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Nursing Theorist Presentation: Dorothea E. OremIntroduce the nursing theorist and pertinent personal information (2)Dorothea Elizabeth Orem, born in 1914 (Baltimore, MD), died June 22 of 2007. She received a diploma in nursing in the early 1930s and went on the earn BSN (1939), MSN (1945) and honorary doctorates of science (1976, 1980) and Humane Letters (1988). Early nursing experiences included practice roles as a staff nurse in medical-surgical and pediatric settings as well as an assistant director of nursing role in a general hospital. She was also involved in nursing education as a teacher of biological sciences in a nursing program and as an assistant director of a school of nursing. She served as a nurse consultant with the Indiana State Board of Health from 1949-1957 (beginning s of theoretical model during time with SBOH) later as a consultant in the Office of Education for the U.S. Department of Health, Education, and Welfare. Illustrate the theoretical model created by the nursing theorist (2)Self-Care Deficit Theory of Nursing:Evolved over the course of 4 decadesOrigins: (1949-1959)- she began to develop ideas regarding the uniqueness of nursingIn effort to formalize a framework by which to organize nursing knowledge, she asked… “What is nursing?”“How was it different from other disciplines? How was it similar?”“What is the domain and what are the boundaries of nursing as a field of practice and a field of knowledge?”“What condition exists when judgments are made that people need nursing?”(Answer: The inabilities of people to care for themselves at times when they need assistance because of their state of personal health)Ideas evolved from: Unique experiences of her personal nursing career, Observations in practice, Study of formal logic and metaphysics, use of resources from many fields, Abilities in methods of reflect and questioning, and her collaborations with students, practitioners, researchers, educators, administrators and scholarsEarly Influences: Human organization, action theory (an area of philosophy concerned with theories about the processes causing intentional/willful human bodily movements of more or less complex kind) cite: Wikipedia, , retrieved 10/10/08The works of: Aristotle, Thomas Aquinas (on the Action theory), Barnard (1962), Kotarbinski (1965), Macmurray (1957), Parson, Bales, and Shils (1953), B.J.F Lonergan’s Insight(1958) [on reflective thinking], and essays by Wallace (1979, 1983) [for recent clarifications]. Cite: Orem, D.E (1987). Orem’s general theory of nursing. (p.73)Formalization: (1960-1980) through extensive reading and self-reflection, collaborations with students, practitioners, researchers, educators, administrators and scholars1970-Self-Care Deficit Theory of Nursing – “…not an explanation of the individuality of a particular concrete nursing practice situation, but rather the expression of a singular combination of conceptualized properties or features common to all instances of nursing.” -Orem A general theory of nursing comprising 3 interrelated theories5 Basic assumptions: 1) Humans require deliberate input to self and environment in order to be alive and to function2) The power to act deliberately is exercised in caring for self and others3) Mature humans will sometimes experience limitations in ability to care for self and others4) Humans discover, develop, and transmit ways to care for self and others5) Humans structure relationships and tasks to provide self-careTheory of Self-Care Deficit (or Dependent care deficit)??? “When and why do people require the health service nursing?” (Orem, 1987 p 72) ???Central idea: Individuals are affected from time to time by limitations that do not allow them to meet their self-care needs (limitations b/c of a health condition, internal or external factors)6 propositions: Persons who take action to provide their own self-care or care for dependents have specialized capabilities for actionThe individual’s abilities to engage in self-care or dependent care are conditioned by age, developmental state, life experience, sociocultural orientation, health and available resourcesThe relationship of individuals’ abilities for self-care or dependent care to the qualitative and quantitative self-care or dependent-care demand can be determined when the value of each is knownThe relationship between care abilities and care demand can be defined in terms of equal to, less than, more thanNursing is a legitimate service whena) Care abilities are less than those required for meeting a known self-care demand (deficit relationship)b) Self-care or dependent-care abilities exceed or are equal to those required for meeting the current self-care demand, but a future deficit relationship can be foreseen because of predictable decreases in care abilities, qualitative or quantitative increases in the care demand, or both Persons with existing or projected care deficits are in, or can expect to be in, states of social dependency that legitimate a nursing relationship 2 sets of presuppositions/(assumptions, or “givens” that are more specific to each of the 3 theories than general assumptions)Theory of Self-Care (or Dependent-Care)??? “What is self-care and what is dependent care?” (Orem, 1987 p 72)Central ideas (2): Self-care as learned behavior (learned from interaction and communication in larger social groups) & self-care as deliberate action “Self-care is a human regulatory function that individuals must, with deliberation, perform for themselves or have performed for them (dependent-care) to supply and maintain a supply of materials and conditions to maintain life; to keep physical and psychic functioning and development within norms compatible with conditions essential for life; and for integrity of functioning and development” (Orem 2001)6 propositions:Self-care is intellectualized as a human regulatory function deliberately executed with some degree of completeness and effectivenessSelf-care in its concreteness is directed and deliberate action that is responsive to persons’ knowing how human functioning and human development can and should be maintained within a range that is compatible with human life and personal health and well-being under existent conditions and circumstancesSelf-care in its concreteness involves the use of material resources and energy expenditures directed to supply materials and conditions needed for internal functioning and development and to establish and maintain essential and safe relationships with environmental factors and forcesSelf-care in its concreteness when externally oriented emerges as observable events resulting from performed sequences of practical actions directed by persons to themselves or their environments. Self-care that has the form of internally oriented self-controlling actions is not observable and can be known by others only by seeking subjective information. Reasons for the actions and the results being sought from them may or may not be known to the subject who performs the actionsSelf-care that is performed over time can be understood (intellectualized) as an action system-a self-care system- whenever there is knowledge of the complement of different types of actions sequences or care measures performed and the connecting linkages among them.Constituent components of a self-care system are sets of care measures or tasks necessary to use valid and selected means (i.e., technologies to meet existent and changing values of known self-care requisites)4 presuppositionsTheory of Nursing System- the unifying theory; describes and explains the nursing role??? “What do nurses do when they nurse?”, “What is the product made by nurses?” “What results are sought by nurses?” ???Central idea: Nurses have abilities that they use to determine if nursing help is necessary or “legitimate”Propositions: Nurses relate to and interact with persons who occupy the status of nurse’s patient Legitimate patients have existent and projected continuous self-care requisitesLegitimate patients have existent or projected deficits for meeting their own self-care requisitesNurses determine the current and changing values of patients’ continuous self-care requisites, select valid and reliable processes or technologies for meeting these requisites, and formulate the courses of action necessary for using selected processes or technologies that will meet identified self-care requisitesNurses determine the current and changing values of patients’ abilities to meet their self-care requisites using specific processes or technologiesNurses estimate the potential of patients to (a)refrain from engaging in self-care for therapeutic purposes or (b)develop or refine abilities to engage in care now or in the futureNurses and patients act together to allocate the roles of each in the production of patients’ self-care and in the regulation of patients’ self-care capabilitiesThe actions of nurses and the actions of patients (or nurses’ actions that compensate for the patients’ action limitations) that regulate patients’ self-care capabilities and meet patients’ therapeutic self-care needs constitute nursing systems2 presuppositionsDefine the concepts and principles of the theory (2)Concepts: (6 basic) Self-care-the practice of activities that individuals initiate and perform on their own behalf in maintaining life, health, and well-beingSelf-care agency- the power of individuals to engage in self-care and the capability for self-care (the person who uses this power/self-care ability=self-care agent)Therapeutic self-care demand- a collection of actions to be performed, or a ‘program of action’Self-care deficit- the relationship between self-care agency and therapeutic self-care demands of individuals in which capabilities for self-care, because of existent limitations, are not equal to meeting some or all of the components of their therapeutic self-care demandsNursing agency- the complex property or attribute of persons educated and trained as nurses that is enabling when exercised for knowing and helping others know their therapeutic self-care demands, and in helping others regulate the exercise or development of their self-care agency or their dependent-care agencyNursing system- all the actions and interactions of nurses and patients in nursing practice situations; the “creative end product of nursing”Peripheral concept:Basic conditioning factors: (internal/external factors r/t self-care agency, therapeutic self-care demand, nursing agency)age, gender, developmental state, health state, sociocultural orientation, health care system elements, family system elements, patterns of living, environmental factors and resource availability and adequacy Utilize Fawcett’s Criteria for Evaluation of Nursing Theories and Pertinent Questions to evaluate the theorists’ work (3)Explication of OriginsAre the philosophical claims on which the nursing model is based explicit?Yes, Orem’s Self-Care Framework is based on philosophical, theoretical, and scientific knowledge about human behaviorPhilosophical claims stated in the form of: assumptions, presuppositions, and premises (about human beings, self-care, self-care requisites, deliberate action, nursing, the Theory of Self-Care, the Theory of Self-Care Deficit, the Theory of Nursing System, & the General Theory of Nursing Administration)Examples of things Orem values: individuals’ abilities to care for selves and dependent others; the person’s perspective of his/her health status; physician’s perspective of health status**Orem: “Philosophy will help you think about things, but will not tell you your subject matter”Are the scholars who influenced the model author’s thinking acknowledged and are bibliographic citation given?Yes, Orem has always cited the works of other scholars from a variety of disciplines as influencing her thinking. Bibliographical citations are provided. Contributing to her ability to reflect [B.J.F Lonergan’s Insight (1958)] and question/search for meaning, the study of formal logic and metaphysics, resources from many fields, specific areas of philosophy: Human organization, Action theory (works of Aristotle, Thomas Aquinas, modern logicians, philosophers, psychologists, physiologists, sociologists, industrialists) Talcott Parsons et al (1953)- the context of actionJohn Macmurray (1957)-self as agentM.B. Arnold (1960), Tadeusz Kotarbinski (1965)-science of deliberate human action M. Black (1962), R. Harre (1970)Paul Weiss (1980), William A. Wallace (1983, 1996)-help with more recent clarificationsOthers:The Nursing Development Conference Group- lists 13 individuals (including Orem) involved in the group over the yearsOrem Study Group- lists 11 individuals (including Orem)Orem mentions many others as influencing her theory, including collaborations with students, practitioners, researchers, educators, administrators and scholarsComprehensiveness of ContentDoes the nursing model provide adequate descriptions of all four concepts of nursing’s metaparadigm?Yes, the descriptions of all four of nursing’s metaparadigm concepts are adequate. (Some inconsistencies in language have occurred over the course of the four decades/6 editions with most revisions resulting in clarification, a few more difficulty in understanding) Do the relational propositions of the nursing model completely link the four metaparadigm concepts?Yes, linkages are specified between 3 out of 4 concepts throughout the editionsOnly statement made to link all 4 concepts occurs in the 2nd edition of Orem’s book (1980): “Nursing is made or produced by nurses. It is a service, a mode of helping human beings…Nursing’s form or structure is derived from actions deliberately selected and performed by nurses to help individuals or groups under their care to maintain or change conditions in themselves or their environments. This may be done by individuals or groups through their own actions under the guidance of a nurse or through the actions of nurses when persons have health-derived or health-related limitations that cannot be immediately overcome (Orem, 1980, p.5)Is the researcher given sufficient direction about what questions to ask and what methodology to use?Although guidelines are not explicitly stated, much research has been done that cites the content of Orem’s Self-Care Framework. Orem’s conceptual framework had been used extensively as a guide for nursing research with much variation in the application. Does the educator have sufficient guidelines to construct a curriculum?Guidelines, although not explicitly stated, have been, and are currently being developed based on the content of framework and publications about its use. The framework has been used as a conceptual guide to nursing curriculums in a number of programs, including: associate degree, diploma, baccalaureate, masters and doctorate levels. The seven disciplines of nursing knowledge identified by Orem provide additional framework for curricular content. Application in nursing education takes a variety of forms.Does the administrator have sufficient guidelines to organize and deliver nursing services?Yes, the Self-Care Framework provides ideas to guide 1. The focus of nursing in the health-care institution (ex. To provide nursing care to individuals with health-derived/associated self-care deficits) 2. The purpose of nursing services (ex. To help people enhance their abilities to provide continuing, therapeutic self-care & dependent-care) 3. Characteristics of personnel (ex. Includes nurses, nursing practitioners, & nursing administrators) 4. Settings for nursing services (ex. Many…”nurses may go to where patients are…Or patients may come to clinics or other types of facilities where nurses are available…(Orem, 1989, p.56)) 5. Management strategies and administrative policies (ex. “the proper ordering of persons and material resources so that a functioning whole is continuously created…” (Orem, 1989, p. 61))Is the practitioner given sufficient direction to be able to make pertinent observations, decide that an actual or potential need for nursing exists, and prescribe and execute a course of action that achieves the goal specified in a variety of practice situations?Again, although guidelines are not explicitly stated, the content of the Self-Care Framework gives sufficient direction to practitioners in a variety of practice settings. Examples include use of Orem’s concepts in the development of plan of care for: individual client, families, & communities, as well as use in the development of instruments to measure patient outcomes. ‘Theory-based computer software for bedside care was developed within Orem’s general theory of nursing by Nursing Systems International’ (Metzer, 1995, p. 152) The Self-Care model also ‘linked the patient assessments with nursing diagnosis, expected patient outcomes, discharge planning, quality assurance variables, clinical research, and external agency reports’ (Metzger, 1995, p.152)Logical CongruenceDoes the model reflect more than one world view?No, only that of ‘reciprocal interaction’ is notedDoes the model reflect characteristics of more than one category of nursing knowledge?Although several different categories have been suggested (ie. systems model, interaction model), characteristics of the framework do not support these…characteristics are congruent with classification as a developmental model. Do the components of the model reflect logical translation or reformulation of diverse perspectives?Yes, Orem’s thinking was influenced by a variety of perspectives (nursing and other) and she used resources from a range of disciplines in developing her conceptual framework. Ideas from specific areas of philosophy, metaphysics, etc. were logically translated to fit into her framework. Generation of TheoryWhat theories have been generated from the nursing model?The Self-Care Deficit Theory of Nursing: Theory of Self-Care Deficit, Theory of Self-Care, Theory of Nursing System (grand theories)(?)Credibility of the Nursing Model: social utility, social congruence, social significanceAre education and special skill training required before applying the nursing model in nursing practice?Yes, it is a rather unique framework in: focus, content, style and vocabulary.Need to learn specific “style of thinking and communicating nursing” (Orem, 2001, p.137)Familiarity with language of the theories of deliberate human action enhances understanding of Orem’s work.(Ex. Agent: the person who engages in a course of action or has the power to engage in a course of action) Is it feasible to implement practice protocols derived from the nursing model and related theories?Despite the need for special training and education, the implementation of Self-Care Framework-based practice protocols is feasible. Considering the recommendations and suggestions given by Nunn and Mariner-Tomey (1989), Fernandez et al. (1996), Hooten (1992), and Paternostro (1992) [as cited in the Fawcett evaluation]: full implementation of SC Framework in nursing practice settings would take 6-8 years (evaluation ongoing)To what extent is the nursing model actually used to guide nursing research, education, administration, and practice?Actual application of Orem’s model takes many forms in all of the above arenas. Practice: using the model as a philosophical guide to nursing practice (self-care beliefs), or use the model precisely to develop guides for nursing practice. Can be used to help plan care for individual patient (all ages), families & communities, in diverse practice settings (from health promotion practices to critical care units to nursing service administration)A number (# unknown) of specific institutions use Orem’s model as a framework for practice (including Harry S Truman Hospital in Columbia, MO)Administration: framework-based guidelines r/t: Focus of nursing in the health-care institution, Purpose of nursing services, Characteristics of nursing personnel (high-level technical training or professional level education=nurses), settings for nursing services, management strategies and administrative policies (Fawcett, 2005, p. 254)Education: (*note origins)curricula in associate degree, diploma, and baccalaureate programs; curricular content to differentiate the role and function of the technical nurse from that of the professional nurse; Orem’s nursing process in clinical practice: assessment tools, teaching packets, evaluation models.Research: used for both quantitative and qualitative methodologies; some use the belief or definitions as basis for research; others cite Orem’s concepts & use ideas of others/several theories within a study.There are 23 pages of examples of research studies, instruments, and tools that have been guided by the self-care framework in the Fawcett reading. Does the nursing model lead to nursing activities that meet the expectations of the public and health professionals of various cultures and in diverse geographic regions?Yes, it has and does, however, the emphasis on self-care is not completely congruent with some people’s expectations of nursing practice; (regional and cultural groups can vary); Many examples international application and development of the model; First International Self-Care Deficit Nursing Theory (S-CDNT) Conference- held in KC in 1989 (Participants from: Sweden, Netherlands, Canada, Thailand, Australia, Japan, and US)=Global Impact Does the application of the nursing model, when linked with relevant theories and appropriate empirical indicators, make important and positive differences in the health conditions of the public?Yes, much empirical evidence supports Orem’s claim: nurses contribute to “maintaining health, preventing disease, and disability and restoring or maintaining life processes” by overcoming “health-associated human limitations for engagement in self-care or dependent-care” (Orem, 2001, p. 81). Empirical evidence r/t social significance is equivocal (some +/some- results)-beneficial?When linked with relevant theories, the Orem model has potential to make a positive difference: Improved self-care abilities, less inappropriate use of health services (cost containment), Contributions to the Discipline of NursingWhat is the overall contribution of the nursing model to the discipline of nursing?Orem’s framework presents an optimistic view of patients’ contributions to their health care and an explicit focus on what matters to nurses. Orem has identified the domain and boundaries of nursing as a science and an art as well as nursing’s unique contribution to health-care.Contrast the theory with other nursing theories from the same paradigm (2)Engage peers in a discussion of the theorists’ work (2)Nurses approach and enter concrete ‘situations of nursing practice’ and must ask and answer certain questions: (in order to investigate nursing-relevant details in situations)What does this situation that involves me with others in this time-place localization mean to me, not just as a person but as a person who is Nurse?Why am I here?As a Nurse, what must I know?What do I inquire about?What questions do I need to ask?What meaning do I attach to the information obtained, to the judgments I make?What conclusions are valid?Do I have a language to express what I know so what I know is communicated meaningfully to persons I nurse, to other nurses, and to other health workers?Do I have knowledge of what can be changed through deliberately designed action and what cannot be changed?(Orem, 2001, p.17)These questions identify the kinds of specialized, theoretical knowledge that nurses (should) have.Clarity, time utilization, creativity, and use of audiovisual materials (2) ................
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