Orem's Self-Care Deficit Theory in Critical Care Nursing

Introduction to Modern Nursing and Orem's Theory

The 21st-century nursing profession has greater exposure to new technologies, methods, and techniques than any other period in the past. One definition of modern nursing describes it as "the use of clinical judgment in the provision of care to enable people to improve, maintain, or recover health, to cope with health problems, and to achieve the best possible quality of life, whatever their disease or disability, until death" (Royal College of Nursing, 2003). While technological advancement is certainly a reality of contemporary practice, it is equally important not to lose touch with the holistic approach — that of advocating and caring for the patient based on their individual needs. One framework that can help nurses manage patient care and advocacy is the Self-Care Deficit Theory, based on Orem's Nursing: Concepts of Practice (Orem, 2001).

Orem found the post-World War II medical care system more attuned to disease management than to holistic cure. She believed not only that quality of care and advocacy in hospitals should be improved, but that patients themselves should take some responsibility for their own care and for managing their ability to cope with illness.

Orem's model has three major components: (1) nursing is required because of the individual's inability to perform self-care in many medical situations; (2) as adults age, they deliberately learn and master actions that help direct their survival, quality of life, and well-being; and (3) the product of nursing systems should be the nurse's advocacy in helping people meet their self-care requirements and avoid unnecessary dependency on others (Dorothea Orem, 2010).

Orem's Self-Care Deficit Model

The nurse's role, under this model, is not continual care with no prospect of improvement or change, nor is it merely to dispense medication without explanation. Rather, it is to foster self-advocacy — helping patients understand their conditions and care needs, learn to perform self-care, and remain as independent as possible for as long as possible. Educating clients and their families provides a greater level of empowerment and reduces the need for complete dependence on the healthcare system (Alligood and Tomey, 2005, pp. 255–259).

In some respects, applying Orem's model is problematic within the ICU paradigm. For the ICU nurse, two major concerns arise: (1) advanced technology is not inherently conducive to a holistic care model and tends to reduce the patient to quantifiable body functions; and (2) technology alone cannot care for the whole person during a health crisis. Holistic caring, empathy, and the interconnection of experiences, needs, and responses remain crucial for ICU nurses, so that they do not lose sight of the person in need (Hurlock-Chorostecki, 1999).

ICU patients generally require robust medical intervention. However, within Orem's framework, self-care is understood as the patient's ability to interact with their environment in ways that promote well-being. The theoretical starting point is the potential for self-care. Even neonates use behaviors to signal needs; therefore, this potential — however limited — forms the basis from which nursing care is developed under Orem's model. Each of the elements in the implementation plan below draws on Orem's three-pronged approach: Universal Self-Care Requirements, Self-Care Abilities, and Self-Care Limitations.

Challenges of Applying Orem in the ICU

Theoretical Overview: Appropriate training and use of resources to learn how to apply Orem's theories in a critical care context.

Introduction of the Client: Seeing the client as a whole person — not merely as a burn victim or a diagnosis, but as an individual with a name, a history, and rehabilitative potential.

Plan for Using Orem in a Critical Care Application

Assessment: Clinical assessment of the client's needs, drawing not only on technology but also on direct, personal nursing interaction.

Diagnosis and Planning: Identifying the specific issues that must be addressed, determining how they will be managed, establishing health goals for the patient, and assessing whether the patient has the means to communicate their needs.

Implementation: Enacting the nursing care plan within the self-care model framework, ensuring interventions remain aligned with promoting patient independence where possible.

Evaluation: Reviewing and reconsidering the care plan on an ongoing basis. The ultimate goal is to move the patient out of the ICU, increase mobility, and — where appropriate — assist in facilitating a return home (see, for instance, Wilson and Gramling, 2009).

Conclusion and Evaluation

Depending on the severity of the patient's condition, Orem defines those who are unable to perform self-care as having a self-care deficit, constituting a strong need for nursing care. However, that care must always be delivered within a holistic view of the patient, never losing sight of advocacy and the foundational principles of the care model (Beretta, 2011). Even in the technologically demanding environment of the ICU, nurses must resist reducing patients to clinical data and instead uphold Orem's vision of empowered, person-centered care.