Introduction
The theoretical and conceptual work of nursing development activities through various clinical practices have left many role models for us in the nursing and patient care community. This research paper presents the development of Orem’s Self-care Nursing Model (OSCNM) which is widely used today as the accomplishment of Dorothea Orem’s nursing theory. Such accomplishments illustrated the development of her idea into nursing education, research, and clinical practice. OSCNM was developed when in 1959 Orem realized the lack of a substantive and structured body of nursing knowledge and services in general hospitals. She discovered that patients wish to take care of themselves and in the course of that philosophy, patients recover faster than the usual time period if they are permitted to perform their own self-care. Apart from this central philosophy, self-care deficit theory was developed as an answer to those concerns that initiate in hospitals under issues such as lack of efficient nursing staff, lack of pay rewards, need for nursing recognition, etc. Orem aimed to upgrade nursing quality throughout the state and found out some factors that distract nurses from performing their tasks. Such factors were the reasons faced by the hospital staff in the form of demands regarding issues like length of stay, variations among patient types, scheduling admissions and discharges, etc.
This paper describes some of the aspects that incur during the enhancement of self-care deficit theory. These aspects are inquired on the basis of clinical implication so as to get a clear picture of the strengths and vulnerabilities associated with this model. But before embarking on such a description it will be helpful to evaluate the major components and some background of the model. This will help us to visualize what has caused the transformation of Orem’s theory into applied practical nursing sciences. Therefore, the paper discusses applied nursing science questions and problems that arise from this model in context with the social and interpersonal aspects of contemporary nursing practice.
Self-Care Deficit Model
This model was built to fulfill the categories of one of either two categories of self-care demands, universal self-care and health deviation category. Carey (2000, p. 110) points out that OSCNM presents the concept of universal self-care to incorporate the actions an individual undertakes to maintain basic human needs. These actions include the daily intake of air, food, water, excretion, rest, socialization, well-being, and normalization (Carey, 2000, p. 110). The health deviation category illustrates those conditions under which the patient is not able to meet his/her sufficient needs. For this purpose health, deviation category is also known by Orem as a nursing agency. This condition is due to those ‘self-care demands’ that the individual is not able to maintain due to some critical illness.
Theoretically, the definition of self-care explains a unique relationship that one experiences with self or another by capturing the psychological sense of ‘self-concept’ or ‘self-image’. When dealing with oneself, it pertains to ‘care’. However, when dealing with the patient it requires some caring ethics to be fulfilled that needs the practice to be influential by an audience as a sensible modification of one’s existing self-care practices (Ziguras, 2003, p. 25). Orem’s model emphasized those ethics that promote welfare while maintaining universal self-care. Thus, she constructed an ideal framework through ‘self-care’ under the influence of professional nursing. This ‘self-care’ in context with nursing can be defined as those personal abilities and actions that necessitate individuals to plan, organize, and arrange everything that is necessary for their own care (Kim & Kollak, 2006, p. 42-43). What Orem learned from her own nursing experience provided her the opportunity to put that content in the category of the domain and boundaries of ‘self-care’. She attempted to shift nursing away from a medical model of practice to adjust it in the health and social systems.
Orem’s model suggested that professional care must fulfill all the standards of the clinical setting. This will also provide a legitimate system of self-care resulting in a complete formation of organizing a system of care provision. The range of self-care will be from guidance to support and even acting on behalf of the patient, called by Orem as the “supportive, informative, educative, semi-compensatory as well as partial compensatory nursing system” (Kim & Kollak, 2006, p. 47). Since the model interprets only those deficiencies in self-care as being temporarily or partially limiting and thus needs to be compensated for by professional nursing. Therefore, in order to understand various components of the system, we discuss the self-care model in requisites discussed below.
Self-Care Requisites
Self-care requisites identified by Orem included five criteria that define health by pointing towards all the conditions that in this regard are associated while interacting with the patient. The nurse is not aimed to treat only the disease but is accountable for taking into account the patient as a whole and for meeting his/her mental, physical, biological and spiritual needs. Later after proposing the theory of self-care, Orem felt the need to enhance the theory by adding an additional concept in the form of self-care requisites, which refer to those actions that are taken in order to address the provision of care. These requisites are prevalent under the three requirements of self-care discussed above as universal, developmental and health deviation.
- Universal self-care Requisites are associated with the basic conditioning factor that refers to those needs that pertain generally to people throughout the world irrespective of age, sex, developmental or health state. These are the needs that treat the human and social foundations for the human functions of self-care and the interpersonal function of dependent care (McLaughlin & Taylor, 2003, p. 149). Such courses develop and build upon the themes of deliberate human action. As they require immediate help in terms of formulation of self-care agents they may be dependent or independent. Universal requisites include those common measures that refer to what health specialists usually do, what they avoid while doing, or special adjustments they prefer to make. This also pertains to situations in which they are uncertain what to do either because of a lack of necessary resources or unknown procedures. McLaughlin & Taylor (2003, p. 165) suggests what Orem’s universal self-care requisites are aimed to meet are the four standards including a balanced relationship between activity and rest, solitude and social interaction, hazards prevention and developing and sustaining a realistic self-concept.
- Developmental requisites refer to those processes that are encouraged to enhance life while preventing conditions that might be harmful to extend or rationalize those effects. This is done by developing a sequence of courses that focus on the social or interpersonal aspects of helping or the ways of helping the patient. Such requisites provide guidance and every sort of physical and psychological support.
- Health deviation requisites refer to those needs that arise due to a particular result of a patient’s condition. This also points towards a disease, disability or injury that affects not only specific structures including the physiological and psychological mechanisms of the human body but also impacts human functioning by seriously affecting the patient’s nerves. The patient is subjected to health deviation on a permanent or temporary basis. This also frustrates the patient to receive appropriate medical care so as to immediately acquire relief from the painful situation. Health-deviation self-care activities are not limited to be measured on the basis of interviews, questionnaires, patient’s knowledge or attitudes. But is measured on the basis of various self-care instruments that are allowed to be utilized by the clinician on some specific conditions. The most fundamental is the requirement of the clinician to possess authoritative knowledge of the patient’s pathological and diagnostic processes involved in the subject. These requisites are often transformed into practical personalized situations that are implementable on the basis of only accurate information. Practitioners must know their limitations, what they know, can do and cannot do (McLaughlin & Taylor, 2003, p. 320).
Self-Care: The Reductionist Approach
The reductionist approach in self-care is not developed simultaneously with the ‘self-care’ model. In fact, it is the later enhancement of the clinical practice that with the passage of time embedded in the model. It serves as the ultimate dependency of the individual on the nursing agency of the hospital staff and management. This dependent self-care system divides the individuals into a set of activities that are required for everyday living such as breathing, eating, drinking and eliminating. Such kind of self-care in case management has been adopted within professional groups to aid assessment and diagnosis to those patients who are unable to rely on their own. However below discussed case illustrates some of the weaknesses related to this approach.
Illustration
A middle-aged man diagnosed with Type I diabetes mellitus when admitted with a ‘diabetic foot’ is subjected to an ulcer affecting his right big toe and is unable to cope at home with his illness. Therefore doctors contribute to this patient’s care by taking responsibility for his overall management of medical care in the following stance: nurses contribute for managing his nursing care interventions, dietician for nutritional support, occupational therapist for adjusting his activities of living, a social worker for advice on available support services, physiotherapist for mobility, and diabetes specialist for advising on diabetic management (McSherry, 2006, p. 76). This self-care perspective having practical clinical implications is helpful in delegating professionals their specific areas of responsibility. This indicates the threat that the problems may remain undetected and make the reductionist approach within self-care less effective. This might occur because the division of the problem into various chunks may lead to loss of important information or uncommunicated or fragmented information (Ahn et al, May 2006).
Self-care based on Evidence-Based Practice
EBP allows the nurse to not only consider his/her own judgment regarding the patient’s treatment but also consider the patient’s perspective and values his or her suggestions while applying that evidence in practice. Orem emphasized the clinical expertise of the nurse and referred to his/her assessment of the patient’s condition through findings of physical examination and laboratory reports (Levin & Feldman, 2006, p. 10). However, this is the case pertaining to universal care requisites in which patients’ perspectives are valued the utmost and their self-determined choices are valued on the treatment options presented and available. In the other two requisites self-care can be assessed on the condition whether or not the patient is aware of his/her critical condition. But this requires self-evaluation conduct of EBP.
Since EBP is a broader field than usual research, it considers the findings of the research as a single source of evidence. It does not take into account what it gets from other sources or research. There are other sources including clinical outlines produced under expert panels, theoretical evidence, and case studies (Levin & Feldman, 2006, p. 11). But the main purpose of EBP underlying self-care is not to acquire from the sources, but from the experiences that offer the patient with the best evidence to practice. Therefore, EBP allows the patient under any requisites criteria to assess contemporary protocols and practice and introduce to him/her the latest innovations.
In the light of Critics
Contemporary self-care is not what it was originally based upon in the interest of the patient’s well-being. Today, self-care has transformed into ‘innovations’ that provide profit to marketing and advertising companies. However, this profit is not calculated at the cost of a patient’s risk. In fact, it is measured on the basis of impersonal principles that stand on the foundations of independent individual practitioners and the specific context in which the expertise is applied. Even many experienced practitioners blame the newcomers for relating the social contexts to the modern self-care expert systems to evacuate local and culturally specific content and replace it with a more organized body of knowledge.
There is no doubt that the self-care model has made life easier for nurse practitioners and health care by providing them with a variety of nursing situations, but many practitioners complained about being limited to informing practice in the respective field. The model has been criticized for making a reference to an interchangeable audience, who utilize the model often in their own interest. This has been blamed that many experts reassure their lay clients by advertising their possession of interchangeable institutional knowledge. They disclose and portray their profession unnecessarily by displaying their degrees on the walls of their consulting rooms. This leaves a good impression on the minds of patients and seems useful as long as universal self-care requisites are concerned.
Many modernized practitioners emphasize on risk base calculation in self-care that usually leads to the production of risk-minimization techniques. Such techniques are communicated to individuals in order to facilitate independent self-care. However, in this modernized epoch where there is a much closer relationship between research and behavior modification, the result of this precision is nothing but to indicate to the patient that it will be best in his/her interest to rely on his/her own advice self-care. This in other words alerts the patient to seek other ‘alternative’ forms of self-care. This indicates that practitioners who generally base their risk assessments on scientifically defined risks through self-care techniques advocate risk-minimization strategies not to be endorsed by the scientific community.
Marketing companies advertise their products on the basis of ‘self-care’ and receive mass attention.
Illustration
A company that advertises skincare ranges considers sunscreen with reference to pointing towards the threat of depletion of the ozone layer as a cause of the increased risk of skin cancer. At the same time, they do not consider self-care ethics that requires their advertising airtime to provide sufficient knowledge to people about the process of regenerating the ozone layer. Moreover, the empirical deficits in this model are limited to advance nursing knowledge in this era.
Ending Thoughts
The way Orem has presented before us the concept of ‘self-care’ elucidates the extent to which she was holistic towards the people. Her enhancement on the subject reveals all the essential activity elements of a patient’s therapeutic self-care demands. These demands are to be performed in a manner that they meet formalized and personalized self-care requisites while at the same time keeping in the ethical context. That means the staff must be aware of the responsibility they share with the patient and must fulfill their duties. From self-care to self-care promotion and from Orem’s self-care to contemporary self-management, what matters is how the model is implemented, utilized, practiced, learned, and enhanced.
References
Ahn, C. Andrew, Tewari Muneesh, Poon Chi-Sang & Phillips, S. Russell. (2006). The Clinical Applications of a Systems Approach. Web.
Carey Lynda. (2000). Practice Nursing. Royal College of Nursing.
Kim, Suzie Hesook & Kollak Ingrid. (2006). Nursing Theories: Conceptual and Philosophical Foundations: Springer: London.
Levin F. Rona & Feldman R. Harriet. (2006). Teaching Evidence-Based Practice in Nursing: A Guide for Academic and Clinical Settings: Springer: London.
McLaughlin Katherine Renpenning & Taylor G. Susan. (2003). Self Care Theory in Nursing: Selected Papers of Dorothea Orem: Springer: London.
McSherry Wilfred. (2006). Making Sense of Spirituality in Nursing and Health Care Practice: An Interactive Approach: Jessica Kingsley: London.
Ziguras Christopher. (2003). Self-Care: Embodiment, Personal Autonomy, and the Shaping of Health Consciousness: Routledge: London.