Nursing Science Quarterly, 14:1, January 2001

Dependent-Care

A Theory of Dependent-Care: A Corollary Theory

to Orem’s Theory of Self-Care
Susan G. Taylor, RN; PhD; FAAN
Professor, Sinclair School of Nursing, University of Missouri–Columbia

Kathie E. Renpenning, MScN

MCL Educational Services, Inc., Mesa, Arizona

Elizabeth A. Geden, RN; PhD; FAAN

Professor, Sinclair School of Nursing, University of Missouri–Columbia

Bonnie M. Neuman, RN; PhD

Associate Professor, Armstrong Atlantic State University, Savannah, Georgia

Marcella A. Hart, RN; PhD

Professor, Armstrong Atlantic State University, Savannah, Georgia

Dependent-care has its origins in people’s requirements for regulatory care. The foundations for dependent-care
are found in the ability of individuals to provide their required care. First introduced as a corollary to self-care, this
work emerged through a process of reading and discussion. Models that support the theory of dependent-care are
identified. Premises are stated. There is elaboration of the conceptualizations representing the work that has been
done. There are still elements that need further development, such as specifying the enabling abilities of depend-
ent-care agency and verifying and formalizing the various elements presented.

The theory of self-care is one of the
constituent theories of Orem’s self-care
deficit nursing theory (SCDNT).
Knowledge of self-care is foundational
to a theory of dependent-care. Like
self-care, dependent-care has its origins
in people’s requirements for regulatory
care. Orem (1995) reports that the terms
dependent-care (DC), dependent-care
agency (DCA), and dependent-care
agent were introduced in the 1970s
when it became apparent, in the devel-
opment of SCDNT, that there was a
need for them. In 1980, the term DCA
was used in relation to adults who pro-
vide care activities for infants, children,
and dependent adults. Orem (1985)
more fully explained DCA and DC ac-
tions as part of her conceptualizations
about family. By 1995, the broad con-
ceptual structure of DCA was laid out as
Nursing Science Quarterly, Vol. 14 No. 1,
January 2001, 39-47
© 2001 Sage Publications, Inc.
being “formed by capabilities to per-
form estimative, transitional, and pro-
ductive operations in knowing and
meeting the TSCD (therapeutic self-
care demand) of another” (Orem, 1995,
p. 242). At that time, the importance of
the duality of roles of the individual as
DC agent and self-care (SC) agent was
expressed. The foundations for DC are
also found in the ability of individuals to
provide their required care. The work
reported here is an ongoing development
of DC. The authors working with Orem
and other scholars expanded upon the
existing conceptualizations of depend-
ent-care and developed a theory of DC.
Terms used in this article are defined in
Table 1.
Models and Theories Foundational
to the Theory of DC
The authors studied a number of
models presumed to be foundational to
conceptualizations of DC. In addition to
Orem’s theory of self-care, models or
theories of personalism, deliberate ac-
tion and action system, helping, inter-
personal interaction, adult learning,
technology, and parenting were studied.
A precise review of these is presented to
highlight their foundational contribu-
tions to our work vis-à-vis a theory of
DC.
Personalism
A foundational principle of
personalism is the “affirmation of the
individual person as a person, that is, the
affirmation of her (him) as subject for
her (his) own sake. This requires that the
other be recognized as an end in herself
(himself), as an acting subject who
chooses her (his) own ends and pur-
poses, as a ‘presence,’ an inexhaustible
Keywords: dependent-care, Orem,
self-care, self-care deficit nursing theory

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40 Nursing Science Quarterly, 14:1, January 2001

Table 1 of sets of organized, coordinated ac-

Definition of Terms tions to achieve specified goals (Kotar-
binsky, 1965, as cited in Orem, 1995).
Term Definition
Within Orem’s theory, system refers to
Dependency A relationship between two persons in which one person requires something from an action system, that is, the courses and
another person. The legitimate basis for dependency varies as does the form or sequences of actions that are being or
manifestation of that dependency within the social group. have been performed for some purpose;
Dependent-care The complex, acquired ability of mature or maturing persons to know and meet
a DC system is an action system.
agency (DCA) some or all of the self-care requisites of persons who have health-derived or
health-associated limitations of self-care agency (SCA), which places them in
Helping
socially dependent relationships for care.
Dependent-care “A maturing adolescent or adult who accepts and fulfills the responsibility to know In helping situations, persons are
(DC) agent and meet the therapeutic self-care demand of relevant others who are socially cast into these roles: (a) persons in spe-
dependent on them to regulate the development or exercise of the person’s SCA”
cific places with needs that must be met
(Orem, 1995, p. 457). The responsible person may be responsible by virtue of
legal or social standing. at specific times, and (b) persons who can
DC demand The summation of care measures at a specific point in time or over a duration of help in meeting their needs, that is, help-
(DCD) time for meeting the dependent’s therapeutic self-care demand when his or her ers. Characteristics of helping situations
SCA is not adequate or operational. are summarized by Orem (1995, p. 15).
DC deficit A statement of the relationship between the DC demand and the powers and
DC situations are helping situations.
capabilities of the DC agent to meet the DC demand when the DC demand
exceeds the DCA.
Human Interaction Systems
DC system An action system produced in response to the DC demand. The system consists of
courses and sequences of action that are being or have been performed by DC The characteristics of human inter-
agents in conjunction with the socially dependent person to meet the particular- action systems used by Orem have been
ized self-care requisites of dependent persons. The DC system is purposive,
identified and named by Sorokin (1957,
intentional and influenced by the characteristics of dependency. The system has
social, interpersonal, and technological dimensions. The specific actions that pp. 436-452, as cited in Orem, 1995).
make up the DC system are a function of the therapeutic self-care demand and These include the overall conditioning
SCA of the dependent; the therapeutic self-care demand, SCA, and DCA of the effect of each person on the other per-
caregiver; and the interpersonal dimensions at the time of the provision of care. son; the extensity, intensity, duration,
DC unit Unit composing the socially dependent person with limitations of SCA and the
DC agent or agents. It may also include persons responsible for providing aspects
and continuity of interactions; the dif-
of care who are not by definition DC agents. ferences in the aspiration of interacting
Family “A system or unit of interacting persons related by marriage, birth, or other strong persons; and the organization or lack of
social bonds with commitment and attachment among unit members that includes organization of the positions and roles
future obligations and whose central purpose is to create, maintain, and promote of interacting parties. There are such in-
the social, mental, physical, and emotional development of each of its members”
(Taylor & Renpenning, 1995, p. 361).
teraction components in DC and in
Social A condition that exists when persons require assistance from other members of nursing.
dependency society. It occurs within the context of a particular social unit. The provision of
assistance and the nature of the assistance provided are a function of the general Learning
culture and culture of the specific groups. A common view of learning is that it
is a change that takes place within a per-
son and results in changes in knowl-
being whom I cannot define or classify” personalism can facilitate developing edge, attitudes, and skills. Learning
(Donahue-White, 1997, p. 453). The insight into the concept of DC and the results from formal and informal teach-
fundamental concepts of personalism provision of DC. ing, and planned and incidental events.
are participation, interpersonal commu- The three major approaches to learning
nity, and solidarity. Participation is at Deliberate Action are behavioral, developmental, and in-
the foundation of personal existence. and Action System formation processing. Three types of
“There can be no individual, personal Deliberate action is essentially ac- behavior have been identified, namely,
actualization without participation in tion to achieve a foreseen result that is cognitive or intellectual behavior, affec-
the life of another ‘I,’ that is, in the life preceded by an investigation, reflection, tive or attitude, and psycho- motor or
of another personal subject” and judgment. The concept of deliber- motor skill. Developmental theories
(Donahue-White, 1997, p. 455). Partici- ate action is a description of circum- generally state that learning is a set of
pation also entails joining with others in stances leading to the decision about stages and each stage builds on the
shared activities, purposes, and goals what should be done and the events and other. Typically, adult learning theories
and consists in engagement with others circumstances necessary to bring about also draw attention to the influences of
in the building-up and maintaining of the result selected. DC is a complex of individual differences or styles of learn-
community. The social philosophy of compound actions and the performance ing. Learning is an essential component

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in the development of SCA. Some DC
systems have the development of
self-care agency (SCA) as a purpose.
And DC, like SC, is a learned activity.
Technology
Technology is the “application of
scientific knowledge to the practical
purposes to be achieved in a field”
(Orem, 1995, p. 182). Types of technol-
ogy that have been identified include
processes whereby interpersonal or in-
tergroup relations are brought into exis-
tence and maintained, human assistance
whereby help or service is rendered by
one person to another, and the technolo-
gies that bond persons together in thera-
peutic relations. These are particularly
important in understanding DC.
Parenting
Parenting is a dynamic and learned
process involving individuals, family
units, and society. It is the rearing of a
child or children by parent (father,
mother, or person who stands in loco
parentis). Dynamic, multifaceted, and
complex, it is learned from role model-
ing by family, friends, and peers; formal
classes; reading; and other informal
means (Horowitz, 1994). Goals of par-
enting are to nurture, reassure, protect,
comfort, stimulate, and promote the
journey of the child from birth to ade-
quate adult functioning or, legally, to
age 21 (Adler, 1997; Horowitz, 1994).
While there are relationships between
parenting and DC, parenting is more
than DC, and not all DC is done as a
component of parenting.
Premises
As noted earlier, the theory of SC
and the SCDNT are foundational to the
theory of DC. From these and the afore-
mentioned areas of knowledge and our
own reflections, a set of premises was
developed.
1. Premises about persons in relation.
1.1. Persons can only be satisfacto-
rily defined in relationship to others
and to the natural world.
1.2. Human relationships are essen-
tial to physical and psychological de-
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Figure 1. Dependency Cycle
velopment and ongoing relationships
are essential for continuing develop-
ment of the social self.
2. Premises about the interpersonal ac-
tion system.
2.1. The need for human interaction
is ever-present and continuous. The
nature of the interaction is dynamic.
2.2. Actions systems between two or
more persons have purpose and re-
quire exchange of information to
achieve their purposes.
2.3. In situations of family living
there may be multiple subsystems of
action including parenting and DC.
2.4. The socialization of family
members as SC and DC agents is a
family function.
3. Premises about social dependency.
3.1. Situations exist where depend-
ency, which is where one person re-
quires some form of assistance from
another person, is expected and ac-
cepted by the social group.
3.2. DC exists within the context or
frame of reference of social depen-
dency.
3.3. Throughout the life cycle the de-
pendence may be related to age, de-
velopment, and/or health state. Fig-
ure 1 is an illustration of the dynamic
nature of dependency.
3.4. There are degrees of relation-
ship that can be identified as depend-
ent, interdependent, and independent.
3.5. Conditions of social dependency
may lead to a need for DC systems.
3.6. Dependence may be instrumen-
tal (e.g., needing material assistance),
emotional, or both.
Dependent-Care 41
Theory of Dependent-Care
Responsible maturing and mature
persons initiate and perform care activi-
ties, termed DC, on behalf of socially
dependent persons. This care is pro-
vided for some period of time on a con-
tinuing or intermittent basis. The pur-
poses of DC are meeting the TSCD of
the dependent, promoting development
through the period of dependency, pro-
viding materials to sustain life, main-
taining or developing positive relation-
ships during the period of dependency,
supporting the individual through pe-
riod of dependency, and in some in-
stances, facilitating peaceful death.
This is done through the DC agent
meeting the SC requisites and/or regu-
lating the exercise or development of
SCA. DC is provided in response to a
dependent-care demand (DCD)
through a system consisting of the ac-
tions of two or more persons, including
the person in a state of social depend-
ency unable to meet his or her own re-
quirements for SC and one or more re-
sponsible persons or DC agents. In its
simplest form, the DC system consists
of the actions of a dyadic unit where DC
is a function of the therapeutic self-care
demand and self-care agency of the de-
pendent in conjunction with the DCA of
the other. (See Figure 2.) When the
DCD exceeds the capability of the de-
pendent and the DC agent, a DC deficit
42 Nursing Science Quarterly, 14:1, January 2001
exists. The existence of a DC deficit
may be an indication of the need for
nursing and is the criterion for nursing
to become involved.
The theory of DC articulates with the
theories of self-care, self-care deficit,
and nursing systems. Nursing systems
and DC systems may be thought of as
parallel. Self-care is common to both.
Nursing systems are not DC systems in
that a nursing system consists of sets of
deliberate actions performed by a nurse
or coordinated by a nurse to meet
known or projected TSCD and/or to
protect or regulate the patient’s exercise
of self-care agency. See Orem (1995)
for a fuller discussion of the develop-
ment and exercise of nursing agency
and the design of nursing systems. In
the DC system, the DC agent operates
from a structured body of knowledge
acquired over time through life experi-
ences and information provided by vari-
ous health-related professionals and
other persons.
Elaboration of
Conceptualizations
Persons in Relation and
Social Dependency
No person can exist apart from a hu-
man community (Ashley & O’Rourke,
1989, p. 7). Humans cannot develop ei-
ther physically or psychologically with-
out constant interhuman relationships.
Human contact is needed for continuing
development or maintenance of the so-
cial self. When persons are unable to
care for themselves, a state of depend-
ency exists. Social dependency exists
when persons require assistance from
other members of society. Within soci-
ety, persons may be assigned to social,
cultural, or legal care of another in cir-
cumstances of social dependency. The
provision for assistance and the nature
of the assistance that is provided are
functions of the culture and legitimacy
of the social group. When the reason for
the social dependency is a limitation in
meeting the self-care requirements and
a need for DC exists, the persons in this
social dependency and the factors re-
sulting in this state are of interest to
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Figure 2. Basic Dependent-Care System
NOTE: BCF = basic conditioning factors; SCA = self-care agency; TSCD = therapeutic self-care de-
mand; SCDF = self-care deficit; DCD = dependent-care demand; DCA = dependent-care agency; SCS =
self-care system.
nursing. In addition, the person who
will be responsible for the DC is of in-
terest to nursing. There is an assumption
that the responsible person has more ca-
pacity than the dependent. If the compe-
tency is lacking, there is a responsibility
to engage someone with the essential
capabilities. Dependency occurs as part
of the developmental process. Varia-
tions in dependency include interdepen-
dence and independence within a social
context. A natural cycle of dependency
that occurs over the life span is illus-
trated in Figure 1.
DCD
DC is provided in response to the DC
demand. The purposes of DC are pre-
sented in the statement of the theory.
The following statements characterize
the DCD.
1. DCD is a function of the self-care
limitations of the dependent.
2. DCD is constructed from the self-
care deficit; it is not the same in that it
is a summation of care measures that
require the actions of another person.
3. DCD exists within the dependent and
must be known by the DC agent in or-
der to develop a DC system to meet
that demand.
4. In situations where the dependent is
mature or maturing, knowing the care
demand is a joint action of the de-
pendent and the DC agent.
5. In infants and children, the expres-
sion of demand that is the basis of ac-
tion is constructed by the DC agent in
terms of the particularized SC requi-
sites of the dependent.
6. In situations where the dependent is a
mature or maturing person who is un-
able to participate in making known
the DCD, the DC agent constructs ex-
pression of the demand. This may re-
quire consultation from professionals.
7. Attributes of the DCD vary based on
the nature of the relationship of indi-
viduals making up the DC unit and
the nature of the dependency, which
may be related to age, developmental
state, and/or health state.
8. The quantity and quality of DC re-
quired by an individual are a function
of the complexity of the individual’s
self-care demand and nature of the
self-care limitations. When DC oc-
curs within the family, it is a special-
ized family operation that requires
management. The family is seen as
the most common setting within
which DC occurs and it conditions
the DC system.
When a DC system is needed be-
cause of health deviations, specific fac-
tors that condition DCA include the se-
verity of illness, the complexity of the
technology in use or to be used, the in-
tensity of the dependent’s suffering, the
meaning of the DC relationship, and the
care agents’ tolerance for involvement
in personal care measures for others.
DC may range from providing custodial
care to actively participating in a com-
plex care system. The quantity and
quality of DC assistance required by an
individual are a function of the com-
plexity of the individual’s self-care de-
mand and the nature of the self-care
limitations.
 Dependent-Care 43

Table 2 Table 3
Dependent-Care Units: Dependent-Care Tasks
Persons and Roles
Category of Tasks Specific Tasks
Person Roles
Tasks related to the other Knowing and calculating TSDC of the other
The dependent As individual Contributing to developing the SCA of the other
As person in relationship Regulating the exercise of SCA of the other (relates to operations)
As recipient of care Responding to variations in exercise of SCA of the other
As participant in care Meeting the TSCD (or some component) of the other
The DC agent As individual Systematizing the DC and SC actions into broader systems of living
As person in relationship (e.g., family)
As provider of care (directly Tasks related to the Determining the setting wherein care is to be provided
or as manager or situation of care Managing/modifying the environment
coordinator) Cooperating with other participants
Other caregivers As individual Tasks related Balancing SC and DC roles
As person(s) in relationship to system of care Maintaining the stability of the DC system including validation of the
As provider of care DC actions and system
Communicating with other caregivers

DC Units
The DC unit is made up of (a) the so-
cially dependent person with limita-
tions of SCA and (b) the DC agent(s). It
may also include persons responsible
for providing care who are not by defi-
nition DC agents, such as people em-
ployed to provide care. The persons and
roles within the unit are listed in Table 2.
There are variations in form of DC
units with the simplest form consisting
of a dyad with a single DC agent. In
other forms of DC units, there may be
more than one DC agent. There may be
care providers who do not fit the defini-
tion of DC agent. Such situations re-
quire that the DC agent(s) have the ca-
pabilities to recognize, identify, and
make decisions as to what care is re-
quired, who will provide it, where it will
be provided, who will be the primary
DC agent. The nature of the DC unit
gives rise to the need for communica-
tion and coordination. The specific
communication and coordination re-
quired are a function of the technologi-
cal system required to meet the DCD
and TSCD in conjunction with the inter-
personal dimensions of the DC system.
There are also variations in types of
DC units. Infants, children, the aged,
the ill, and persons with disabilities may
require complete care or assistance with
self-care activities. Variations in type of
DC units may be categorized by age,
type of social dependency, relationship,
and health state. Infants and children re-
quire care from others because they are
in the early stages of development. The
aged person requires total care or assis-
tance whenever declining physical and
mental abilities limit the selection or
performance of self-care actions. DC
may be provided by parent for child,
child for parent, adult for adult, or other
configurations. Cicirelli (1992), in a
discussion of long-term care for the el-
derly, describes other units such as
within-generation, intergenerational,
mixed-gender network (with siblings),
and multidyadic sibling units.
DC Systems
DC systems are the courses and se-
quences of action performed by the de-
pendent-care agent to meet the particu-
larized self-care requisites of socially
dependent persons for whom they are
responsible. The DC system is a human
action system. It is purposive, inten-
tional, and limited by the characteristics
of dependency. (The kinds of actions or
tasks are shown in Table 3.) DC systems
may be wholly compensatory, partly
compensatory, or supportive-educative
based on the ability of the dependent to
participate in care. They have social, in-
terpersonal, and technological dimen-
sions. The specific actions that make up
the DC system are a function of the SC
limitations and SC deficit of the de-
pendent; the TSCD, SCA, and DCA of
the caregiver; the interpersonal dimen-
sions at the time of provision of care;
and the factors that condition the DC
unit. (See Figure 2.)
Factors that condition the DC system
include the existent or projected dura-
tion of the dependency, number of per-
sons involved, reason for existence of
the system, allocation of roles and re-
sponsibilities in this and prior care sys-
tems, resources, the attributes of the re-
lationship of the persons in the unit
(e.g., intensity and intimacy), the attrib-
utes of the relationship, and the nature
of or reason for social dependency. As
the number and kinds of health-devia-
tion SC requisites that must be met in
specific time frames increase, so does
the complexity of DC systems. When
more than one DC agent is involved
over time, the DC system will vary with
each DC giver, in part because of vary-
ing capabilities of the caregiver but also
because of variations in the interper-
sonal dimensions of the DC system.
When the DCS is needed because of
changes in health, specific factors that
condition DCA include the severity of
the illness, the complexity of the tech-
nology in use or to be used, the intensity
of the dependent’s suffering, the mean-
ing of the DC relationship, and the toler-
ance of the DC agent for involvement in
personal care measures for others.
Not all helping systems are DC sys-
tems. For example, there may be a series
of intermittent activities that are helpful
to an individual who is not socially
dependent on the helpers. This may
be when a health deviation is present or
when conditions that would interfere
with development are present, but the

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44 Nursing Science Quarterly, 14:1, January 2001
individual is not socially dependent. So-
cial dependency is a core feature of a
DC system. There also is a need to dif-
ferentiate between a DC system and in-
dividual care-giving acts. In a DC sys-
tem, there is calculation of the TSCD,
assessment of SCA to meet that de-
mand, and identification of a DC agent
who takes some responsibility for meet-
ing components of the TSCD for the de-
pendent person. Taking a series of ac-
tions in an ordered way to meet the SC
requisites makes it a care system. When
the recipient of the care is socially de-
pendent, a DC system is established.
The following statements summarize
some attributes of the DC system:
1. Conditions of social dependency may
lead to the need for DC systems.
2. The quality of the DC system is a
function of the degree of knowing the
DCD.
3. The nature of the relationship that ex-
ists between the dependent person
and the DC agent is a major condi-
tioning factor in the establishment of
the DC system.
4. Factors to be considered in assisting
or designing a DC system include
4.1. the gender, age, and develop-
mental state of the dependent;
4.2. the extent of the development of
the SCA of the dependent and the de-
gree to which it is exercised; and
4.3. the relationship and state of the
interpersonal relations between the
dependent person and the DC agent.
5. The willingness of the dependent per-
son to accept help and the sense of
duty on the part of each will affect
what can be accomplished.
6. When more than one DC agent is in-
volved over time, the DC system will
be modified with each DC giver, in
part because of varying capabilities
of the caregiver but also because of
variations in the interpersonal dimen-
sions of the DC system.
7. In addition to conditioning factors
noted in theory of SC, basic condi-
tioning factors in DC include the na-
ture of the social unit, the relationship
of the persons in the unit, the nature
of allocation of roles and responsibil-
ities in this and prior care systems,
and the values of the family of origin.
8. The quality and characteristics of the
DC system are conditioned by the ca-
pability of the dependent to commu-
nicate to the DC agent information
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about sensation, perceptions, beliefs,
and values. This information is made
known when the dependent volun-
teers it. Other important information
must be gleaned by the DC agent’s in-
quiring and observing. The quality of
the communication conditions the
nature and quality of the DC system.
9. If the DC agent is responsible for
managing care of requirements for
more than one dependent, there is a
need for that person to develop a sys-
tem to manage requirements of all of
the dependents.
Relationships Between
SCA and DCA
SC and DC are both behaviors
learned within the context of the group
and within a sociocultural context.
DCA is developed to meet the require-
ments for continuing care that is regula-
tory of the functioning and development
of one’s dependents. The development
of SCA and DCA is interdependent and
occurs to some extent simultaneously
within the context of ordinary living re-
lationships. The development of SCA
begins with the experience of being
cared for by another. That is, through
being taken care of, I learn to care for
myself, and at the same time I am learn-
ing to care for another. This parallel de-
velopment is most obvious in cultures
where DC is highly valued such as in the
Mexican-American home where care of
others is frequently demonstrated
(Villarruel & Denyes, 1997). Some ca-
pacity for and engagement in SC are
necessary for DC. The quality of one
type of agency is not dependent on the
quality of the other. Developmental
changes enable a person to move from
DC to self-care or vice versa. The tran-
sition from SC to DC may be gradual or
abrupt, time-limited or continuous. An
event that produces a set of SC limita-
tions may disrupt this transition. Ongo-
ing self-care limitations may result in
the need for continuing DC. There is an
interaction or interrelationship between
the exercise of SCA and the exercise of
DCA. DC actions are a manifestation of
the relationship between the exercise of
DCA and the exercise of SCA. There is
a complementary relationship between
the quantity and quality of SC and DC
required at any point in time. Biehler
(1992) refers to “shared agency” in her
writings about DC systems involving
children. Neville (1987) identified and
Renpenning confirmed in her experi-
ence that the dependent appears to in-
corporate some of the capability of the
DC agent into his or her own description
of SCA; that is, the dependent describes
himself or herself as being capable of
more activity related to the productive
operations of self than would appear to
the outside observer to be the case. In
studying spousal caregivers, it was
noted that the caretaking tasks or tasks
associated with accomplishing SC of
the dependent passed back and forth be-
tween the dependent person and the
DC agent depending on the ability of
the dependent to exercise SCA at a par-
ticular time (Corbin & Strauss, 1984;
Schumacher, 1996). The DC agent has
the dual roles of SC and DC agent. Con-
sequently, the capacity to deliver DC
is affected by the TSCD of the DC
agent.
DCA
The elements of DCA require that
the caregivers have the capabilities to
know the therapeutic self-care demand
and self-care abilities of those who are
dependent on them. They must also pos-
sess the skills needed to regulate the de-
velopment or exercise of SCA of the de-
pendent. DCA is “other-directed,” that
is, the actions taken and decisions made
are for the purpose of helping another
person, not one’s self; however, actions
taken on behalf of another may be bene-
ficial or harmful to the self.
The development of DCA by indi-
viduals is usually a response to needs of
family members or friends for help with
their continuing SC. DCA is developed
to meet existent and emerging needs of
the persons to be helped or taken care
of. More likely than not, the primary fo-
cus in its development is mastery of the
productive operations of SC. When pro-
ductive operations must be adjusted to
specific human and environmental con-
ditions, there is a need for the develop-
ment of capabilities for performing esti-
mative and transitional operations of

self-care. There is always a need for de-
velopment of capabilities to recognize
emergency situations and to act promptly
and effectively.
The diagnostic processes relate to
DC operations (estimative, transitional,
and productive). These operations are
concerned with
1. Specifying the TSCD of the depend-
ent.
2. Evaluation of adequacy of SCA of the
dependent.
3. Evaluation of the adequacy of the
DCA.
4. Meeting components of TSCD of the
dependent.
5. Regulating the exercise of SCA of the
dependent.
6. Regulating the exercise of the DCA.
There are enabling abilities or power
components as a part of the structure of
DCA. They may include such abilities
as the ability to establish helping/car-
ing relations or the ability to deter-
mine conditions under which the de-
pendent can and will exercise SCA.
There are also foundational capabili-
ties and dispositions (FCD) associated
with DC. FCD associated with DCA
include those identified in relation to
SCA as well as the DC agent’s capabili-
ties for and dispositions toward caring
for another. Power components and FCD
of DCA need further development and
refinement.
Dependent as Recipient of Care
There is a paucity of literature focus-
ing on the recipient of care. Russell,
Bunting, and Gregory (1997) support
the notion that the recipients of care ac-
tively shape the DC system through
their actions. They propose the concept
of protective-care receiving, that is, the
efforts of an elder to defend herself or
himself from problems associated with
receiving care and shielding others
from difficulties they could experience
as caregivers.
The DC system is influenced by the
extent to which the SCA of the depend-
ent is developed, adequate, and exer-
cised. The communication system be-
tween the dependent and the DC agent
influences the effectiveness of the DC
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system. Of particular importance is the
extent to which the dependent can com-
municate his or her needs to the DC
agent.
DC and Family
DC should be differentiated from
other kinds of care provided to socially
dependent persons, including par-
enting. If the functions of the family
(Taylor, 1989) are considered, DC may
be seen to be a subset of family func-
tioning. Within the family, persons
other than the parents may provide DC.
Parenting is concerned with the devel-
opment of the human person in all di-
mensions. As a component of the
parenting function, children are moved
from infancy to maturity. DC and
parenting are not synonymous. Not ev-
ery parenting act is a DC act. Similarly,
because there are other social relation-
ships that are important in the develop-
ment of human persons, not all DC ac-
tions are parenting actions.
When there is a parenting system in
place, the DC system is a subsystem of
the parenting system. In a parenting sit-
uation, the DC system occurs within the
context of and is influenced by the
parenting system. When the DC system
is a subsystem of the family system, it is
the function of the family to integrate
aspects of self-care and DC into an
overall satisfactory plan of living and
development (Taylor & Renpenning,
1995). Family is the most common set-
ting for DC but not the only setting.
Burke, Kauffmann, Costello, Wiskin,
and Harrison (1998) developed a listing
of tasks to be accomplished by families
in managing a child with a chronic con-
dition; the listing provides some insight
into the nature of capabilities founda-
tional to effective DC.
DC and Nursing
Social dependency falls within the
domain of nursing when, within the de-
pendency situation, there is an inability
of one person to provide SC and the
other person providing assistance to the
dependent has limitations in ability to
provide care. When there is a limitation
in the caregiver’s ability to meet SC re-
quirements, both the dependent and the
Dependent-Care 45
care agent are of concern to nurses.
When the DCA is not qualitatively or
quantitatively adequate to meet the
TSCD of the dependent, a nursing sys-
tem may be indicated. The nursing sys-
tem will consist of the actions taken in
cooperation with the members of the
unit to meet the SC requisites of one or
more or all of the members of the unit or
to regulate the development or exercise
of their SCA or DCA (see Figure 3). At
the same time, the nurse is concerned
with maintaining the functional integ-
rity of the unit, whether it is the DC unit,
the family, or another social group.
Nurses are increasingly placed in po-
sitions where they must work with fami-
lies or individuals to identify and select
persons psychologically and physically
able and willing to function as DC
agents for family members or friends.
This is a demand on nurses in hospitals
and home care nursing programs. There
is increasing recognition of the impor-
tance of involving families and signifi-
cant others in the care of persons, not
only at home but also in institutions,
through the initiation of DC systems.
When patients with chronic conditions
move back and forth between institu-
tional care and home, nursing has a re-
sponsibility for maintaining support for
the DC system. Nurses recognize the
importance of protecting the health and
well-being of DC agents. They under-
stand the energy-depleting effects of
maintaining systems of DC in the home
or in institutions and the stress associ-
ated with it. TSCDs of DC agents must
be calculated and means for meeting
them should be proposed.
DC units consisting of two or more
persons are considered as multiperson
nursing situations, wherein the objec-
tives of the nursing system are primarily
aimed at achieving nursing results for
the dependent individual. When the
nurse anticipates developing a nursing
system that includes the family, the first
step is to determine the unit of service.
The question to be answered is, Will the
nurse be responsible for providing nurs-
ing to an individual who is a member of
a family, to a dependent person who has
a caregiver within a family, or to the
family as a unit?
46 Nursing Science Quarterly, 14:1, January 2001
Figure 3. Elements of a Nursing System in Dependent-Care Situations
NOTE: BCF = basic conditioning factors; SCA = self-care agency; SCDF = self-care deficit; DCD = de-
pendent-care demand; DCA = dependent-care agency; SCD = self-care demand, SCS = self-care system;
NA = nursing agency; TSCD = therapeutic self-care demand.
The nursing system in situations of
DC may be directed to the DC agent in
relation to identifying or managing the
DC deficit using a supportive-educative
system. In addition, the nursing system
may be a partly or wholly compensatory
system in relation to identifying or man-
aging the SC deficit of the dependent.
Nurses may become associated with a
DC situation (a) at the inception of the
dependent unit, (b) when the dependent
unit has been in existence for some
time, or (c) when there is a shift from the
individual as unit of service to depend-
ent unit as unit of service.
The initial focus of the nursing sys-
tem is on recognition of the need for a
DC system and the development of
DCA in reference to the productive
(assistive) operations of care. When
productive operations must be adjusted
to specific conditions, there is a need for
the development of capabilities for per-
forming the estimative and transitional
operations. There is always the need for
development of capabilities to recog-
nize emergency situations and to act
promptly and effectively.
The stability of the DC unit is a ma-
jor factor in prescribing the care system
for the dependent. If there is a different
DC giver each time the nurse interacts
with the patient, as in a home visit, the
DC system needs to be reevaluated fre-
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Table 4
Factors to Be Considered in
Assessing the DC Situation
Object of Variables to
Assessment Be Considered
Patient Level of performance of activities
of daily living (ADL)
Ability to work with body
Cognitive ability
Compliance level
General health state
Emotional stability
Level of anxiety
Level of energy
Presence of symptoms
Motivation
Perspective on interpersonal
relations—acceptance of care
Perception regarding competence
of caregiver
Perceived relationship to caregiver
Primary Intact mental processes
DC agent Desire to help
Cognitive ability
quently. Adjustments must be made to Physical limitations
account for the variations of DCA and General health state
Ability to work with another’s
the impact of the varying caregiver abil-
body
ities on the dependent person. Variables Emotional stability
to consider in making decisions about Motivation
DC and SC are detailed in Table 4. Tay- Level of anxiety
lor and Robinson-Purdy (1989) in a Level of energy
Perceived relationship with
study of preparation for hospital dis-
patient
charge noted that factors identified as Home Presence of necessary facilities
relevant to the spouse were different environ- Access to support by other
from those of the dependent. There was ment persons or agencies
a greater emphasis on the relationship Facilities for privacy
Availability of resources
between the caregiver and patient, roles
Technical or Need for manipulation of special
and responsibilities of the caregiver demand equipment
within and without the home, and the Complexity of tasks
effect that the care of another will have Critical observations needed
on the caregiver. The DC givers’ own Expected duration of tasks
Number of activities necessary
health states were of great concern as
Amount of coordination of
was their perception of their ability to activities
provide the care both physically and Amount of equipment needed
emotionally. Other factors were the
prior roles and responsibilities of both NOTE: DC = dependent care
parties and the uncertainty of ability, in-
security, or lack of confidence in ability basic conditioning factors (BCFs) have
to provide the care on the part of the care- the potential to affect the values of SCA
giver. The complexities of the nursing and TSCD. Both SCA and DCA are ca-
system are magnified by the complexi- pacities and capabilities for action,
ties of the DC system. though the action or the intention of the
action is different in each instance. Lim-
Summary itations in ability to take care of self or
dependent establish the basis for nurses
The theory of DC is complex. It par- to design and produce systems of care.
allels Orem’s theory of self-care in a DC theory is different from the theory of
number of ways. For example, certain SC in that the self-care deficit (SCDF) of

the dependent gives rise to the DCD,
and it is the DCD against which a judg-
ment of the adequacy of the responsible
person’s DCA is made. As noted earlier,
depending on the situation, a nursing
system may be designed to address the
SCDF of the dependent, the DCD,
and/or the DCA of the responsible per-
son. The work presented here has
emerged through a lengthy process of
reading, examining real situations, re-
flection, and discussion. It began at one
of the University of Missouri–Colum-
bia SCDNT summer institutes and sub-
sequently became a focus of a study
group that included Dr. Orem and 10
Orem scholars. As with any work of this
kind, it is not complete. It is a beginning.
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