Foundations of Nursing Practice

Theorist in Nursing

CAMPOS, LORMIE A.
MACAVINTA, JOSEPH CELRIN III
Students-MSN
MARIA GIRLIE D. JORDAN, MSN
Professor

Saint Paul University Philippines

Tuguegarao City
Cagayan Valley North
DOROTHEA E. OREM
Dorothea E. Orem was born in 1914 in
Baltimore, Maryland.

In the early 1930s, she earned her

nursing diploma from the Providence
Hospital School of Nursing in
Washington, D.C.

She went on to complete her Bachelor

of Science in Nursing in 1939 and her
Masters of Science in Nursing in 1945,
both from the Catholic University of
America in Washington, D.C.

Dorothea Orem died on June 22,

2007.
Career of Dorothea E. Orem
Dorothea Orem had a distinguished career in nursing.

She earned several Honorary Doctorate degrees. She was

given Honorary Doctorates of Science from both Georgetown
University in 1976 and Incarnate Word College in 1980.

She was given an Honorary Doctorate of Humane Letters from

Illinois Wesleyan University in 1988 and a Doctorate Honoris
Causae from the University of Missouri in Columbia in 1998.

She was also given many awards during her career: the
Catholic University of America Alumni Achievement Award for
Nursing Theory in 1980, the Linda Richards Award from the
National League for Nursing in 1991, and was named an
honorary Fellow of the American Academy of Nursing in 1992.
Self-Care Deficit Nursing Theory (SCDNT)
 The Self-Care Deficit Nursing Theory, also known as the Orem Model
of Nursing, was developed by Dorothea Orem between 1959 and
2001.

It is considered a grand nursing theory, which means the theory covers

a broad scope with general concepts that can be applied to all
instances of nursing.

The central philosophy of the Self-Care Deficit Nursing Theory is that

all patients want to care for themselves, and they are able to recover
more quickly and holistically by performing their own self-care as much
as they're able.

This theory is particularly used in rehabilitation and primary care or

other settings in which patients are encouraged to be independent.
 Orem developed the Self-Care Deficit Theory of Nursing, which
is composed of three interrelated theories: (1) the theory of self-
care, (2) the self-care deficit theory, and (3) the theory of
nursing systems (Dorothea E. Orem, n.d.).

The condition that validates the existence of a requirement for

nursing in an adult is the absence of the ability to maintain
continuously that amount and quality of self-care which is
therapeutic in sustaining life and health, in recovering from
disease or injury, or in coping with their effects. With children,
the condition is the inability of the parent (or guardian) to
maintain continuously for the child the amount and quality of
care that is therapeutic. (Orem, 1991)
MAJOR CONCEPTS
Nursing is as art through which the practitioner of nursing
gives specialized assistance to persons with disabilities which
makes more than ordinary assistance necessary to meet needs
for self-care. The nurse also intelligently participates in the
medical care the individual receives from the physician.

Humans are defined as men, women, and children cared for

either singly or as social units, and are the material object of
nurses and others who provide direct care.

Environment has physical, chemical and biological features. It

includes the family, culture and community.
 Health is being structurally and functionally whole or sound.
Also, health is a state that encompasses both the health of
individuals and of groups, and human health is the ability to
reflect on ones self, to symbolize experience, and to
communicate with others.

Self-care is the performance or practice of activities that

individuals initiate and perform on their own behalf to maintain
life, health and well-being.

Self-care agency is the humans ability or power to engage in

self-care and is affected by basic conditioning factors.

Basic conditioning factors are age, gender, developmental

state, health state, sociocultural orientation, health care system
factors, family system factors, patterns of living, environmental
factors, and resource adequacy and availability.
 Therapeutic Self-care Demand is the totality of self-care actions
to be performed for some duration in order to meet known self-
care requisites by using valid methods and related sets of actions
and operations.

Self-care Deficit delineates when nursing is needed. Nursing is

required when an adult (or in the case of a dependent, the parent
or guardian) is incapable of or limited in the provision of
continuous effective self-care.

Nursing Agency is a complex property or attribute of people

educated and trained as nurses that enables them to act, to know,
and to help others meet their therapeutic self-care demands by
exercising or developing their own self-care agency.

Nursing System is the product of a series of relations between

the persons: legitimate nurse and legitimate client. This system is
activated when the clients therapeutic self-care demand exceeds
available self-care agency, leading to the need for nursing.
SUBCONCEPTS
Self-care Requisites or requirements can be defined as
actions directed toward the provision of self-care. It is
presented in three categories:

A. Universal self-care requisites are associated with life

processes and the maintenance of the integrity of human
structure and functioning.

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 process and

excrements
5. The maintenance of a balance between solitude and social
interaction

6. The prevention of hazards to human life, human functioning,

and human well-being

7. 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 constitutional
characteristics and the talents of individuals.
B. Developmental self-care requisites are either specialized
expressions of universal self-care requisites that have been particularized
for developmental processes or they are new requisites derived from a
condition or associated with an event.

C. Health deviation self-care requisites are required in conditions of

illness, injury, or disease or may result from medical measures required to
diagnose and correct the condition.

1. Seeking and securing appropriate medical assistance

2. Effectively carrying out medically prescribed diagnostic, therapeutic,

and rehabilitative measures.

3. Being aware of and attending to or regulating the discomforting or

deleterious effects of prescribed medical measures.
4. Modifying the self-concept (and self-image) in accepting
oneself as being in a particular state of health and in need of
specific forms of health care

5. Learning to live with the effects of pathologic conditions and

states and the effects of medical diagnostic and treatment
measures in a life-style that promotes continued personal
development

The Three Basic Nursing Systems:

(1) 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.
 (2) The partly compensatory nursing system is represented
by a situation in which both nurse and 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.

(3) In the supportive-educative system also known as

supportive-developmental 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.
Relationship of the major components
of Orems self-care deficit theory

R indicates a relationship between components; < indicates a

current or potential deficit where nursing would be required
ASSUMPTIONS
Humans engage in continuous communication and interchange
among themselves and their environments to remain alive and to
function.

People should be self-reliant and responsible for their own care and
others in their family needing care.

Nursing is a form of action interaction between two or more

persons.

Successfully meeting universal and development self-care requisites

is an important component of primary care prevention and ill health.

A persons knowledge of potential health problems is necessary for

promoting self-care behaviors.
 Self-care and dependent care are behaviors learned within a socio-
cultural context.

In humans, the power to act deliberately is exercised to identify needs

and to make needed judgments.

Mature human beings experience privations in the form of action in

care of self and others involving making life-sustaining and function-
regulating actions.

Human agency is exercised in discovering, developing, and

transmitting to others ways and means to identify needs for, and
make inputs into, self and others.

Finally, groups of human beings with structured relationships cluster

tasks and allocate responsibilities for providing care to group
members who experience privations for making required deliberate
decisions about self and others (Orem, 1995).
STRENGTHS/WEAKNESSES
A. Strengths
Provides a comprehensive base to nursing practice.

It has utility for professional nursing in the areas of

nursing practice nursing curricula ,nursing education
administration ,and nursing research.

Specifies when nursing is needed.

Her self-care approach is contemporary with the concepts

of health promotion and health maintenance.
B. Weaknesses

Orems theory is simple yet complex. The use of self-care

in multitude of terms, such as self-care agency, self-care
demand, self-care deficit, self-care requisites, and
universal self-care, can be very confusing to the reader.

Orems definition of health was confined in three static

conditions which she refers to a concrete nursing
system, which connotes rigidity.

Throughout her work, there is limited acknowledgement of

the individuals emotional needs.
ANALYSIS
There is a superb focus of Orems work which is self-care. Even
though there is a wide range of scope seen in the encompassing
theory of nursing systems, Orems goal of letting the readers view
nursing care as a way to provide assistance to people was apparent
in every concept presented.

From the definition of health which is sought to be rigid, it can now be

refined by making it suitable to the general view of health as a
dynamic and ever changing state.

The role of the environment to the nurse-patient relationship, although

defined by Orem was not discussed.

The role of nurses in maintaining health for the patient was set by
Orem with great coherence in accordance with the life-sustaining
needs of every individual.

Although Orem viewed the importance of the parents or guardian in

providing for their dependents, the definition of self-care cannot be
directly applied to those who needs complete care or assistance with
self-care activities such as the infants and the aged.
BETTY NEUMAN, RN Ph.D., FAAN
- Dr. Betty Beuman was born 1924 near Lowell, Ohio.
- In 1947 she received RN Diploma from Peoples Hospital
School of Nursing, Akron, Ohio.
- Gained experience as a hospital, staff, and head nurse; school
nurse and industrial nurse; and as a clinical instructor in
medical-surgical, critical care and communicable disease
nursing in California
- In 1957 Dr. Neuman attended the University of California at
Los Angeles (UCLA) with double major in psychology and
public health. She received BS in nursing from UCLA.
- In 1966 she received Masters degree in Mental Health,
Public Health Consultation from UCLA.
- Recognized as pioneer in the field of nursing involvement in
community mental health.
- In 1972 her model was first published as a 'Model for
teaching total person approach to patient problems' in Nursing
Research.
- In 1985 she received her doctorate in Clinical Psychology
from Pacific Western University.
- In 1998 she received a second honorary doctorate, this one
from Grand Valley State University, Allendale, Michigan.
 The Neuman Systems Model

The Neuman Systems Model was originally developed in 1970 at

the University of California, Los Angeles, by Betty Neuman,
Ph.D., RN.

The model was developed by Dr. Neuman as a way to teach an

introductory nursing course to nursing students.

The goal of the model was to provide a wholistic overview of the

physiological, psychological, sociocultural, and developmental
aspects of human beings.

After a two-year evaluation of the model, it was published in

Nursing Research (Neuman & Young, 1972).
The Neuman Systems Model
 Major Concepts

Human being
Viewed as an open system that interacts with both internal and external
environment forces and stressors.
The human is in constant change, moving toward a dynamic state of
system stability or toward illness of varying degrees.

Environment
A vital arena that is germane to the system and its function.
The environment may be viewed as all factors that affect and are
affected by the system.

The internal environment exists within the client system.

All forces and interactive influences that are solely within boundaries
of the client system make up this environment.

The external environment exists outside the client system.

Major Concepts

Health
Is defined as the condition or degree of system stability and is viewed as a continuum
from wellness to illness.
When system needs are met, optimal wellness exists. When needs are not
satisfied, illness exists.
When the energy needed to support life is not available, death occurs.

Nursing
Is to define the appropriate action in situations that are stress-related or in relation to
possible reactions of the client or client system to stressors.
Nursing interventions are aimed at helping the system adapt or adjust and to retain,
restore, or maintain some degree of stability between and among the client system
variables and environmental stressors with a focus on conserving energy.

Open System

A system in which there is a continuous flow of input and process, output and feedback.
It is a system of organized complexity, where all elements are in interaction.
Major Concepts

Basic Stricture and Energy Resources

The basic structure, or central core, is made up of those basic survival factors common to the
species.
These factors include the system variables, genetic features, and strengths and weaknesses of
the system parts.

Client variables
Newman views the individual client holistically and considers the variables simultaneously and
comprehensively.

The physiological variable refers to the structure and functions of the body.
The psychological variable refers to mental processes and relationships.
The sociocultural variable refers to system functions that relate to social and cultural
expectations and activities.
The developmental variable refers to those processes related to development over the lifespan.
The spiritual variable refers to the influence of spiritual beliefs.
Major Concepts

Flexible line of defense

A protective accordion-like mechanism that surrounds and protects the normal line of
defense from invasion by stressors.

Normal line of defense

An adaptational level of health developed over time and considered normal for a
particular individual client or system; it becomes a standard for wellness-deviance
determination.

Lines of resistance
Protection factors activated when stressors have penetrated the normal line of defense,
causing a reaction synptomatology. (Neuman, 1995)
 Subconcepts
Stressors
A stressor is any phenomenon that might penetrate both the flexible and
normal lines of defense, resulting in either a positive or negative outcome.

Intrapersonal stressors are those that occur within the client system
boundary and correlate with the internal environment.
Interpersonal stressors occur outside the client system boundary, are
proximal to the system, and have an impact to the system.
Extrapersonal stressors also occur outside the client system boundaries
but are at a greater distance from the system than are interpersonal
stressors. An example is social policy.

Stability
A state of balance or harmony requiring energy exchanges as the client
adequately copes with stressors to retain, attain, or maintain an optimal
level of health thus preserving system integrity.
Subconcepts
Degree of Reaction
The amount of system instability resulting from stressor invasion of the
normal line of defense.

Entropy
A process of energy depletion and disorganization moving the system
toward illness or possible death.

Negentropy
A process of energy conservation that increases organization and
complexity, moving the system toward stability or a higher degree of
wellness.

Input/output
The matter, energy, and information exchanged between client and
environment that is entering or leaving the system at any point in time.

Reconstitution
The return and maintenance of system stability, following treatment of
stressor reaction, which may result in a higher or lower level of
wellness.
Primary prevention

Occurs before the system reacts to a stressor; it includes health promotion and
maintenance of wellness.

Focuses on strengthening the flexible line of defense through preventing stress and
reducing risk factors.

Occurs when the risk or hazard is identified but before a reaction occurs.

Strategies that might be used include immunization, health education, exercise, and
lifestyle changes.
Secondary prevention

Occurs after the system reacts to a stressor and is provided in

terms of existing symptoms.
Focuses on strengthening the internal lines of resistance and,
thus, protects the basic structure through appropriate treatment
of symptoms.
Aimed to regain optimal system stability and to conserve energy
in doing so.
If secondary prevention is unsuccessful and reconstitution does
not occur, the basic structure will be unable to support the
system and its interventions, and death will occur.
Tertiary prevention
Occurs after the system has been treated through secondary
prevention strategies.

Its purpose is to maintain wellness or protect the client system

reconstitution through supporting existing strengths and
continuing to preserve energy.

Tertiary prevention may begin at any point after system

stability has begun to be reestablished (reconstitution has
begun). Tertiary prevention tend to lead back to primary
prevention. (Neuman, 1995)
Assumptions
Each client system is unique, a composite of factors and
characteristics within a given range of responses.
Many known, unknown, and universal stressors exist.
The particular interrelationships of client variables at any
point in time can affect the degree to which a client is
protected by the flexible line of defense against possible
reaction to stressors
Each client/client system has evolved a normal range of
responses to the environment that is referred to as a
normal line of defense.
When the flexible line of defense is no longer capable of
protecting the client/client system against an
environmental stressor, the stressor breaks through the
normal line of defense.
Assumptions

The client, whether in a state of wellness or illness, is a

dynamic composite of the interrelationships of the
variables.

Implicit within each client system are internal resistance

factors known as lines of resistance, which function to
stabilize and realign the client to the usual wellness state.

The client as a system is in dynamic, constant energy

exchange with the environment. (Neuman, 1995).
Strengths
The major strength of the model is its flexibility for use in all areas of
nursing administration, education, and practice.

Neuman has presented a view of the client that is equally applicable to

an individual, a family, a group, a community, or any other aggregate.

The Neuman Systems Model, particularly presented in the model

diagram, is logically consistent.

The emphasis on primary prevention, including health promotion is

specific to this model.

Once understood, the Neuman Systems Model is relatively simple, and

has readily acceptable definitions of its components.
Weaknesses

The major weakness of the model is the need for further

clarification of terms used.

Interpersonal and extrapersonal stressors need to be

more clearly differentiated.
Analysis
The delineation of Neuman of three defense lines was not clearly
explained. In reality, the individual resist stressors with internal and
external reflexes which were made complicated with the formulation
of different levels of resistance in the open systems model of
Neuman.
Neuman made mention of energy sources in her model as part of the
basic structure. It can be more of help when Neuman has enumerated
all sources of energy that she is pertaining to. With such, new nursing
interventions as to the provision of needed energy of the client can be
conceptualized.
The holistic and comprehensive view of the client system is
associated with an open system. Health and illness are presented on
a continuum with movement toward health described as negentropic
and toward illness as entropic. Her use of the concept of entropy is
inconsistent with the characteristics of entropy which is closed, rather
than an open system
References:
Dorothea E. Orem. Retrieved January 13, 2017, from
http://nursingtheories.weebly.com/dorothea-e-orem.html

Dorothea Orems self-care theory. Retrieved January 13, 2017, from

http://currentnursing.com/nursing_theory/self_care_deficit_theory.html

Retrieved January 13, 2017, from

https://upload.wikimedia.org/wikipedia/en/f/f0/Dorothea_Orem.jpg

Retrieved January 13, 2017, from http://www.nursing-

theory.org/nursing-theorists/Dorothea-E-Orem.phphttp://www.nursing-
theory.org/nursing-theorists/Dorothea-E-Orem.php
References:
Betty Neuman. (n.d.). Retrieved January 15, 2017,
from http://nursingtheories.weebly.com/betty-
neuman.html

Betty Neuman. (n.d.). Retrieved January 15, 2017,

from
http://www.nurses.info/nursing_theory_person_neum
an_betty.htm