Violeta A. Berbiglia and Barbara Banfield 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 to 1957) in Indiana working in the Division of Hospital and Institutional Services of the Indiana State Board of Health. Her goal was to upgrade the quality of nursing in general hospitals throughout the state. During this time, Orem developed her definition of nursing practice (Orem, 1956). 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). Later that year, Orem became an assistant professor of nursing education at CUA. She subsequently served as acting dean of the School of Nursing and as associate professor of nursing education. She continued to develop her concepts of nursing and self-care at CUA. Formalization of concepts sometimes was accomplished alone and sometimes with others. Members of the Nursing Models Committee at CUA and the Improvement in Nursing Group, which later became the Nursing Development Conference Group (NDCG), all contributed to the development of the theory. Orem provided intellectual leadership throughout these collaborative endeavors. In 1970, Orem left CUA and began her own 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 working, alone and with colleagues, on the development of Self-Care Deficit Nursing Theory (SCDNT). Orem’s many papers and presentations provide insight into her views on nursing practice, nursing education, and nursing science. Some of these papers are now available to nursing scholars in a compilation edited by Renpenning and Taylor (2003). Other papers of Orem and scholars who worked with her in the development of the theory are archived in Johns Hopkins University. 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” (p. 3). 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. What distinguishes these health services from one another is the helping service that each provides. Orem’s Self-Care Deficit Nursing Theory 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?”(p. 20). 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” (Orem, 2001, p. 20). It is the proper object or focus that determines the domain and boundaries of nursing, both as a field of knowledge and as a field of practice. The specification of the proper object of nursing marks the beginning of Orem’s theoretical work. The efforts of Orem, working independently as well as with colleagues, resulted in the development and refinement of the Self-Care Deficit Nursing Theory (SCDNT). Consisting of a number of conceptual elements and three theories that specify the relationships among these concepts, the SCDNT is a general theory, “one that is descriptively explanatory of nursing in all types of practice situations” (Orem, 2001, p. 22) Orem’s familiarity with literature was not limited to nursing literature. In her discussion of various topics related to nursing, Orem cited authors from a number of other disciplines. The influence of scholars such as Allport (1955), Arnold (1960a, 1960b), Barnard (1962), Fromm (1962), Harre (1970), Macmurray (1957, 1961), Maritain (1959), Parsons (1949, 1951), Plattel (1965), and Wallace (1979, 1996) can be seen in Orem’s ideas and positions. Familiarity with these sources helps to promote a comprehensive understanding of Orem’s work. Foundational to Orem’s SCDNT is the philosophical system of moderate realism. Banfield (1997) conducted a philosophical inquiry to explicate the metaphysical and epistemological underpinnings of Orem’s work. This inquiry revealed consistency between Orem’s views regarding the nature of reality, the nature of human beings, and the nature of nursing as a science and the ideas and positions associated with the philosophy of moderate realism. Taylor, Geden, Isaramalai, and Wongvatunyu (2000) also explored the philosophical foundations of the SCDNT. 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. With regard to the nature of human beings, “the view of human beings as dynamic, unitary beings who exist in their environments, who are in the process of becoming, and who possess free-will as well as other essential human qualities” is foundational to SCDNT (Banfield, 1997, p. 204). This position, which reflects the philosophy of moderate realism, can be seen throughout Orem’s work. Orem (1997) identified “five broad views of human beings that are necessary for developing understanding of the conceptual constructs of self-care deficit nursing theory and for understanding the interpersonal and societal aspects of nursing systems” (p. 28). These are the view of (1) person, (2) agent, (3) user of symbols, (4) organism, and (5) object. The view of human beings as person reflects the philosophical position of moderate realism; it is this position regarding the nature of human beings that is foundational to Orem’s work. She made the point that taking a particular view for some practical purpose does not negate the position that human beings are unitary beings (Orem, 1997, p. 31). 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. “Deliberate action refers to actions performed by individual human beings who have intentions and are conscious of their intentions to bring about, through their actions, conditions or states of affairs that do not at present exist” (Orem, 2001, pp. 62-63). When engaging in deliberate action, the person acts as an agent. The view of person-as-agent also is reflected in other conceptual elements of the SCDNT. In relation to the view of person-as-agent and the idea of deliberate action, Orem cited a number of scholars, including Arnold, Parsons, and Wallace. She identified seven assumptions regarding human beings that pertain to deliberate action (Orem, 2001, p. 65). These explicit assumptions, while addressing deliberate action, rest upon the implicit assumption that human beings have free will. The SCDNT represents Orem’s work regarding the substance of nursing as a field of knowledge and as a field of practice. She also put forth a position regarding the form of nursing as a science, identifying it as a practical science. The work of Maritain (1959) and Wallace (1979), philosophers associated with the moderate realist tradition, are cited in relation to her ideas about the form of nursing science. In practical sciences, knowledge is developed for the sake of the work to be done. In the case of nursing, knowledge is developed for the sake of nursing practice. Two components make up the practical science: the speculative and the practical. The speculatively practical component is theoretical in nature, while the practically practical component is directive of action. The SCDNT represents speculatively practical knowledge. Practically practical nursing science is made up of models of practice, standards of practice, and technologies. 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. In relation to this proposed structure of nursing sciences, Orem stated, “the isolation, naming, and description of the two sets of sciences are based on my understanding of the nature of the practical sciences, on my knowledge of the organization of subject matter in other practice fields, and on my understanding of components of curricula for education for the professions” (pp. 174–175). In addition to the two components or types of practical science, scientific knowledge necessary for nursing practice includes sets of applied sciences and basic non-nursing sciences. In the development of applied sciences, theories from other fields are used to solve problems in the practice field. These applied nursing sciences have yet to be identified and developed. Box 14-1 depicts the structure of nursing science. 1. The theory of self-care, which describes why and how people care for themselves 2. The theory of self-care deficit, which describes and explains why people can be helped through nursing 3. The theory of nursing systems, which describes and explains relationships that must be brought about and maintained for nursing to be produced The major concepts of Orem’s theories are identified here and discussed more fully in Orem (2001), Nursing: Concepts of Practice (see Figure 14-1). 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, p. 522). 1. The factor to be controlled or managed to keep an aspect(s) of human functioning and development within the norms compatible with life, health, and personal well-being UNIVERSAL SELF-CARE REQUISITES 1. Maintenance of a sufficient intake of air 2. Maintenance of a sufficient intake of food 3. Maintenance of a sufficient intake of water 4. Provision of care associated with elimination processes and excrements 5. Maintenance of balance between activity and rest 6. Maintenance of balance between solitude and social interaction 7. Prevention of hazards to human life, human functioning, and human well-being 8. 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 Developmental self-care requisites (DSCRs) were separated from universal self-care requisites in the second edition of Nursing: Concepts of Practice (Orem, 1980). Three sets of DSCRs have been identified, as follows: 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, p. 522). Self-care deficit is a relation between persons’ therapeutic self-care demands and their powers of self-care agency in which the constituentdeveloped self-care capabilities within self-care agency are not operable or are not adequate for knowing and meeting some or all components of the existent or projected therapeutic self-care demand (Orem, 2001, p. 522). 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, p. 518). 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. The purpose of nursing design is to provide guides for achieving needed and foreseen results in the production of nursing toward the achievement of nursing goals; these units taken together constitute the pattern that guides the production of nursing (Orem, 2001, p. 519). 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, p. 519). As a practical science, nursing knowledge is developed to inform nursing practice. Orem (2001) stated, “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. As nurses enter into nursing practice situations, they use their knowledge of nursing science to assign meaning to the features of the situation, to made judgments about what can and should be done, and to design and implement systems of nursing care. From the perspective of the SCDNT, desired nursing outcomes include meeting the patient’s therapeutic self-care demand and/or regulating and developing the patient’s self-care agency. The conceptual elements and the three specific theories of the SCDNT are abstractions about the features common to all nursing practice situations. The SCDNT was developed and refined through the use of intellectual processes that focused on nursing practice situations. For example, Orem reflected on her nursing practice experiences to identify the proper object of nursing. In their work related to the SCDNT, the Nursing Development Conference Group (1979) engaged in analysis of nursing cases and in processes of analogical reasoning. In a tribute to Orem, Allison (2008) talks about the Nursing Development Conference Group, saying that “these nurses came together because they were interested in and willing to commit themselves to examining nursing situations in order to formalize ways of thinking about nursing that they felt were descriptive of nursing and would contribute to nursing knowledge” (p. 50). Since the SCDNT was first published, extensive empirical evidence has contributed to the development of theoretical knowledge. Much of this is incorporated into continuing refinement of the theory; however, the basics of the theory remain unchanged.
Self-Care Deficit Theory of Nursing
CREDENTIALS AND BACKGROUND OF THE THEORIST
THEORETICAL SOURCES
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 requisite (maintenance, promotion, prevention, and provision) (Orem, 2001, p. 523)
USE OF EMPIRICAL EVIDENCE
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