Self-care deficit theory of nursing
Chapter 14: Self-care deficit theory of nursing
Violeta A. Berbiglia, Barbara Banfield*
PowerPoit by Dr. Sergio Osegueda
Dorothea E. Orem (1914–2007)
“Nursing is practical endeavor, but it is practical endeavor engaged in by persons who have specialized theoretic nursing knowledge with developed capabilities to put this knowledge to work in concrete situations of nursing practice.” (Orem, 2001)
Credentials and background of the theorist
Dorothea Elizabeth Orem was born in Baltimore, Maryland, in 1914.
She began her nursing career at Providence Hospital School of Nursing in Washington, DC, where she received a diploma of nursing in the early 1930s.
Orem received a bachelor of science degree in Nursing Education from Catholic University of America (CUA) in 1939, and she received a master’s of science degree in Nursing Education from the same university in 1946.
Orem’s early nursing experiences included operating room nursing, private duty nursing (home and hospital), hospital staff nursing on pediatric and adult medical and surgical units, evening supervisor in the emergency room, and biological science teaching.
Orem held the directorship of both the nursing school and the Department of Nursing at Providence Hospital, Detroit, from 1940 to 1949. After leaving Detroit, she spent 8 years (1949–1957) in Indiana working at the Division of Hospital and Institutional Services of the Indiana State Board of Health.
In 1957, Orem moved to Washington, DC, to take a position at the Office of Education, U.S. Department of Health, Education, and Welfare, as a curriculum consultant. From 1958 to 1960, she worked on a project to upgrade practical nurse training.
That project stimulated a need to address the question: What is the subject matter of nursing? As a result, Guides for Developing Curricula for the Education of Practical Nurses was developed (Orem, 1959).
In 1970, Orem left CUA and began her consulting firm. Orem’s first published book was Nursing: Concepts of Practice (Orem, 1971).
She was editor for the NDCG as they prepared and later revised Concept Formalization in Nursing: Process and Product (NDCG, 1973, 1979).
In 2004 a reprint of the second edition was produced and distributed by the International Orem Society for Nursing Science and Scholarship (IOS). Subsequent editions of Nursing: Concepts of Practice were published in 1980, 1985, 1991, 1995, and 2001. Orem retired in 1984 and continued developing the self-care deficit nursing theory (SCDNT).
Georgetown University conferred the honorary degree of Doctor of Science on Orem in 1976.
She received the CUA Alumni Association Award for Nursing Theory in 1980.
Other honors included Honorary Doctor of Science, Incarnate Word College, 1980; Doctor of Humane Letters, Illinois Wesleyan University, 1988; Linda Richards Award, National League for Nursing, 1991; and Honorary Fellow of the American Academy of Nursing, 1992.
She was awarded the Doctor of Nursing from the University of Missouri in 1998.
At age 92, Dorothea Orem’s life ended after a period of being bedridden. She died Friday, June 22, 2007, at her residence on Skidaway Island, Georgia.
Orem’s many papers and presentations provide insight into her views on nursing practice, nursing education, and nursing science.
Orem (2001) stated, “Nursing belongs to the family of health services that are organized to provide direct care to persons who have legitimate needs for different forms of direct care because of their health states or the nature of their health care requirements”
Like other direct health services, nursing has social features and interpersonal features that characterize the helping relations between those who need care and those who provide the required care.
Orem’s SCDNT provides a conceptualization of the distinct helping service that nursing provides.
The primary source for Orem’s ideas about nursing was her experiences in nursing. Through reflection on nursing practice situations, she was able to identify the proper object, or focus, of nursing. 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?”
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”
Originally, three specific theories were articulated: the theory of nursing systems, the theory of self-care deficits, and the theory of self-care.
An additional theory, the theory of dependent-care, has been articulated.
This theory is regarded as being parallel with the theory of self-care and serves to illustrate the ongoing development of the SCDNT
In addition to her experiences in nursing practice situations, Orem was well versed in contemporary nursing literature and thought.
Foundational to Orem’s SCDNT is the philosophical system of moderate realism.
These inquiries revealed consistency between Orem’s views regarding the nature of reality, human beings, the environment, and nursing as a science–ideas and positions associated with the philosophy of moderate realism
Orem did not specifically address the nature of reality; however, statements and phrases that she uses reflect a moderate realist position. Four categories of postulated entities are identified as establishing the ontology of the SCDNT (Orem, 2001, p. 141). These four categories are (1) persons in space-time localizations, (2) attributes or properties of these persons, (3) motion or change, and (4) products brought into being.
Orem (1997) identified “five broad views of human beings that are necessary for developing understanding of the conceptual constructs of the SCDNT and for understanding the interpersonal and societal aspects of nursing systems” (p. 28). These are the view of person, agent, user of symbols, organism, and object.
The view of person-as-agent is central to the 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.
Orem (2001) identified two sets of speculatively practical nursing science: nursing practice sciences and foundational nursing sciences.
The set of nursing practice sciences includes (1) wholly compensatory nursing science, (2) partly compensatory nursing science, and (3) supportive developmental nursing science.
The foundational nursing sciences are (1) the science of self-care, (2) the science of the development and exercise of the self-care agency in the absence or presence of limitations for deliberate action, and (3) the science of human assistance for persons with health-associated self-care deficits.
Structure of nursing science
Wholly compensatory nursing
Partly compensatory nursing
Foundational nursing sciences
The science of self-care
The science of the development and exercise of self-care agency in the absence or presence of limitations for deliberate action
The science of human assistance for persons with health-associated self-care deficits
Applied nursing sciences
Basic nonnursing sciences
MAJOR CONCEPTS & DEFINITIONS
The self-care deficit nursing theory is a general theory composed of the following four related theories:
The theory of self-care, which describes why and how people care for themselves
The theory of dependent-care, which explains how family members and/or friends provide dependent-care for a person who is socially dependent
The theory of self-care deficit, which describes and explains why people can be helped through nursing
The theory of nursing systems, which describes and explains relationships that must be brought about and maintained for nursing to be produced
Basic nursing systems.
Self-care comprises the practice of activities that maturing and mature persons initiate and perform, within time frames, on their own behalf in the interest of maintaining life, healthful functioning, continuing personal development, and well-being by meeting known requisites for functional and developmental regulations (Orem, 2001
Dependent-care refers to the care that is provided to a person who, because of age or related factors, is unable to perform the self-care needed to maintain life, healthful functioning, continuing personal development, and well-being.
A self-care requisite is a formulated and expressed insight about actions to be performed that are known or hypothesized to be necessary in the regulation of an aspect of human functioning and development, continuously or under specified conditions and circumstances.
A formulated self-care requisite names the following two elements:
The factor to be controlled or managed to keep an aspect of human functioning and development within the norms compatible with life, health, and personal well-being
The nature of the required action
Universal self-care requisites
Universally required goals are to be met through self-care or dependent care, and they have their origins in what is known and what is validated, or what is in the process of being validated, about human structural and functional integrity at various stages of the life cycle
Eight self-care requisites common to men, women, and children are suggested:
Maintenance of a sufficient intake of air
Maintenance of a sufficient intake of food
Maintenance of a sufficient intake of water
Provision of care associated with elimination processes and excrements
Maintenance of balance between activity and rest
Maintenance of balance between solitude and social interaction
Prevention of hazards to human life, human functioning, and human well-being
Promotion of human functioning and development within social groups in accordance with human potential, known human limitations, and the human desire to be normal; normalcy is used in the sense of that which is essentially human and that which is in accordance with the genetic and constitutional characteristics and talents of individuals (Orem, 2001, p. 225)
Developmental self-care requisites
Provision of conditions that promote development
Engagement in self-development
Prevention of or overcoming effects of human conditions and life situations that can adversely affect human development (Orem, 1980,
Health deviation self-care requisites
Health deviation self-care requisites exist for persons who are ill or injured, who have specific forms of pathological conditions or disorders, including defects and disabilities, and who are under medical diagnosis and treatment.
The characteristics of health deviation as conditions extending over time determine the types of care demands that individuals experience as they live with the effects of pathological conditions and live through their durations.
Therapeutic self-care demand
Therapeutic self-care demand consists of the summation of care measures necessary at specific times or over a duration of time to meet all of an individual’s known self-care requisites, particularized for existent conditions and circumstances by methods appropriate for the following:
• Controlling or managing factors identified in the requisites, the values of which are regulatory of human functioning (sufficiency of air, water, and food)
• Fulfilling the activity element of the requisites (maintenance, promotion, prevention, and provision) (Orem, 2001,
Dependent-care demand is the summation of care measures at a specific point in time or over a duration of time for meeting the dependent’s therapeutic self-care demand when his or her self-care agency is not adequate or operational (
The self-care agency is a complex acquired ability of mature and maturing persons to know and meet their continuing requirements for deliberate, purposive action to regulate their own human functioning and development (Orem, 2001)
Dependent-care agency refers to the acquired ability of a person to know and meet the therapeutic self-care demand of the dependent person and/or regulate the development and exercise of the dependent’s self-care agency.
Self-care deficit is the relationship between an individual’s therapeutic self-care demand and his or her powers of self-care agency in which the constituent-developed self-care capabilities within self-care agency are inoperable or inadequate for knowing and meeting some or all components of the existent or projected therapeutic self-care demand (Orem, 2001)
Dependent-care deficit is a relationship that exists when the dependent-care provider’s agency is not adequate to meet the therapeutic self-care demand of the person receiving dependent-care.
Nursing agency comprises developed capabilities of persons educated as nurses that empower them to represent themselves as nurses and within the frame of a legitimate interpersonal relationship to act, to know, and to help persons in such relationships to meet their therapeutic self-care demands and to regulate the development or exercise of their self-care agency (Orem, 2001
Nursing design, a professional function performed both before and after nursing diagnosis and prescription, allows nurses, on the basis of reflective practical judgments about existent conditions, to synthesize concrete situational elements into orderly relations to structure operational units.
Nursing systems are series and sequences of deliberate practical actions of nurses performed at times in coordination with the actions of their patients to know and meet components of patients’ therapeutic self-care demands and to protect and regulate the exercise or development of patients’ self-care agency (Orem, 2001
• Acting for or doing for another
• Guiding and directing
• Providing physical or psychological support
• Providing and maintaining an environment that supports personal development
• Teaching (Orem, 2001)
Basic conditioning factors
Basic conditioning factors condition or affect the value of the therapeutic self-care demand and/or the self-care agency of an individual at particular times and under specific circumstances.
Ten factors have been identified:
• Developmental state
• Health state
• Pattern of living
• Health care system factors • Family system factors
• Sociocultural factors
• Availability of resources
• External environmental factors
Use of empirical evidence
As a practical science, nursing knowledge is developed to inform nursing practice. Orem (2001) stated that “nursing is practical endeavor, but it is practical endeavor engaged in by persons who have specialized theoretic nursing knowledge with developed capabilities to put this knowledge to work in concrete situations of nursing practice” (p. 161). The provision of nursing care occurs in concrete situations.
The conceptual elements and the specific theories of the SCDNT are abstractions about the features common to all nursing practice situations.
Orem (2001) identifies five premises underlying the general theory of nursing:
Human beings require continuous, deliberate inputs to themselves and their environments to remain alive and function in accordance with natural human endowments.
2. Human agency, the power to act deliberately, is exercised in the form of care for self and others in identifying needs and making needed inputs.
3. Mature human beings experience privations in the form of limitations for action in care for self and others involving making of life-sustaining and function-regulating inputs.
4. Human agency is exercised in discovering, developing, and transmitting ways and means to identify needs and make inputs to self and others.
5. Groups of human beings with structured relationships cluster tasks and allocate responsibilities for providing care to group members who experience privations for making required, deliberate input to self and others (p. 140)
Presented as a general theory of nursing that represents a complete picture of nursing, the SCDNT is expressed in the following three theories:
Theory of nursing systems
Theory of self-care deficit
Theory of self-care
Theory of nursing systems
The theory of nursing systems proposes that nursing is human action; nursing systems are action systems formed (designed and produced) by nurses through the exercise of their nursing agency for persons with health-derived or health-associated limitations in self-care or dependent-care.
Nursing agency includes concepts of deliberate action, including intentionality, and the operations of diagnosis, prescription, and regulation.
Theory of self-care deficit
The central idea of the theory of self-care deficit is that the requirements of persons for nursing are associated with the subjectivity of mature and maturing persons to health-related or health care–related action limitations.
These limitations render them completely or partially unable to know existent and emerging requisites for regulatory care for themselves or their dependents.
They also limit the ability to engage in the continuing performance of care measures to control or in some way manage factors that are regulatory of their own or their dependent’s functioning and development
Theory of self-care
Self-care is a human regulatory function that individuals must, with deliberation, perform themselves or must have performed for them to maintain life, health, development, and well-being.
Self-care is an action system. Elaboration of the concepts of self-care, self-care demand, and self-care agency provides the foundation for understanding the action requirements and action limitations of persons who may benefit from nursing.
Theory of dependent-care
The theory of dependent-care “explains how the self-care system is modified when it is directed toward a person who is socially dependent and needs assistance in meeting his or her self-care requisites” (Taylor & Renpenning, 2011, p. 24).
For persons who are socially dependent and unable to meet their therapeutic self-care demand, assistance from other persons is necessary.
Orem’s insight led to her initial formalization and subsequent expression of a general concept of nursing. This generalization then made possible inductive and deductive thinking about nursing.
Acceptance by the nursing community
Orem’s SCDNT has achieved a significant level of acceptance by the international nursing community, as evidenced by the magnitude of published material and presentations at the International Orem Society World Congresses (2008, 2011, and 2012).
In research using the SCDNT or components, Biggs (2008) found more than 800 references. Berbiglia (2014) identified selected practice settings and SCDNT conceptual foci from a review of more than 3 decades of use of the SCDNT in practice and research and publicized selected international SCDNT practice models for the 21st century.
From the time of publication of the first edition of Nursing: Concepts of Practice in 1971, Orem was engaged in continual development of her conceptualizations. She worked by herself and with colleagues.
The sixth and final edition was published in 2001. Her work with a group of scholars, known as the Orem Study Group, further developed the various conceptualizations and structured nursing knowledge using elements of the theory.
Nursing: Concepts of Practice (Orem, 2001) is organized with two foci: nursing as a unique field of knowledge and nursing as practical science.