Nurse Practitioner Models of Care -- Dorothea Orem
The objective of this work in writing is to choose a model of nursing care. The model chosen is that of Dorothea Orem. Orem's 'Self-Care Deficit Theory' is a general theory of nursing and one of the most utilized models in nursing in contemporary times.
Dorothea Orem - Background
Dorothea Orem was born in 1914 in Baltimore, Maryland. Orem earned her nursing diploma in the earlier part of the 1930s from Providence Hospital School of Nursing, Washington, D.C. As well as receiving three honorary doctorates and an Alumni Achievement Award for Nursing Theory in 1980 from Catholic University of America. (Bridge, Cabell, and Herring, paraphrased) Orem gained experience early in her nursing career in various hospital clinical settings as a staff nurse.
The work of Bridge, Cabell, and Herring (nd) states that Orem recalls from early in her career while serving as director of nursing service at a hospital in Detroit, Michigan that "she was asked a substantive question and didn't have an answer because she 'had no conceptualization of nursing'." (p.2) Orem is reported to have related that while working at Indiana University she found that there was difficulty in the articulation of nurses to the administrators of the hospital in regards to their needs "in the face of demands made upon them regarding such issues as length of stay, scheduling admissions and discharges…" (Bridge, Cabell, and Herring, nd, p. 2)
According to Orem, she had recognized a need "to look for the uniqueness of nursing. Specifically she was looking to answer questions such as 'What is Nursing?', 'What is the domain and what are the boundaries of nursing a field of practice and a field of knowledge?' And 'What condition exists when judgments are made that people need nursing?' (Bridge, Cabell, and Herring, nd, p. 2) The International Orem Society is reported to have stated is as follows: "What do nurses encounter in their world as they design and produce nursing for others? What meaning can and should nurses attach to persons, things, events, conditions, and circumstances they encounter?" (Bridge, Cabell, and Herring, nd, p.2)
II. Orem's Theory of Nursing
It is reported that Orem (1978) stated that the task "…required identification of the domain and boundaries of nursing as a science and an art." (Bridge, Cabell, and Herring ) Following having reflected upon her own experiences in nursing Orem is reported to have said that the answer came as a "…flash of insight, an understanding that the reason why individuals could benefit from nursing was the existence of…self-care limitations." (Orem, 1978 cited in: Bridge, Cabell, and Herring, nd, p.2)
Four concepts are used by Orem to explain the nursing metaparadigms. Those four are: (1) human beings; (2) environment; (3) health; and (4) nursing. Orem stated that a human being or 'humanity' as "an integrated whole composed of internal physical, psychological and social nature with varying degrees of self-care ability." (Chinn & Kramer, 2004, cited in, p.4) A human being is stated by Orem to have the ability to "reflect, symbolize and use symbols." (Bridge, Cabell, and Herring, nd, p.2) Orem uses the terms "individual, patient, multiperson unit, self-care agent, dependent-care agent" when she referred to humans. (Fawcett, 2005 in: Bridge, Cabell, and Herring, nd, p.2)
When addressing the concept of health Orem states that health and healthy "are terms used to describe living things…[it is when]they are structurally and functionally whole or sound…includes that which make a person human, operating in conjunction with physiological and psychophyisiological mechanisms and material structure (biologic life) and in relation to an interacting with other human beings (interpersonal and social life." (Bridge, Cabell, and Herring, nd, p. 4) Health is defined by Orem as "a state of physical, mental and social well-being, and not merely by the absence of disease or infirmity." (Foster and Bennett, 2001 in Bridge, Cabell, and Herring, nd,, p.4-5)
III. Nursing and the Environment
Nursing is viewed by Orem as "an art through which the practitioner of nursing gives specialized assistance to persons with disabilities of such a character that greater than ordinary assistance is necessary to meet daily needs for self-care and to intelligently participate in the medical care they are receiving from the physician." (Bridge, Cabell, and Herring, nd, p. 5) According to Orem, the environment is "…encompassed by two dimensions-physical, chemical and biologic features and socioeconomic features. Physical, chemical, and biologic features include things such as atmosphere, pollutants, weather conditions, pets, infectious organisms and the like. Socioeconomic features of the environment focus on the family and the community and include such things as gender and age roles, cultural roles, and cultural prescriptions of authority." (, p. 5) Orem notes that these two dimensions may interact with one another and emphasizes the "…potential contribution of environment to a person's development, stating that "It is the total environment, not any single part of it that makes it developmental" (Orem, 2001, p. 58, cited in Fawcett, 2005 in: Bridge, Cabell, and Herring, nd, p. 6) From Orem's view the environment is a "prevailing internal and external conditions in some time and place frame of reference." (Fawcett, 2005 cited in: Bridge, Cabell, and Herring, nd, p. 6) Orem's Self-Care Deficit Theory is a 'Conceptual Framework for Nursing" as follows:
R = relationships
<=deficit relationship, current or projected
The Self-Care Deficit Theory of Orem is shown in the following illustration labeled Figure 1.
Orem's Self-Care Deficit Theory
Source: (Bridge, Cabell, and Herring, nd)
Orem had two purposes for development of the Self-Care Framework: (1) she was attempting to identify the meaning of nursing; and (2) she was attempting to develop a body of nursing knowledge based on research. (Bridge, Cabell, and Herring, nd, p. 7) Self-Care is stated to be a term that Orem sued to refer to "…actions of individuals directed to self or environment to regulate factors or conditions in the interest of that individual's life, health, and well-being."( Bridge, Cabell, and Herring, nd, p. 7)
IV. Orem's Self-Care System
The self-care system is comprised by: (1) actions that over time are performed and through analysis organized into systems that are coordinated into actions; (2) dependent care system which is a system of action that is coordinated in meeting the dependent individuals requirements of self-care; and (3) data that describes self-care and which through analysis arrives t the self-care system. (Bridge, Cabell, and Herring, nd, p. 7) Orem uses the term self-care agency to define: (1) power that human beings inherently posses that is needed for deliberate action; (2) self-care skills; and (3) the relationship that exists between 1 and 2. (Bridge, Cabell, and Herring, nd, 7)
V. Self-Care Limitations, Demand, and Requirements
Self-care limitations is a term used by Orem to describe the following: (1) actual, defined as absences of an essential action or system of action from the repertoire; (2) predicted, of the human absence or restriction of one or more human capabilities for engagement in deliberate action; and (3) positive/negative, the temporary or permanent or relatively permanent effect of the value of a capability on an individual action repertoire (McLaughlin-Renpenning, & Taylor, 2002 in: Bridge, Cabell, and Herring, nd, p. 7).
Therapeutic Self-Care Demand is reported to represent "…the totality of action required to meet a set of self-care requirements using a set of technologies" (McLaughlin-Renpenning, & Taylor, 2002, p.175 in: Bridge, Cabell, and Herring, nd, p. 7). Comprising self-care requirements are the following: (1) formulated goals, (2) orientations of Self-care, (3) action systems, and (4) expressions of input requirements for human functioning, for growth and development, for preventing, curing, and controlling disease processes. The types of self-care requirement are stated to be those as follows: (1) Universal Type -- which refers to requirements that are general for all people require adjustments to age, sex, developmental state, and health state, and (2) Health Deviation Type - requirements that have their origins in disease processes and their effects; or in medical technologies. According to Orem, "if a person's capabilities are inadequate to meet the therapeutic demand a self-care deficit exists." (Bridge, Cabell, and Herring, nd, p. 8)
VI. Nursing Agency
Orem stated that nursing agency is that which is used to name the "human power and action repertoire associated with nursing practice." (Bridge, Cabell, and Herring, nd, p. 8) Nursing agency includes: (1) the establishment of the relationship legitimacy; (2) beginning oeprationalization and maintenance of an interpersonal system with client and their family; and (3) diagnosis in regards to the two patient variables. (Bridge, Cabell, and Herring, nd, p. 8) Orem held that there are three types of nursing systems including those which are: (1) Wholly compensatory systems, required for individuals who are unable to control and monitor their environment and process information; (2) Partly compensatory systems, designed for individuals who are unable to perform some (but not all) self-care activities; and (3) Supportive-educative (developmental) systems, designed for persons who need to learn to perform self-care activities (Bridge, Cabell, and Herring, nd, p.8).Orem's theory is reported…