal: Help individuals maintain
their health so they can function
in their roles
Actions: A process of action,
reaction, interaction, and
transaction directed toward
establishment of goals and goal
attainment.
Peer Discussion
“We need to order home health for Mr. Orem before he is
discharged.”
The Orem Model of Nursing or Self Care Deficit Nursing Theory
states nurses have to administer care when the patients cannot
provide care to themselves.
Eastern Kansas VA
Home Based Primary Care (HBPC)
Mission Statement
“…to provide compassionate care to veterans at home
and in the community, promoting optimal
independence of the veteran and support to the
caregiver.”
References
Chinn, P., & Kramer, M. (1991). Theory and Nursing (3rd Ed.). St. Louis: Mosby.
Fawcett, J. (2005). Contemporary Nursing Knowledge: Analysis and Evaluation of
Nursing Models and Theories (2nd Ed.). Philadelphia, PA: F.A. Davis Company.
Hartweg, D. L. (1995). Dorothea Orem: Self-Care Deficit Theory. In C.M.
McQuiston & A.A. Webb (Eds.), Foundations of Nursing Theory: Contributions
of 12 Key Theorists (pp. 139-202). Thousand Oaks, CA: Sage Publications, Inc.
Marriner-Tomey, A. (1994). Nursing Theorists and Their Work (3rd Ed.). St Louis:
Mosby.
Marriner-Tomey, A., & Alligood, A. (2002). Nursing Theorists and Their Work (5th
Ed.). St Louis: Mosby.
Orem, D. E. (2001). Nursing: Concepts of Practice (6th ed.). St. Louis, MO: Mosby,
Inc.
Wikipedia: Philosophy of action. (Oct. 7, 2008). Retrieved October 10, 2008, from
Wikipedia: http://en.wikipedia.org/wiki/Philosophy_of_action