Self Care Theory In Nursing : Selected Papers Of Dorothea Orem

Forewordhis publication of the collected papers of Dorothea E. Orem is asignificant and valuable contribution to the nursing literature. Thesewritings give insight into the development and range of thinkingabout nursing over the years. Orem's conceptualizations have provided amental model essential to the development of nursing as a discipline ofknowledge—a practical science with applied sciences and the foundationalnursing sciences. As Mary B. Collins, an experienced clinical nurse, oncesaid, "It gives me the words to express what 1 know to be nursing."Through six editions of her book, Nursing: Concepts of Practice, andtwo editions of Concept Formalization in Nursing: Process and Product bythe Nursing Development Conference Group, of which Orem was theleader, key contributor, and editor, Orem has provided the theoreticalstructure upon which to develop and expand nursing knowledge. She hasclarified nursing's particular contribution to health care and given directionfor its future development.Dorothea Orem has a unique ability to listen to a group of nursesexpressing their concerns and ideas about nursing and to analyze andconceptualize the essence of meaning in what is being said. Throughthis process she frequently formulates an abstract model to illustrate therelationships among the concepts.Dorothea Orem has always been gracious and considerate about others'ideas and exemplifies a scholarly approach to whatever subject is underconsideration. She always functions as an integral part of the group, neverdominating, but sharing with others in a collaborative working relationship.She quietly encourages input from nurses, facilitating in developing theirideas, helping them gain insights and stimulating them to take a similarscholarly approach to nursing.Notable about Orem is not only her depth of thought but also hercontinuing growth over the years in developing her conceptualizations, asTxv

xviForewordevidenced in this collection of papers and the six editions of her book. Inthe most recent edition of Nursing: Concepts of Practice, Orem not onlyadded to the structure of her nursing theories but laid the groundworkfor areas needing further development in the practical science of and thefoundational sciences of nursing.For more than thirty years, Orem's concepts, based on the self-caredeficit theory of nursing, have given direction to many nurses, inspiringthem to seek better ways to develop and express the knowledge base ofnursing. She has been a consultant to many groups of nurses in education,practice, and nursing administration, both nationally and internationally.She also has made a significant contribution in developing a theory ofnursing administration. From the late 1960s to the present, numerousregional and international conferences and institutes based on her conceptualizations have taken place. In honor of her contributions to nursing,Orem has received recognition from many sources, including Sigma ThetaTau, the National League for Nursing, the Distinguished Alumni Awardfrom The Catholic University of America, and three honorary doctorates.The International Orem Society for Nursing Science and Nursing Scholarship was established in 1990 for the purpose of advancing nursing scienceand nursing scholarship through the use of Dorothea E. Orem's conceptualizations in nursing education, practice, and research. The Society seeks toestablish a worldwide network for interaction among nursing scholarsand sponsors conferences and promotes scholarly activities designed toencourage the advancement of nursing science.Much research has been done based on the self-care deficit nursingtheory, beyond serving as the basis for master's theses and doctoral dissertations. A few examples of its use are: the early development by Horn andSwain (1977) at the University of Michigan on Criterion Measures of NursingCare', the W. K. Kellogg Foundation grant to Alcorn State University fordevelopment of family-centered adolescent health promotion centers inrural Mississippi; the establishment of the Center for Experimentation andDevelopment in Nursing at The Johns Hopkins Hospital during the late1960s and early 1970s, whose projects for developing nursing practicewere based on Orem's concepts; and a grant for a post-doctoral programat Wayne State University for scholars to work with the theory. Moreover,the self-care deficit nursing theory has been used to develop nursing practice in many service agencies, such as hospitals, home health care, andcommunity health agencies. It is the basis for nursing practice and education in Thailand and is being used in other countries around the world.

ForewordxviiIn education, it has been the basis of nursing courses and curricula inbaccalaureate and community college nursing programs.Orem served as a consultant for many of these agencies, helping themto develop creative and innovative approaches to achieve desired outcomes.Some of this work has been published. Her model has provided impetusfor the development of exemplary programs in nursing practice, in theteaching of nursing and nursing curricula, as well as in nursing research.As two members of the former Nursing Development Conference Groupwho early on had the benefit and privilege of working with Orem andapplying her ideas in both practice and education, we have found hermental model for nursing to be insightful, logical, and representative ofthe reality of nursing. Working with Orem's conceptualizations has beenboth exciting and challenging in our professional lives. Orem has providedthe structure for the ongoing and future development of nursing as apractical science and as a practice discipline.Sarah E. Allison, RN, MSN, EdDCora S. Balmat, RN, MSN, PhDMembers of the Nursing Development Conference GroupREFERENCEHorn, B. J., & Sevain, M. A. (1977). Development of Criterion Measures of NursingCare: Volumes I and 11. Prepared for National Center for Health Services Research.Hyattsville, MD.

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IntroductionHOW THIS BOOK CAME ABOUTWe, the editors of this book, both have a long association with DorotheaOrem—Susan Taylor since 1976 and Kathie Renpenning since 1983. Collaboration between the two of us began in 1983 at the instigation of Oremand continues to this day through theory development activities, writingand publishing, and giving presentations in North America, South America,Asia, and Europe. As we have worked with Orem and learned of hertheoretical and conceptual work, we also got to know her personally andwere privileged to have access to her working papers and presentations.There is great value in these materials and we wanted to share them withthe nursing community.The papers that are included in this book are representative of Orem'sthinking throughout the years. Most of the papers were developed forpresentation. In a few instances notes that Orem had made in preparationfor presentations, writings, or classes are included. The materials are presented in chronological order to illuminate the development of Orem'sideas about nursing theory, education, and practice over time. At the endof the book there are papers by nurses in other countries which highlightthe status of Orem's theory internationally.Papers that had been typed were scanned into the computer and editedfor accuracy. Handwritten papers were edited for readability, abbreviationsconverted into words, transcribed by a professional typist, and edited byone of us. Some format changes were made for readability and publicationstyle such as the format of references, lists, and publications. The originalpapers were not written in a particular style. However, whenever possibleAPA was used in editing.xvc

xxIntroductionAs with any historical document, these papers need to be read withconsideration of the historic and cultural context in which they werewritten or presented. For example, it should be noted that in the earlyyears, the use of man or the pronoun he was acceptable when referring tothe individual. Because of where Orem was working, the early focus is onhospital nursing, while in later years many settings were represented.THE ROOTS OF DEVELOPMENT OF SELF-CAREDEFICIT NURSING THEORYIn 1945, after working as a nurse in the operating room, emergency room,private duty, pediatrics, and adult medical/surgical nursing and teachingat The Catholic University of America (CUA), Orem accepted a positionas Director of Nursing Service and Director of Nursing Education at Providence Hospital in Detroit. In a personal communication (11/20/97) sherecounted an experience she had when she was director of the school.We had a good program, good students. We were having a curriculum committeemeeting, and a question was asked; it was a substantive question. I had noglimmer of an answer to it. I knew there was something missing. I was directorof the school. We had a good faculty. It was a question that raised questions inmy mind. What's the answer? I don't know. 1 knew that I should, but, if youdon't have a conceptualization of nursing there are certain things that you can'tanswer. You're oriented to doing this and doing that and doing the other.The lack of a substantive, structured body of nursing knowledge surfacedagain when she was working in Indiana. She went to Indiana in 1949, withthe Indiana State Board of Health, Hospital Division, to help in upgrading ofnursing services in general hospitals. She worked closely with Ann PoormanDonovan, conducting studies of organizational structure of nursing servicesand variations in types of patients and length of stay. She described thisperiod.Some of the things we came up with included the demands placed on nursesby length of stay of patients, by the scheduling of admission and discharges, byhow activities were planned throughout the day in nursing units . . . nurses haddifficulty representing their needs to hospital administrators. They didn't knowhow to talk about nursing, they didn't know how to represent what they needed.The same would be true in communicating with boards of trustees and withphysicians. But one of the things I found in talking with physicians was that if

Introductionxxiyou talk nursing, they understood. They weren't anti-nursing, they just neededsomebody to represent things properly to them, (personal communication, 11720/97)Orem reports that it was at the end of writing a report on the study ofadministrative positions that she felt the need to write a chapter on hospitalnursing services and then a chapter on the art of nursing that includedher first definition of nursing.I actually had to construct it. I think one of the important things was that I hadsome conceptualization of how a science develops because of my backgroundin biology, including the sequence of courses through bachelor's and master'sprograms in biology. At least, I had some understanding of scientific knowledge.I knew that it didn't exist in nursing, but to develop nursing science, thatwasn't in my mind. I was concerned with expressing what nursing is. (personalcommunication, 11/20/97)The first two chapters reflect the results of her thinking at this time.Although the study from which these chapters are extracted was done inthe 1950s they are included here for the definition of nursing with thefirst specification of self-care limitations of persons as the object of nursingand the clear statements of the inherent distinctions between nursing andmedicine. During this time in nursing there was beginning to be a focuson planning nursing care. Orem became aware that the "point of departurefor planning care had to be the patient's, not the nurses', tasks." Theemphasis on planning nursing care led Orem to ask, "What is the basisfor planning? What are you planning? To me, there wasn't anything"(personal communication, 11/20/97).Following her work in Indiana, Orem returned to Washington, D.C.,and took a position with the Office of Education, Vocational Section ofthe Technical Division, where there was an ongoing project to upgradepractical nurse training. It was at this time that the more formal work ofstructuring began including authoring Guides for Developing Curricula forthe Education of Practical Nurses (Orem, 1959).In my thinking that started at that time, I came to the conclusion that thequestion that had to be answered was "Why do people need nursing?" I didn'tgo back to the work I had done in Indiana. I didn't look at nursing referencesbut I asked myself the question. I can still remember the situation in which Ihad the insight to answer the question "Why do people need nursing?" Theknowledge was within me. I was able to use that knowledge in answering the

xxiiIntroductionquestion. I remember sitting, how I was sitting at the desk when I did ask andanswer that question. It is a specific memory. From that time onward, theknowledge I had about nursing began to structure itself. It wasn't anything I diddeliberately, but the pieces started to come together, (personal communication,11/20/97)NURSING THEORY AND NURSING EDUCATIONOrem returned to the CUA School of Nursing in 1959 to teach graduatestudents and direct them in their research. During the next twenty years thedevelopment of self-care deficit nursing theory, theory-based curriculumbuilding, and the design of nursing practice from a nursing theory perspective occurred synergistically as can be seen particularly in chapters 3-16.These chapters reflect Orem's interaction with educators and practitioners.In addition to being active in curriculum development at CUA Orem wasactive as a curriculum consultant for schools of nursing developing nursingtheory based curricula. The interactions with faculty at CUA and threeother schools (Morris Harvey College, Charleston, West Virginia, the newlydeveloping nursing program at the University of Southern Mississippi,Hattiesburg, Mississippi, and the Georgetown University School of Nursing,Washington, D.C.) were particularly meaningful in the development ofself-care deficit nursing theory. Publications and papers describing thiswork contain much information of interest to nursing educators and historians. These materials are outside the scope of this book, as they weredeveloped by people working with Orem and not Orem herself. In 1974,the accrediting body of the National League for Nursing (NLN) revisedthe standards for accreditation to include the requirement that nursingcurricula have a theoretical basis (NLN, 1972). This was a stimulus forcontinuing theory development.There are identifiable themes in the chapters on education. In the earlyones, Orem is dealing with the then current issue of levels of nursingeducation programs and the need for maintaining standards that wouldbe helpful to both the profession and society. This was a period whenthere was a nursing personnel shortage and increasing complexity in practice. This led to the development of the nursing technician programs inthe junior and community colleges as well as an increase in the numberof baccalaureate programs for nurses in colleges and universities, andmaster's clinical specialization. The ideas expressed in these papers remainmeaningful in the contemporary health care milieu, as ways of dealing

Introductionxxiiiwith the current issues of nursing shortages and the essential and legitimateroles of professional nursing are debated. The later papers reflect theinfluence of theory development on Orem's understanding of curriculumdevelopment and the need for theoretical understanding of the object ofnursing. She spoke and wrote to the need for knowing the object of nursingand using structured knowledge to build curricula. She maintained herbelief that the intellectual work of nursing is most appropriately the workof the professionally educated nurse.NURSING THEORY AND NURSING PRACTICECoincidentally with the curriculum work, the Nursing Development Conference Group (NDCG), which grew out of the CUA Nursing ModelsCommittee, was formalized in 1968. This group was made up of elevennurses from a variety of backgrounds in education and practice who wereconcerned about the lack of an organizing framework for nursing. Thisgroup set about working with Orem and the embryonic self-care deficitnursing theory to continue the work of formulating the theory. One of the"laboratories" for analyzing nursing and designing of nursing practice wasThe Center for Experimentation and Development of Nursing at The JohnsHopkins Hospital. Orem was an active consultant to this center and personnel from the center were members of the NDCG. The results of the deliberations of Orem and the NDCG were published in two editions of ConceptFormalization: Process and Product (NDCG, 1973 and 1979). The scholarlyactivity and productivity of this group under the leadership of Orem isillustrated in chapter 16.With the publication of the first edition of Nursing: Concepts of Practice(Orem 1971) information about self-care deficit nursing theory becamewidely disseminated and Orem came to be much in demand as a speakerand consultant in relation to the theory itself and in relation to nursingpractice and education issues. In chapters 17-31 the development of thetheory can be seen and the specific contribution of the theory to advancingnursing education and nursing practice can be appreciated.Orem frequently refers to self-care deficit nursing theory as a theory ofnursing practice. The theory emerged in part as Orem sought answers tothe question "Why does a person need a nurse?" Answering the questionhas resulted in the lifelong work of theorizing about nursing and making"explicit the elements and relationships that give form and meaning to

xxivIntroductionnursing as a field of practice and a field of knowledge" (Orem, 2001, p. 489).In the first chapter in this book Orem lays out the essential requirements forthe practice of nursing. Although this was written in 1955 it still hasmeaning today. This early work has been influential in Orem's thinkingas self-care deficit nursing theory has evolved.Orem's facility for listening to nurses; observing and analyzing practicesituations; breaking down and analyzing systems, individual acts, andsequences of actions; and categorizing and structuring the disparate piecesof information, as well as her ability to bring out the scholar in practicingnurses resulted in the Nursing Development Conference Group's contributing to laying out the substantive structure of the variables of concern tonursing (NDCG, 1973, 1979). This also resulted in making explic

27. Theory Development in Nursing (1988) 248 28. The Development of the Self-Care Deficit Theory of 254 Nursing: Events and Circumstances (1988) 29. A Perspective on Theory-Based Nursing (1988) 267 30. Multiple Roles of