Self Care Deficit Theory of Nursing

The Self-Care Deficit Nursing Theory (SCDNT) developed by Dorothea Orem and published in 1971 is one of the most influential and extensively utilized theories in nursing. The theory stemmed from research conducted when Orem was tasked by the U.S. Department of Health and Welfare (HEW) to improve nurse training. Through this project Orem researched in what circumstances nurses were needed to provide care. The goal was to direct the selection of educational material used in educating nurses based on the needs of the patient. After leaving HEW, Orem continued her work developing in the concept of self-care at Catholic University of America. In 1971, Orem published Nursing: Concepts of Practice. The theory “delineates when patients are unable to care for themselves, even with the assistance of family members” (Johnson & Webber, 2010). This inability for self-care develops a demand for care that can be filled by a nurse, much like the supply and demand theory in economics. The goal of the SCDNT was to lay a foundation to direct nursing knowledge (education) and guidance for the development of nursing practice.

SCDNT “is the extension of [Virginia] Henderson’s concept of nursing and seems to incorporate a medical perspective” (Hanucharurnkul, 1989). Orem, like Henderson is considered a needs based theorist. The overall theory is derived from three integral concepts: theory of self-care, theory of self-care deficit, and theory of nursing systems. SCDNT states that self-care is therapeutic and required for growth and development. It also details the elements that are required in order for a person to have achieved a level of self care such as, basic conditioning factors and self care requisites.

If at any point in the health continuum a person is unable to provide for either their basic conditioning factor or requisites a self care deficit is created. Some of these deficits can be filled by family or social support elements. However, when the self care deficit can no longer be filled due to illness or some other factor it may be necessary to seek a relationship with someone specifically trained to fulfill these deficits. The relationship that is established between the patient and the nurse specifically outlined and defined by the nursing agency. Finally, the SCDNT outlines the nursing systems that are available based on the extent of the self care deficit of the patient. For example, a patient with severe brain trauma may require a wholly compensatory system where the nurse performs all self care activities for the individual. Yet, a person with newly diagnosed hypertension may require a simple supportive-educational system which will be a very brief encounter (Johnson & Webber, 2010).

However, with the breadth of the human condition it is difficult to find one theory that encompasses all nursing phenomena. Many nursing theories are used in conjunction other theories with similar focus for a more comprehensive practical application. Orem’s SCDNT has been used in conjunction with Roy’s Adaptation Model. Roy’s model follows the same four concepts of nursing. The differences include “Roy’s definition of person includes the biopsychosocial aspect as well as that of a living adaptive system…The environment plays a more significant role in Roy’s models. It is the world within and around the person that can stimulate the person to make adaptive responses” (James, 1992). This model complements the Orem model in that there is not only a need for care, but a personal response to the care provided that facilitates the restoration of the person to provide self care. Many similarities have also been found between Orem’s model and Imogene King’s Theory of Goal Attainment. While King is considered an interaction theorist and her goal attainment theory focuses primarily on the nurse-patient relationship and interactions toward a common goal to fulfill the individual’s role in society versus self-care. “Orem’s and King’s perspective of the four components of nursing metaparadigm (person, health, environment and nursing) as well as how a person can be helped through nursing as reflected in the theory of nursing system and the theory of goal attainment” have many similarities and their differences are often complementary (Hanucharurnkul, 1989).

Overall, the theory is very clear and concise. It has been used extensively to guide nursing practice. According to Johnson and Webber, Orem’s book Nursing: Concepts of Practice has been revised five times with the most recent update in 2001. The theory itself is also continually review and updated. “Orem’s conceptual model is used to guide nursing practice more than other conceptual models in the United States” (Hanucharurnkul, 1989). The theory has also been used as the basis for modern nursing theorists.

Criterion 2 – Boundaries are consistent with nursing practice

Orem’s SCDNT very carefully delineates the way in which a nurse can assist others in order to fulfill a self care deficit. Orem identifies the five methods of helping as: acting for and doing for others, guiding others, supporting another, providing and environment promoting personal development in relation to meet future demands, and teaching another (Dorothea Orem’s self-care theory, 2010). Overall, these areas in which nurses help encompass the primary functions within the boundaries of nursing care. Through these five areas of helping the nurse is able to function in a multitude of settings including the hospital, nursing home, rehabilitation center, school, or even in the patients home.

Additionally, all groups of care recipients are encompasses by the theory. The care deficit implies that at each developmental level there is some established self-care baseline. Under SCDNT the theory of nursing systems delineates how a patient’s deficit can be met. There are three major nursing systems outlined in the theory and include all relevant care recipients. Within the theory the role on the nurse will change based on the nursing system implemented for the care recipient.

Once a care recipient falls outside of the parameters of the need for care based on a specific care deficit and following a specified nursing the theory has more difficult time identifying care needs. Critics of SCDNT have stated that “the model may indeed make a substantial and valued difference in the lives of people whose self care abilities are curtailed due to acute or chronic conditions, but may not make the same difference enhancing prevention and promoting well-being” (Hartweg, 1990). Following this rationale the role of the nurse as educator and advocate may have difficulty falling under the self care deficit model. Health promotion activities do indeed fall within Orem’s model. Hartweg cites numerous instances where health promotion falls directly within major elements of the models current structure including, therapeutic self care demand and universal self care requisites. Exercise for health promotion was cited by the article as an example of a health promotion activity that is not only therapeutic for growth and development as well as universal self care requisite.

Criterion 3 – Language is understandable and includes minimal jargon

The SCDNT was meticulously developed over a period spanning more than 30 years. The published theory is comprehensive. Yet the overall theory is quite understandable and the terminology specific to the theory (jargon) is often defined with minimal or uncomplicated definitions. The most complex terminology within the theory surround the agent and agency relationship established between the care recipient and the nurse. For example, the terms dependent care agent and dependent care agency require a more in-depth definition than the term partially compensatory nursing system or basic conditioning factors, both of which are largely self explanatory.

Criterion 4 – Major concepts are identified and defined

The major components of Orem’s theory are explicitly laid out and detailed. The major components of the theory are threefold the theory of self-care, the theory of self-care deficit, and the theory of nursing systems. Within each of the major components are key concepts and definitions specific to that component. Once all of the key concepts are defined within the framework of their major component a correlation is made regarding how all the components interrelated to create and comprehensive nursing theory.

The universal concepts that are included in most nursing theories are also covered in Orem’s SCDNT. Orem carefully defines these universal concepts: care recipient (person), the role of the nursing, the definition of health, and the role of the environment in the context of the theory specific concept of self care. The theory also defines when a person would need to change or alter self care. This deviation from normal self care activities occurs when a person has an illness, an injury, or an active disease process. These deviations often arise in a self care deficit.

The theory of nursing systems is the major component of SCDNT that describes in detail how the patient’s needs are met. It also defines the scope of nursing with respect to health care situations. This includes a broad overview of the role of nurse and care receiver and then details very specific roles of the nurse and care receiver as well. All of the definitions are correlated to how the nurse and the care receiver will meet the specified self care deficit.

Criterion 5 – Concepts stimulate the formation of propositions

Propositions are easily formed from the core concepts within the SCDNT. The concept of self care implicitly states the proposition that an individual is able to provide care for oneself. Similarly, the theory of self-care deficit implies the proposition that a nurse will fill a self care deficit when the individual is unable to do so. Within the nursing systems lies the proposition that legitimate patients have self care deficits for meeting self care requisites. At each main concept under the framework of SCDNT a multitude of propositions can be established. These propositions help establish the integral relationship among the concepts within the model.

Criterion 6 – Variables and assumptions help you understand and interpret propositions

As with all nursing theories, there is an established set of assumptions that are defined as they apply to the theory. The assumptions defined in the SCDNT are essential to the understanding of the theory at a very macro level. The internal and external variables are important to the specific concepts within the theory. For example, the assumption that people require continuous and self directed care for health, development and well-being is paramount to understanding all of the major theoretical aspects. It is would be impossible to understand the need for self care, the presence of a self care deficit and a nursing system that would fill the particular deficit of care recipient if the assumption was not made that humans require continuous care and maintenance.

The variables within the model help to describe and promote understanding of the major concepts. The variable ‘self care requisites’ provides a deeper understanding, or a micro level, of exactly what a self care deficit might be. The macro concept here would be that the nurse would fill the self care deficit as it arises, but in order to know there is a deficit one must know what self care requisites are present at varying developmental stages. If a person was unaware that bathing was a self care requisite, then the person would be equally unaware of a deficit if they were unable to bathe themselves.

Criterion 7 – Theoretical knowledge helps explain and predict phenomena

The phenomenon which states “human beings have varying abilities to care for themselves during illness” (Johnson & Webber, 2010) is explained in detail within the context of the SCDNT. The SCDNT not only explains the phenomenon, but the theory of nursing systems is predictive of the care receiver’s outcome in relation to their ability to resume self care. While this is one of the main phenomena explained by Orem’s theory there are many instances in which phenomenon can be explained through application of the theory.

Utilizing a practical application of the model explaining and predicting phenomena would be to explore the phenomenon that exercise reduces cholesterol levels within the body and thus reduces the risk of heart attack. Consider Patient A, a non-smoker, healthy weight individual who consumes a moderately balanced diet but does not exercise regularly. The rationale for not exercising is that he is a healthy weight and should not need to exercise. Under the SCDNT Patient A has a self care deficit by not exercising because he is unaware of his cholesterol level. The nurse is able to assist the patient through the nursing agency relationship interpret the cholesterol level and provide education on the correlation between cholesterol and the risk of heart disease as well as exercise and the reduction in cholesterol. Through this simple example the phenomenon was explained in the context of the SCDNT and the outcome to the patient can be predicted.

Criterion 8 – Theoretical knowledge influences nursing practice

SCDNT “has been proposed as a conceptual model for nursing practice. Because the immediate goal of a conceptual model is to guide practice, evaluation of a model’s usefulness in practice is a necessary and important step. Although a model may be potentially useful in a specific and well-defined setting, its ultimate usefulness depends on whether nurses are able to adapt it to their settings” (Wagnild, Rodriguez & Pritchett, 1987). In a study conducted by Wagnild, et al of graduates from schools which teach the SCDNT as the primary model of instruction it was found that a majority of these graduates continued using the model as the primary basis of their practice. However, it was noted that in most of the respondents stated that the healthcare setting in which they worked was conducive to self care. The vast majority of study respondents that were not actively utilizing the theory in practice stated one of two main reasons they were not using the theory; the healthcare setting was not conducive to self care or they did not have time to utilize the theory in practice. It was concluded by the study that the SCDNT is adaptable to a multitude of healthcare practice settings.

Furthermore, it has been suggested that there is a disparity between the theoretical nurse practice models, nursing diagnosis, and the nursing process. “The list of diagnoses accepted for testing and refinement by the North American Nursing Diagnosis Association (NANDA) has been developed inductively from nurses’ particular experiences and perceptions, no common theoretical base is shared by both. This theoretical discrepancy offers the possibility for a lack of fit between the two conceptual constructions” (Jenny, 1991). A study conducted that tasked nursing students to assign a specific nursing diagnosis to each self care requisite produced a positive correlation between nursing diagnoses and the self care requisites. Most of the nursing diagnoses were assigned appropriately. Furthermore, the students participating in the study expressed a very high level of satisfaction with the exercise as useful learning tool. Those diagnosis that were inappropriately assigned underscored the need for either a more detailed teaching of the meaning of the diagnosis or a more in-depth understanding of the self care boundaries outlined in Orem’s SCDNT (Jenny, 1991).

Finally, SCDNT has been used as a basis for evidence-based practice. “Evidence-based nursing practice is the conscientious, explicit, and judicious use of SCDNT-guided, research based information in making decisions about care delivery” (Fawcett, 2003) to the care recipient. At present, strong empirical data is just not available to support evidence-based practice that is rooted in the SCDNT. More concrete and comprehensive research is needed and encouraged by supporters of Orem’s model. According to Spearman, Duldt, and Brown (1993), a study of the literature on Orem’s theory produced 31 empirical studies. Of these 31 studies, 87 percent utilized ‘insufficient use’ or ‘minimal use’ of the SCDNT theory. “Society [has mandated] that disciplines and professions providing health care generate a relevant, accurate and reliable knowledge base to guide their practice” (Spearman, et al 1993).

Conclusion

As one of the premier nursing theories available today, Orem’s SCDNT is widely taught as a nursing practice model to nursing students and is used practically within health care settings. It has been determined to be adaptable to a multitude of care settings as well as applicable to a wide variety care recipients. The model has been updated numerous times and has been used as a platform for the development of new theories in nursing. The one area that is lacking is that of a fully researched body of empirical evidence to render the SCDNT a solid foundation for evidenced based nursing practice. As the science of nursing evolves the requirement for adequate testing of theories will become the standard.