1. D OROTHEA O REM ’ S S ELF -C ARE F RAMEWORK Zachary Medler Emily Williams Sara Kinne

2. Dorothea Orem, 1914-2007

3. I SSUES AND P URPOSE Questions or Problems to Solve

4. o Our assignment is to compare and contrast nursing models while working effectively in an on-line group. We also need to demonstrate the use of the critical thinking process using the elements of reasoning. o Our group has chosen to analyze Dorothea Orem’s Self- Care Framework, also known as the Self-Care Deficit Theory of Nursing. o In today’s world, people are living longer, becoming sicker and hospital stays are much shorter then they use to be. To understand and use Orem’s theory is of great benefit as the need for self-care to maintain optimal health and the responsibility of caring for oneself and their dependents is increasing.

5. Orem’s Self-Care Framework is broken down into self-care self-care agency power components basic conditioning factors therapeutic self-care demand self-care deficit nursing agency implications for nursing practice.

6. S ELF -C ARE Self-care is voluntary activities that people perform to take care of themselves and their environment to maintain life, health and well- being.

7. S ELF -C ARE A GENCY A self-care agency is an individual’s ability “to determine the presence and characteristics of specific requirements for regulating their own functioning and development, make judgments and decisions about what to do, and perform care measures to meet specific self- care requisites” (Kearney-Nunnery, 2008, p. 59). A self-care agency is acquired and can be affected by many variables, such as one’s environment, age, developmental state, life experience, health and available resources.

8. P OWER C OMPONENTS According to Kearney-Nunnery (2008) the person’s ability to perform self-care is influenced by 10 power components: Ability to maintain attention and exercise requisite vigilance with respect to self as self-care agent, and internal and external conditions and factors significant for self-care. Controlled use of available physical energy that is sufficient for the initiation and continuation of self-care operations. Ability to control the position of the body and its parts in the execution of the movements required for the initiation and completion of self-care operations. Ability to reason within a self-care frame of reference.

9. P OWER C OMPONENTS (C ON ’ T ) Motivation. Ability to make decisions about care of self and to operationalize these decisions. Ability to acquire technical knowledge about self-care from authoritative sources, to retain it, and to operationalize it. A repertoire of cognitive, perceptual, manipulative, communication, and interpersonal skills adapted to the performance of self-care operations. Ability to order discrete self-care actions or action systems into relationships with prior and subsequent actions toward the final achievement of regulatory goals of self-care. Ability to consistently perform self-care operations, integrating them with relevant aspects of personal, family, and community living.

10. B ASIC C ONDITIONING F ACTORS According Kearney-Nunnery (2008) a person’s ability to perform self-care is also influenced by 10 internal and external factors. These are called basic conditioning factors and include: age gender developmental state health state sociocultural orientation health-care system factors family system factors patterns of living environmental factors resource availability and adequacy.

11. T HERAPEUTIC S ELF -C ARE D EMAND Therapeutic self-care demands are actions that individuals need to perform at certain times or over a course of time to maintain life, health, and well-being and to meet all of an individual’s known self-care requisites. There are three types of self-care requisites: universal self-care developmental self-care health deviation self-care

12. U NIVERSAL SELF - CARE REQUISITES Universal self-care requisites are “actions that need to be performed to maintain life processes, the integrity of human structure and function, and general well-being” (Kearney-Nunnery, 2008, p.60). Examples of universal self-care requisites include air, water, and food, elimination, balance between activity and rest and between social interaction and solitude, prevention of harm and promotion of normalcy.

13. D EVELOPMENTAL SELF - CARE REQUISITES Developmental self-care requisites are “actions that need to be performed in relation to human developmental processes, conditions, and events and in relation to events that may adversely affect development (Kearney-Nunnery, 2008, p.60). Examples of these requisites include death of a loved one, adjusting to a new job, adjusting to body changes, toilet training a child and learning healthy eating.

14. H EALTH DEVIATION SELF - CARE REQUISITES Health deviation self-care requisites are “actions that need to be performed in relation to genetic and constitutional defects, human structural and functional deviations and their effects, and medical diagnostic and treatment measures prescribed or performed by physicians (Kearney- Nunnery, 2008, p.60). These requisites are required in conditions of illness, injury, or disease. Examples are obtaining appropriate medical care, effectively caring out subscribed treatments or medications, learning about your condition and how to deal with it and live with it if it’s a chronic condition.

15. S ELF -C ARE D EFICIT The self-care deficit is an imbalance between the self-care agency and the therapeutic self-care demand. A person’s self-care agency is unable to identify and care for all of their self-care demands. When a person cannot meet their self- care needs due to limitations there is a deficit. Nursing interventions are beneficial when a health related situation limits an individual’s ability to care for oneself or creates a situation where the individual’s knowledge is not sufficient enough to maintain their own health and wellness. For nursing to be needed there needs to be a self-care deficit.

16. N URSING A GENCY Nursing agency is a characteristic that allows nurses to know and help others to know their therapeutic self-care demands, meet them and positively affect the development of their self-care agency. When a nursing agency is activated, a nursing system is produced. A nursing system is thought out actions carried out by the nurse or patient in efforts to meet the patient’s therapeutic self-care demands and positively affect the development of the patient’s self-care agency or dependent-care agency. There are 3 types of compensatory systems: total partial educative/supportive The goal of nursing is to help people meet their therapeutic self-care demands through the application of nursing systems.

17. N URSING A GENCY - TYPES Total compensatory support is when the nurse provides all the care for the patient. The patient is unable to care for themselves.

18. N URSING A GENCY - TYPES Partial compensatory support is when both the nurse and the patient provide in the self-care requirements.

19. N URSING A GENCY - TYPES Educative/ supportive compensatory support is when the nurse is only the educator, consultant or resource person and the patient provides all of their own self-care.

21. I MPLICATIONS FOR N URSING P RACTICE Nurse’s actions are intended to help people meet their own and their dependents therapeutic self-care demands. Orem’s practice approach to ensure this is called Professional-Technologic Operations of Nursing Practice. It includes case management operations, diagnostic operations, prescriptive operations, regulatory operations and control operations. In case management operations the nurse uses a case management method to direct each of the nursing diagnostic, prescriptive, regulatory, and control operations. The nurse maintains an overview of the interrelationships between the social, interpersonal, and professional technological systems of nursing. They also use appropriate tools to collect and document information, and to measure the quality of nursing.

22. I MPLICATIONS FOR N URSING P RACTICE ( CON ’ T ) In diagnostic operations the nurse determines the unit of service for nursing practice and why the patient needs nursing. They gather demographic information about the patient and information about the type and limitations of their health-care situation and nursing’s authority within those boundaries. In prescriptive operations the nurse collaborates with the patient and if appropriate their family to identify all care measures needed to meet all therapeutic self- care demands. They also identify the roles to be played by the nurse or nurses, patient and dependent or dependents in meeting the therapeutic self-care demands and in regulating the patient’s development of self-care agency or dependent-care agency.

23. I MPLICATIONS FOR N URSING P RACTICE ( CON ’ T ) The regulatory operations include design of nursing systems for performance of regulatory operations, planning for regulatory operations and production of regulatory care. In regulatory operations: design of nursing systems for performance of regulatory operationst he nurse designs systems (actions/ interventions) and chooses whether to use the wholly compensatory, partially compensatory or supportive-educative nursing system depending on who can or should perform the self- care activities. The systems are then implemented using one or more of the following: acting or doing for the patient, providing a developmental environment, supporting the patient psychologically, guiding the patient and teaching the patient. In regulatory operations: planning for regulatory operations the nurse determines what is needed to carry out the actions selected for the patient. Such as what time and place, necessary environmental conditions, equipment, supplies, the number and qualifications of nurses and other health-care providers needed to carry out the systems and evaluate the effects, the organization and timing of tasks to be performed and designation of who is to perform the tasks.

24. I MPLICATIONS FOR N URSING P RACTICE ( CON ’ T ) In regulatory operations: production of regulatory care nursing systems are produced by the actions of the nurses and patients during their encounters. The nurse produces and manages the selected nursing systems and methods of helping for as long as the patient has a self-care or dependent- care deficit. They do this by performing and regulating or assisting patient’s with their self/ dependent-care tasks, coordinating self/ dependent care tasks performance, helping patients, their families and others bring about systems of daily living for patients that support the completion of self/ dependent-care. Also by guiding, directing and supporting patients in their exercise or in their withholding of their self/ dependent-care agency, stimulating patient’s interests in self/dependent-care, by being available when questions arise, supporting and guiding patients in learning activities and as they experience illness or disability and their need for change to meet new self-care requisites. In control operations the nurse determines if the nursing system that was created is produced and if there is a fit between the current subscription for nursing and the nursing system being used. Nurses ensure the patient’s functioning is achieved through performance of care measures to meet their self-care demand and their use of self/dependent- care agency is being properly regulated. They also determine if developmental change is in the process and is adequate and the patient is adjusting to any decrease in powers to participate in self/dependent care.

25. A SSUMPTIONS AND P OINT OF V IEW Origins of the nursing model

26. D OROTHEA O REM ’ S H ISTORICAL B ACKGROUND Born in 1914 in Baltimore, Maryland. Education: Received her diploma of nursing at Providence Hospital School of Nursing in Washington, D.C. in the early 1930s Obtained her BS in nursing education from the Catholic University of America (CUA) in 1939, and in 1946 her MS in Nursing Education, also from CUA. Early nursing experiences Private duty nursing (hospital and home) Operating room nursing Hospital staff nursing on pediatric and adult med/surg units Biological science teaching Evening supervisor in an emergency room Furthering her career Director of the school of nursing and department of nursing at Providence Hospital in Detroit, MI from 1940 to 1949 Worked for the Division of Hospital and Institutional Services of the Indiana State Board of Health from 1949 to 1957

27. D OROTHEA O REM ’ S H ISTORICAL B ACKGROUND - CON ’ T Furthering her career, con’t In 1957 took a position as a curriculum consultant at the Office of Education, U.S. Department of Health, Education, and Welfare, in Washington, D.C. and for 2 years worked on a project to upgrade practical nurse training. Later in 1957 she became an assistant professor of nursing education at CUA In 1970 Orem moved on from CUA and began her own consulting firm. Orem received many honors in her career, including From Georgetown University: Honorary Doctor of Science in 1976 CUA Alumni Association Award for Nursing Theory in 1980 Honorary Doctor of Science, from Incarnate word College, 1980 Doctor of Human Letters, Illinois Wesleyan University, 1988 Linda Richards Award, National League for Nursing, 1991 Honorary Fellow of the American Academy of Nursing, 1992 Doctor of Nursing Honoris Causae from University of Missouri, 1998

28. D OROTHEA O REM ’ S H ISTORICAL B ACKGROUND - CON ’ T While working at CUA Orem continued to develop and formalize her concepts of nursing and self care, sometimes alone and sometimes with others. The group she worked with later came to be known as the Nursing Development Conference Group (NDCG). Retired in 1984, yet continued to work on her Self-Care Deficit Nursing Theory (SCDNT). Dorothea passed away at age 92, after a period of being bedridden, on June 22, 2007. Many of her papers are available for nursing scholars in an edited compilation.

29. P HILOSOPHIC V ALUES OF N URSING AND K NOWLEDGE D EVELOPMENT According to Alligood and Tomey, “her goal was to upgrade the quality of nursing in general hospitals throughout the state,” (pg. 265). Orem had recognized early in her career that for nursing to advance as a field of knowledge and field of practice, an organized and structured knowledge body would be needed. Her main source of her ideas on nursing, was from her personal nursing experience. “The question that directed Orem’s (2001) thinking was “What condition exists in a person when judgments are made that a nurse(s) should be brought into the situation?”(p.20). The condition that indicates the need for nursing assistance is “the inability of persons to provide continuously for themselves the amount and quality of required self-care because of situations of personal health” (Orem, 2001, p. 20). It is the proper object or focus that determines the domain and boundaries of nursing, both as a field of knowledge and as a field of practice. The specification of the proper object of nursing marks the beginning of Orem’s theoretical work” (Alligod & Tomey, 2010, p. 266-267).

30. P HILOSOPHIC V ALUES OF N URSING AND K NOWLEDGE D EVELOPMENT - C ON ’ T “Foundational to Orem’s SCDNT is the philosophical system of moderate realism” (Alligood & Tomey, 2010, p. 267). A philosophical inquiry conducted by Banfield in 1997 showed consistency with Orem’s views “regarding the nature of reality, the nature of human beings, and the nature of nursing as a science and the ideas and positions associated with the philosophy of moderate realism” (Alligood & Tomey, 2010, p. 267). “Orem (1997) identified “five broad views of human beings that are necessary for developing understanding of the conceptual constructs of self- care deficit nursing theory and for understanding the interpersonal and societal aspects of nursing systems” (p. 28). These are view of (1) person, (2) agent, (3) user of symbols, (4) organism, and (5) object” (Alligood & Tomey, 2010, p. 267).

31. P HILOSOPHIC V ALUES OF N URSING AND K NOWLEDGE D EVELOPMENT - C ON ’ T Person-as-agent is central to Orem’s SCDNT. “Self- care, which refers to those actions in which a person engages for the purpose of promoting and maintaining life, health, and well-being, is conceptualized as a form of deliberate action” (Alligood & Tomey, 2010, p. 267-268). The individual acts as an agent when participating in deliberate action. Orem’s theory of self-care deficit represents her work regarding the substance of nursing as a field of knowledge and as a field of practice. She also identified the form of nursing as a science, a practical science. There are two components that make up practical science: the practical and the speculative. Practically practical is directive of action, and speculatively practical is theoretical in nature. SCDNT is speculatively practical knowledge.

32. P HILOSOPHIC V ALUES OF N URSING AND K NOWLEDGE D EVELOPMENT - C ON ’ T “Orem’s articulation of the form of nursing science provided the framework for the development of a body of knowledge for the education of nurses and for the provision of nursing care in concrete situations of nursing practice. The SCDNT with its conceptual elements and three theories identifies the substance or content of nursing science” (Alligood & Tomey, 2010, p. 269). Orem’s theory is used and has developed nursing knowledge all over the world. “In 1988, nursing theory and its importance to the development of nursing science were introduced to the graduate faculty and students at Ramathibodi School of Nursing, Mahidol University in Bangkok. Orem’s self-care model was introduced as one of the grand theories and became a popular model for use especially by a number of graduate faculties who were clinical experts. These individuals became very active in application of Orem’s theory to practice and guided masters’ nursing students in application to both practice and research. These faculty and students became the advocates of Orem’s work and were the primary reasons for advancement of Orem’s theory” (Hanucharurnkul, 2009, p. 16).

33. I NFORMATION AND C ONCEPTS Human Being Environment Health Nursing

34. O REM ’ S S ELF -C ARE M ODEL DEFINES THE FOUR GLOBAL CONCEPTS BY Human being relates to the patient and/or family support system Environment can be physical or emotionally influenced depending on the setting/situation Health is the state of wellness (physical/emotional) of the patient and family, including associated needs or deficits Nursing is the degree of care relative to patient/family deficits requiring to bring patient/family to the fullest possible level of function

35. I NTERPRETATION & I NFERENCE AND I MPLICATIONS & C ONSEQUENCES Evaluation of the nursing model

36. C LARIFICATION OF ORIGINS. I S THIS PHILOSOPHY UNIQUE TO NURSING ? I S IT CLEAR WHAT INFLUENCED THIS MODEL ? The theory of self-care is accomplished on a daily basis by mature individuals in order to maintain a healthy lifestyle (Orem, 2001). According to Banfield (1997), Orem’s Self-Care Theory was influenced by the “philosophical system of moderate realism”.

37. C ONTENT. D OES THIS MODEL ADEQUATELY DESCRIBE THE FOUR GLOBAL CONCEPTS ? – OR - D OES THIS MODEL ADD TO THE GLOBAL CONCEPTS ? Orem’s Self-Care Model states that each of the global concepts can influence, or be influenced by factors/needs in any and all of the remaining concepts, for example an individual’s physical health can be affected by their environment; lack of appropriate nursing care or problems with family members, and poor living conditions.

38. N ARROW VIEW ? (C AN THIS MODEL BE USED IN OB AND OR?) H AVE OTHER THEORIES BEEN GENERATED FROM THIS MODEL ? A RE THE CONCEPTS ABSTRACT OR SPECIFIC ? Orem’s self-care nursing theory can be used in various settings as well as OB and OR. The nurse would select the nursing system as according to the patients needs. According to Kearney-Nunnery (2008) the systems are referred to as Wholly compensatory nursing system – patient is unable to perform self-care actions -Partly compensatory nursing system – patient is able to perform in some but not all self-care actions Supportive-education nursing system – patient is able to perform all self-care actions The concepts to this model are abstract which allows for multiple settings to apply it. The theory of planned behavior is associated with Orem’s Self-Care Framework (Villarruel, et al, 2001).

39. W HAT PRACTICE SITUATIONS CAN / HAS THIS MODEL BEEN USED IN ? “Dorthea Orem's Self Care Theory is one of the general theories that can be applied to multiple settings in nursing practice. The dialysis arena is one area of nursing practice in which the application of this theory would be appropriate because it is crucial for patients to be actively involved in self care” (Simmons 2009). “Nurses, can be invaluable sources of support and providers of education for new caregivers of stroke survivors; they are often in an ideal position to address the needs and concerns of caregivers due to their close contact with patients and their families” Bakas et al., 2002; Dorsey & Vaca, 1998).

40. C ASE S TUDY Sarah S. is a 45-year-old single American woman who has had type 2 diabetes for 7 years. She recently had a scab to her right big toe from stubbing it that wasn’t healing. Sarah was referred to a vascular surgeon from her primary care physician. The surgeon ruled out peripheral vascular disease and referred Sarah to his office’s diabetes educator. Sarah is a secretary at a local school and struggles to pay her bills as she is the sole provider for herself and her mother. She enjoys eating out, watching movies and being with her family. She is an only child who lives in an apartment with her 80 year old widowed mother who has limited mobility due to her chronic rheumatoid arthritis.

41. C ASE S TUDY (C ON ’ T ) Sarah’s mother is dependent on her for all of her activities, house work, shopping, etc. With Sarah being overweight, heavy cleaning is exhausting for her. She tells the diabetes educator, “I’m so tired all the time, but my mother doesn’t think we need to hire a cleaning lady. She was so good to me growing up, now I need to return the favor.” When the nurse questioned her about her blood glucose monitor she stated “I have one somewhere, I don’t have time to use it, but I try avoiding foods I shouldn’t eat.” Sarah also stated that she is too exhausted to participate in an exercise program. Through assessment of Sarah and her family, the diabetes educator was able to identify Sarah’s needs and discussed and carried out actions to help Sarah meet her self-care demands and enhance her self-care agency.

42. C ASE S TUDY Q UESTIONS Q: What is affecting Sarah’s self-care agency? Q: As a diabetic what should some of Sarah’s therapeutic self-care demands be? Q: Does Sarah have a self-care deficit, if so why? Q: What type of compensatory system was the diabetes educator using?

43. Z ACHARY M EDLER ’ S R EFERENCES Bakas, T., Austin, J., Okonkwo, K., Lewis, R., & Chadwick, L. (2002). Needs, concerns, strategies, and advice of stroke caregivers the first 6 months after discharge. Journal of Neuroscience Nursing, 34, 242-251. Banfield, B. E. (1997). A philosophical inquiry of Orem’s self-care deficit in nursing theory. Dissertation Abstracts International, 58, 5885B. Dorsey, M. & Vaca, K. (1998). The stroke patient and assessment of caregiver needs. Journal of Vascular Nursing, 16(3), 62-67. Nunnery-Kearney, R. (2008). Advancing Your Career: Concepts of Professional Nursing (4 th.ed., pp.61-70). Philadelphia: F.A. Davis. Orem, D.E. (2001). Nursing: Concepts of practice (6 th ed., p.522). St. Louis, MO: Mosby. Simmons, L. (2009). Dorothy Orem’s self-care theory as related to nursing practice in hemodialysis. Nephrology Nursing Journal, 36, 419 Villarruel, A. M., Bishop, T. L., Simpson, E. M., Jemmot, L. S., & Fawcett, J. (2001). Borrowed theories, shared theories, and the advancement of nursing knowledge. Nursing Science Quarterly, 14, 158-163.

44. E MILY W ILLIAMS ’ R EFERENCES Kearney-Nunnery, R. (2008). Advancing Your Career: Concepts of Professional Nursing. Philadelphia, PA: F. A. Davis Company. Kumar, C. (2007). Application of Orem’s Self-Care Deficit Theory and Standardized Nursing Languages in a Case Study of a Woman with Diabetes. International Journal of Nursing Terminologies and Classifications, 18 (3), 103-110. doi:10.1111/j.1744-618X.2007.00058.x Alligood, M.R. &Tomey, A.M. (2006). Nursing Theorists and Their Work (6 th ed.). St Louis, MO: Mosby Elsevier. Nursing Theories: A Companion to Nursing Theories and Models. (2010). Dorothea Orem's Self-Care Theory. Retrived from http://currentnursing.com/nursing_theory/self_care_d eficit_theory.html http://currentnursing.com/nursing_theory/self_care_d eficit_theory.html

45. S ARA K INNE ’ S R EFERENCES Alligood, M.R. &Tomey, A.M. (2010). Nursing Theorists and Their Work (7 th ed.). St Louis, MO: Mosby Elsevier. Banfield, B. E. (1997). A philosophical inquiry of Orem’s self-care deficit in nursing theory. Dissertation Abstracts International, 58, 5885B. Hanucharurnkul, S. (2009). Self-Care Deficit Nursing Theory in Research and Practice in Thailand. Self-Care, Dependent-Care & Nursing, 17 (1), 16-20. http://www.orem-society.com/