Orem's and Watson's Nursing Theories: A Comparative Analysis

Introduction

Theory guides practice. This is true of many things, but is especially true of nursing. While many processes, actions, and rules are involved in becoming a great nurse, understanding and applying theory must be among the most important aspects. Nursing theory allows practitioners to examine concepts and then attempt their practical application when theories are tested. Evidence-based practice, for example, is the productive intersection of theory and application: when theories are constructed, they are tested, and if effective, are incorporated into standard practice. This essay provides a synthesis of nursing theory by examining two important frameworks — Orem's Self-Care Theory and Watson's Theory of Human Caring — and traces how nursing theory has evolved since its beginnings.

Background on Nursing Theory

Many say nursing is as old as humankind. If there was someone sick, there was someone willing to care for that person and nurse them back to health. The word "nurse" comes from the Anglo-French nurice and the Latin nutrica, both meaning "to nourish." Nurses nourish patients emotionally, mentally, and physically and provide them with the means of returning to good health (Parker & Smith, 2015). When examining nursing theory, its purpose is to help practitioners comprehend the process of nursing and improve their own thinking related to it. "The purpose of nursing theory goes beyond its study within courses. Nursing theory becomes alive when the ideas are brought to practice. The usefulness of theory in practice is one way that we judge its value and worth" (Parker & Smith, 2015, p. 27).

Many theories exist across various fields, and nursing is no different. It is up to the individual to decide which theory to apply to their own thinking and practice. It is helpful to examine theories via primary sources or the work of prominent scholars who have studied selected theories. Historically, theory was one of the primary forces driving nursing forward, since healthcare in general demanded constant improvement and innovation.

Improvement and innovation cannot be achieved without theory. Even now, new nursing theories continue to emerge that may one day become responsible for standard practice and care. Emergency nursing, for example, requires quick thinking and a broad knowledge of various ailments. Without theory, practitioners have no direction to explore the different dimensions of what it means to be a nurse.

William K. Cody is a respected contributor to Nursing Science Quarterly. In one of his articles, he discusses how convinced he is that theory guides practice — a significant point, because some argue the opposite. As Cody writes:

"To assert the alternative, that theory arises from practice to an equal or greater extent than theory guides practice, would be a misrepresentation of the contemporary art and science of nursing theory development. In actuality, this assertion has been made widely and, I would venture to say, to the detriment of theory development in nursing" (Cody, 2003, p. 225).

Practice comes from thought, and the process of thought is the foundation of theory. One thinks something and then it becomes real through practice. Theories are tested, and sound theories are then implemented into nursing. But the first step is always the initial idea.

Nursing theory has evolved considerably in recent times and has become a primary means of improving patient care. One outcome of this evolution is evidence-based practice — a mode of thinking grounded in theory. One article noted that nurse educators and nurses must embrace both theory-based practice and evidence-based practice, as each offers benefits for improvement and innovation (McCrae, 2012). Evidence-based practice can be considered a step further than theory-based practice: one cultivates a theory, implements it, and then gathers evidence of its usefulness. Practice does not exist without theory, and practitioners are beginning to recognize this more fully.

This recognition can be seen through Carr's four principal approaches, which explain the nature of theory. "Carr terms these approaches the 'common-sense' approach, the 'applied-science' approach, the 'practical' approach, and the 'critical' approach. Each approach is recoverable from the explicit and implicit content of scholarly literature" (Fealy, 1999, p. 74). The common-sense approach locates or grounds theory within everyday understanding, articulated in the world of practice, where it can be refined, reconstructed, and validated (Ghaye & Lillyman, 2014).

An applied-science approach means conforming to standards of validity, reliability, and rigor as established by scientific convention. The practical approach nourishes practical clinical wisdom and is used to support and inform clinical decisions (Ghaye & Lillyman, 2014). A critical approach allows one to understand, through theory, why a practice exists as it does, taking into consideration how political, social, and historical forces serve to constrain or liberate what is done. Seen through these perspectives, nursing theory is integral to everything — especially evidence-based practice.

Orem's Self-Care Theory

Orem's Self-Care Theory — also known as the Self-Care Deficit Nursing Theory or Orem's Model of Nursing — is a grand nursing theory developed by Dorothea Orem between 1959 and 2001. The theory stems from the totality paradigm, based on adaptation to one's environment (Masters, 2014). Thanks to this theory, numerous randomized controlled trials in nursing have demonstrated improved quality of care. The theory is widely applied in primary care and rehabilitation settings, where patients are encouraged to strive for independence.

Achieving independence as quickly as possible is one of the central aims of the theory when applied to primary care or rehabilitative settings. Human beings have a remarkable capacity to adapt to their surroundings, and creating an environment that promotes rapid independence may produce better outcomes for patients.

Orem described her model as a general theory consisting of three interrelated components. "The three inter-related theories include the theory of self-care, the theory of self-care deficit, and the theory of nursing systems" (Masters, 2014, p. 154). These three parts focus not on the individual in isolation, but on persons in relation to others — emphasizing the "I," the "you and me," and the "we." Together, these theories form Orem's personal theory: if there is no one available to care for the patient, a model exists to support self-care.

Applied to emergency department nursing, patients who must wait hours to be seen can benefit from a nurse's brief intervention. In a state of pain and anxiety, a nurse can help the patient achieve a calmer state — for example, by teaching them to elevate an injured limb or practice deep breathing. These interventions build patient independence and help them adapt to the current situation.

The theory assumes that patients want to care for themselves. When permitted to do so to the best of their ability, the assumption is that they recover more quickly and holistically. Orem identified self-care requisites, classified as follows:

There are also self-care deficits, which occur when a person cannot meet their own self-care requisites. In such cases, the nurse determines these deficits and defines appropriate support modalities.

As an example from emergency nursing practice, consider a patient who is obese, experiencing pain, and cannot remain still enough for a blood pressure reading. Because of the patient's size, a standard cuff cannot be used, so a larger one is required. The nurse must determine whether the patient can hold still; if not, due to pain, pain medication may need to be administered first. Some literature has noted that patients wait a considerable time before receiving pain relief for injuries in the emergency department: "The median time to pain medication administration for patients presenting to our ED with extremity fractures was 72.5 minutes" (Heilman, Tanski, Burns, Lin, & Ma, 2016, p. 1). Shortening that window is theoretically viable — and that is precisely the point of theories like Orem's: to think differently and explore where those ideas lead.

When patients cannot support themselves and experience self-care deficits, Orem's theory includes support modalities. Nurses are encouraged to recognize and rate a patient's dependency according to the following scale:

Total Compensation applies when the patient lacks independence entirely, requiring nursing assistance for all activities. Partial Compensation means the patient can perform some tasks — such as using the bathroom independently — but needs help with others, such as walking. Educative/Supportive means the patient is largely independent but needs assistance with behavior control, decision-making, or obtaining information (Meleis, 2012; Abotalebidariasari, Memarian, Vanaki, Kazemnejad, & Naderi, 2016).

In emergency department practice, these three categories might correspond to three distinct patients: one who is bedridden following surgery and requires complete assistance; another who underwent minor surgery and can self-administer medication but needs help bathing; and a third experiencing an infection who simply needs education about proper antibiotic use.

Orem described the nurse's role in terms of counselor, advocate, educator, and teacher. She incorporated inductive and deductive thinking into her theory and provided a foundation for understanding the various complexities of patient recovery (Dickson, Buck, & Riegel, 2011). Without theories like Orem's, there is little framework with which to understand context. Patients benefit from a higher level of understanding in order to recover and communicate effectively with their care team.

Conclusion

In conclusion, nursing theory has contributed substantially to what nursing is today. Countless contributions have been made, with influential frameworks such as Orem's Self-Care Theory and Watson's Theory of Human Caring generating further theories and research avenues that have driven the continued development of modern nursing. Theories and conceptual frameworks are the backbone of practice, and while evidence-based practice is essential, its roots lie in theory — and theory-based practice has seen renewed attention in recent years.

The reason for this renewed interest is clear: there is a growing demand for clinics and hospitals to innovate, to address patient needs, and to improve patient satisfaction. This requires creative thinking and calls on nurses to move beyond the traditional nursing role and become leaders. The future of nursing is becoming far more complex than the past has demonstrated, and it is this demand for complexity and innovation that requires nurses to step outside their comfort zones and approach their work from new perspectives.