orem theory

nursing

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NURSING THEORY OF DOROTHA E. OREM:

INTRODUCING THE THEORIST:
Dorotha E. Orem, MSNEd, DSC, RN, is described as a pioneer in the development
of distinctive nursing knowledge. She began her nursing education at Providence
Hospital School of Nursing in Washington, D.C. After graduating in the early
1930s, she obtained her Bachelor of Science in nursing education in 1945 from the
Catholic University of America. During her professional nursing career, she has
worked as a staff nurse, private duty nurse, nurse educator and administrator, and
nurse consultant.
Orem contends that the term “care” describes nursing in a most general way, but
does not describe in a way that distinguishes it from other forms of care. She
argues that nursing is distinguished from other human services and other forms of
care by the way in which it focuses on human beings.
Since 1970, Orem has worked as a consultant in nursing and nursing education
with the firm of Orem and Shields in Chevy Chase, Md. She has received several
national awards including an honorary Doctor of science degree from Georgetown
University, Washington, D.C.in 1976, and the Catholic University of America’s
Alumni Achievement Award for Nursing Theory in 1980.

During 1958-59, as a consultant to the Office of Education, and Welfare, Dorotha
E.Orem participated in a project to improve practical (vocational) nurse training.
This work stimulated her to consider the question, “What condition exists in a
person when that person or others determine that that person should be under
nursing care?” Her answer concluded that the human condition associated with the
need for nursing is the existence of a health-related limitation in the ability of
persons to provide for self the amount and quality of care required. This
encompassed the idea that a nurse is “another self.” This evolved into her nursing
concept of “self-care.” That is, when able, individuals care for themselves. When
the person is unable to provide self-care, then the nurse provides assistance.

In 1959, Orem’s concept of nursing as the provision of self-care was first
published. In 1965, she joined with several faculty members from the Catholic
University of America to form a Nursing Model Committee, including Orem,
continued their work through the Nursing Dev elopment Conference
Group(NDCG). This group was formed to produce a conceptual framework for
nursing and to establish a discipline of nursing. The NDCG published Concept
Formalization in Nursing: Process and Product in 1973 and 1979.

Orem further developed her nursing concepts of “self-care” and in 1971 published
Nursing Concepts of Practice. The second and third additi0ns of the book were
published in 1980 and 1985. The first edition focused on the individual. The

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second edition was expanded to include multiperson units (families, groups and
communities). The third edition has evolved to present Orem’s general theory of
nursing which is constituted from three related theoretical constructs:(1) the theory
of self-care, (2) the theory of self-care deficits, and (3) the theory of nursing
systems.
Orem’s general theory of nursing:
According to Orem “nursing has its special concern the individual’s need for self-
care action and the provision and management of it on a continuous basis in order
to sustain life and health, recover from disease or injury, and cope with their
effects. In her third edition of Nursing: Concepts of Practice, Orem develops her
general theory of nursing in three related parts. These parts are :( 1) self-care, (2)
self-care deficit, (3) nursing systems.
THE THEORY OF SELF -CARE:
The theory of self-care includes self-care, self-care agency, and therapeutic self-
care demand as well as self-care requisites. Self-care is the “practice of activities
that individuals initiate and perform on their own behalf in maintaining life, health
and well-being.” “Self-care…..effectively performed contributes in specific ways
to human functioning, and human development. Self-care agency is a human
ability which is “the ability for engaging in self-care.”

“The individual’s abilities to engage in self-care…are conditioned by age,
developmental state, life experience, socio-cultural orientation, health and
available resources” Normally, adults voluntarily care for themselves. Infants,
children, the aged, the ill, and the disabled require complete care or assistance with
self-care activities.” The therapeutic self-care demand is the “totality of self-care
actions to be performed for some duration in order to meet self-care requisites by
using valid methods and related sets of operations and actions.”
Orem presents three categories of self-care requisites or requirements as :( 1)
universal, (2) developmental, and (3) health deviation. Self-care requisites can be
defined as actions directed toward the provision of self-care. Universal self-care
requisites are associated with life processes and maintenance of the integrity of
human structure and functioning. They are common to all human beings during all
stages of life cycle and should be viewed as interrelated factors, each affecting the
others. A common term for these requisites is the activities of daily living. Orem
identifies self-care requisites as:
1. The maintenance of a sufficient intake of air.
2. The maintenance of a sufficient intake of water.
3. The maintenance of a sufficient intake of food.
4. The provision of care associated with elimination processes and
excrements.
5. The maintenance of balance between activity and rest.

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6. The maintenance of balance between solitude and social interaction.
7. The prevention of hazards to human life, human functioning, and human
well-being.
8. The promotion of human functioning and development within social
groups in accord 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 accord with the genetic and
constitutions characteristics and the talents of individuals.

THE THEORY OF SELF -CARE DEFICIT:
The theory of self-care deficit is the core of Orem’s general theory of nursing
because it delineates when nursing is needed. Nursing is required when an adult
(or in he case of a dependent, the parents or guardian) is incapable or limited in the
provision of continuous effective self-care. Nursing may be provided if the “care
abilities are less than those required for meeting a known self-care demand….(or)
self-care or dependent care abilities exceed or are equal to those required for
meeting the current self-care demand but a future self-care deficit relationship can
be foreseen because of predictable decreases in care abilities, qualitative or
quantitative increases in the care demand or both; when individuals need “to
incorporate newly prescribed ,complex self-care measures into their self-care
systems, the performance of which requires specialized knowledge and skills to
be acquired through training and experience; or the individual needs to help “in
recovering from disease or injury, or in coping with its effects. It is important to
note that the first category includes universal, developmental and health deviation
self-care needs while the other categories focus on health deviation self-care.

Orem identifies five methods of helping. These are:
1. Acting for or doing for another.
2. Guiding another.
3. supporting another(physically or psychologically)
4. Providing an environment that promotes personal development in relation
to becoming able to meet present or future demands for action.
5. Teaching another.

The nurse may help the individual by using any or all of these methods to
provide assistance with self care.
Orem presents a model to show the relationship between her concepts. From
this model, it can be seen that a given time an individual has specific self-care
abilities as well as therapeutic self-care demands. If there are more demands
than abilities, nursing care can be used to describe the domain of nursing.

Orem has identified five areas of activity for nursing practice:

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1) Entering into and maintaining nurse-patient relationships with individuals,
families, or groups until patients can legitimately be discharged from
nursing.
2) Determining if and how patients can be helped through nursing.
3) Responding to patients’ requests, desires, and needs for nurse contacts and
assistance.
4) Prescribing, providing and regulating direct help to patients and their
significant others in the form of nursing.
5) Coordinating and integrating nursing with the patient’s daily living, other
health care needed or being received, and social and educational services
needed or being received.
Self-care has been defined and the need for nursing explained in the first and
second theories. In Orem’s third theory of nursing systems, she outlines how
the patient’s self-care needs will be met by the nurse, the patient, or both.




A conceptual framework for nursing:


R=relationship
V= deficit relationship, current or projected

Self-
care

Therapeu
tic self-
care
demand
Nursing
capabiliti
es
Self-
care
capabili
ties
R
R R
R
V
NURSE
PATIENT

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THE THEORY OF NURSING SYSTEMS:
The nursing system, designed by the nurse is based on the self-care needs and
abilities of the patient to perform self-care activities. Orem has identified three
classifications of nursing systems to meet the self-care requisites of the patient.
These systems are: the wholly compensatory system, the partly compensatory
system, and the supportive educative system.
The design and elements of the nursing system define “(1) the scope of nursing
responsibility in health care situations, (2) the general and specific roles of nurses
and patients, and (3) reasons for nurses’ relationships with patients, and (4) the
kinds of actions to be performed and the performance patterns and nurses’ and
patients actions in regulating patients’ self-care agency and in meeting their
therapeutic self-care demand.”
The wholly compensatory nursing system is represented by a situation in which the
individual is unable “to engage in those self-care actions requiring self-directed
and controlled ambulation and manipulative movement or the medical prescription
to refrain from such activity ….. Persons with these limitations are socially
dependent on others for their continued existence and well-being.” Subtypes of the
wholly compensatory system are nursing systems for people who are: “1) unable
to engage in any form of deliberate action, for example, persons in coma 2)
….aware and who may be able to make observations, judgments and decisions
about self-care and other matters but cannot or should not perform actions
requiring ambulation or manipulative movements 3)…unable to attend to
themselves and make reasoned judgements and decisions about self-care and other
matters but who can be ambulatory and may be able to perform some measures of
self-care with continuous guidance and supervision.” Examples of persons in the
second subtype could include those with those C3-C4 vertebral fractures and, the
third subtype, persons with advanced senility or some forms of mental retardation.

The partly compensatory nursing system is represented by a situation in which
“both nurse and patient perform care measures or other actions involving
manipulative tasks or ambulation…. [Either] the patient or the nurse may have the
major role in the performance of care measures.” An example of person needing
nursing care in the partly compensatory nursing system would be an individual
who has had recent abdominal surgery. This patient might be able to wash his or
her face and brush teeth but needs the nurse for help in ambulating and in
changing the surgical dressing.

The third nursing system is the supportive-educative system. In this system the
person “is able to perform or can and should learn to perform required measures of
externally or internally oriented therapeutic self-care but cannot do so without
assistance.” This is also known as supportive-developmental system. In this
system the patient is doing all of his self-care. The “patient’s requirements for help
are confined to decision making, behavior control, and acquiring knowledge and

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skills.” The nurse’s role is then to promote the patient as a self-care agent. An
example of a person in this type of system would be a sixteen-year-old who is
requesting birth control information.

Orem states that “one or more three types (of systems) may be used with a single
patient. For example, a woman in labor may move from a supportive-educative
system in early labor to a partly compensatory system as her labor advances. If
she requires a cesarean delivery, her care might require her to be in a wholly
compensatory system as she recovers from the anesthetic. Later, as she prepares to
go home, a supportive-educative system would again be appropriate.







WHOLLY COMPENSATORY SYSTEM












PARTLY COMPENSATORY SYSTEM











Accomplishes patient’s therapeutic self-care

Compensates for patient’s inability to engage in self-care
Supports and protect patient

Performs some self-care measures for patient

Compensates for patient’s self-care limitations of
patient
Assists patient as required

Performs some self-care measures

Nurse
action
Patient action
limited
Nurse
action

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SUPPORTIVE-EDUCATIVE SYSTEM















Regulates self-care agency

Accepts care and assistance from nurse

Accomplishes self-care

Regulates the exercise and development of
self-care agency

Patient
action
Patient
action
Nurse
action

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Comparison of Orem’s Nursing Process and The
Nursing Process









Application of Orem’s Theory to Nursing Process

ASSESSMENT
Personal Universal Developmental Health Medical Self-care
Factors Self-care Self-care Deviations Problem Deficits
And Plan
Age Air, water, food Specialized Conditions Physician’s Difference
Sex Excrements needs for of illness perspective between
Height Activity and rest developmental or injury of condition self-care
Weight Solitude and process needs and
Culture social-interaction New requisites Medical self-care
Race Hazards to life from a condition diagnosis capabilities
Marital and well-being Treatments
Status Requisites to correct Medical
Nursing process Orem’s Nursing Process
1.Assessment STEP 1.Diagnosis and prescription; Determine why nursing
is needed. Analyze and interpret –make judgements
regarding care.
2. Nursing diagnosis STEP 2. Design of a nursing system and plan for delivery
of care.
3. Plans with scientific
rationale
4. Implementation STEP 3. Production and management of nursing systems
5. Evaluation

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Religion Promotion of associated injury treatment
Occupation human functioning with a
and development event


Nursing Diagnosis Plan Implementation Evaluation
Based on self-care Nursing goals Nurse-patient actions Effectiveness of
Deficits and objectives: to: nurse-patient
a. Congruent a. Promote patient actions to:
with nursing and self-care needs a. Promote
diagnosis b. Meet self-care patient as
b. Based on needs self-care
self-care c. Decrease agent
demands self-care deficits b. Meet self-care
c. Promotes needs
patient as c. Decrease
self-care agent self-care deficits
Designing the Nursing
system :
a. Wholly
compensatory
b. Partly
compensatory
c. Supportive-educative

Appropriate methods of
helping:
a. Guidance
b. Support
c. Teaching
d. Acting or doing for
e. Providing
developmental
environment

The following example will demonstrate the use of Orem’s model and nursing
process:
OREM’S WORK AND THE CHARACHTERISTICS OF A THEORY
characteristics of theory is as follows:
1. Theories can interrelate concepts in such a way as to create a different
way of looking at a particular phenomenon.
2. Theories must be logical in nature.

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3. Theories should be relatively simple yet generalizable.
4. Theories are the basis for hypothesis and can be tested.
5. Theories contribute to and assist in increasing the general body of
knowledge within the discipline through the research implemented to
validate them.
6. Theories can be used by the practitioners to guide and improve their
practice.
7. Theories must be consistent with other validated theories, laws, and
principles.
STRENGHTS AND LIMITATIONS

STRENGTHS OF THE OREM’S THEORY:
1. A major strength of the Orem’s theory is that she specifies when nursing is
needed.
2. she also includes continuing education as part of professional component
of nursing education
3. Orem promotes the concept of professions nursing. she defines the roles of
vocational, technical and professional nurses and recognizes the
importance of each
4. She emphasizes that nurses are educated not trained. In the process of
education, nurses learn to “think nursing” as an action distinct from the
“skilled performance of standardized sets of operations or skilled
performance of tasks.”
5. Her self-care premise is contemporary with the concept of health
promotion and health maintenance. Self-care in Orem’s theory is
comparable to holistic health in that both promote individual’s
responsibility for health care. This is especially relevant with today’s
emphasis on early hospital discharge, home care, and outpatient services.
6. Orem has expanded her focus of individual self-care to include
multiperson units (families, groups, communities). Although most of her
third edition still focuses on individual, she recognizes the value of family
members and significant others for the individual’s provision of self-care.
7. According to Orem, “nurses should select the type of nursing system or
sequential combination of nursing system that will have the optimum effect
in achieving the desired regulation of patient’s self-care agency and the
meeting of their self-care requisites.” Some practioners have found Orem’s
theory to be more clinically applicable when more than one system is used
concurrently.
8. Orem recognizes the term “client” as a regular seeker of health services but
prefers the term “patient” for one who is “under the care of nurses,
physicians, or other direct health care providers.”

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LIMITATIOMS OF OREM’S THEORY:
1. Orem’s use of term system is different than that used in general system
theory. She defines a system as a “single, whole thing.” In general system
theory, a system is viewed as a dynamic flowing process.
2. Health is often viewed as dynamic and ever-changing. Orem’s visual
presentation of the boxed nursing systems implies three static conditions of
health.
3. Throughout her work there is limited acknowledgement of the emotional
needs of humans.
4. Orem has organized her third edition into the three broad divisions of an
introduction, theoretical development and application in nursing practice.
She has defined the terms used within the theory i.e., nursing agency and
self-care agency. However, some terms need more clarification, i.e.
diagnosis, prescription, technologies and therapeutic self-care demands.
5. The term self-care is used with different connotations. This multitude of
terms such as self-care agency, self-care demand, self-care premise, self-
care deficit and universal self-care can be confusing to the reader.
6. A limitation is found in her references. While Orem’s third edition was
published in 1985, some of her references could be considered outdated
relative to contemporary nursing for example. For example many of journal
articles in her lists of selected readings are from 1960’s and are not
accompanied by comparison articles from 1980.