CRITIQUE

OF
DOROTHEA OREM’S
SELF-CARE DEFICIT
THEORY

By: Pauline G. Chan, R.N.

To: Professor Charlie D. Baldon, Ph.D., M.N., R.N.
Introduction:
Nursing in the 21st century has evolved greatly compared to Nightingale’s time. Within
the past decades, the nurses faced a series of challenges concomitantly with time. In order for the
profession to keep up, change is vital. There is no denying that change is necessary because it is
the only constant thing in this world. Acknowledging the efforts made by our forerunners and
pioneers of the nursing profession, we still continue to study and inculcate in our minds their
teachings and their legacy.

If we look deeper into the past, these pioneers have nothing and their sources were
scarce, but still they were able to develop nursing theories which served as a guide to all aspiring
nurses. It has served a great deal in the evolvement of the nursing profession. Nowadays, we are
shepherd by what we call evidence-based practice.

One of the theorists that left a legacy goes by the name of Dorothea Orem. Her theory
entitled Self-Care Deficit Nursing Theory has influenced a great number of researches and
practitioners who incorporated her theory into their practice. But being one of the first nursing
theorists, her theory presented with some gaps and flaws. That is why it has come to my attention
to pursue, fill in the gaps, correct the flaws and add some information in which I think is
important to consider in her theory.

Metaparadigm in Nursing:

Orem’s Self-Care Deficit Nursing Theory addresses the client’s self-care needs. Unlike
the other theories that are patient- centered, this theory is said to be goal-oriented. She explained
that the theory is aimed towards making the patients perform self-care activities. Therefore, for
me, promoting independence in the part of the patient and focusing on the patient’s ability to
perform self-care is a patient centered approach.

Person

In Orem’s operational definition of a person, human beings are different from other living
things in terms of capacity. In agreement with the statement, human beings are indeed a unique
species because we are able to reason out and continue to grow as we learn new things every
day. Our capacity to perform a series of tasks is endless if we put our mind into it. She also stated
that she believes that individuals have the potential to be developed and learned. I think what I
have explained in the previous statement is what she is trying to convey but had a grammatical
error instead. The phrase “have the potential to be developed and learned” is like a metaphor
wherein humans are being compared to robots wherein they are developed and learned. Humans
indeed has the potential to develop characteristics needed to excel, the potential to learn and
keep learning, rather than the potential to be developed and learned in which it sounds like an
experiment rather than referring to an actual human being and his capabilities.

Health

With regards to defining health, Orem has adopted the World Health Organization
definition. For the World Health Organization, health is defined as a state of physical, mental and

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social well-being and not merely the absence of a disease or infirmity. The definition being too
vague I think it would be better if Orem had an operational definition of her own because it
contradicts with the other points in her theory. In her Self-care Deficit Nursing Theory
(SCDNT), those people who are considered sick or ill are the main target or the reason why this
theory was created. I think the theory is for an individual with an existing illness or someone
whose system failed to put up a barrier to fight with foreign bodies which resulted to a disease or
a client who has experienced too many external factors that has caused disequilibrium in his
system which resulted to an illness. Because a well individual does not need a dependent care
agent or a nursing agency to help or aid in performing his activities of daily living (ADL).

Environment

Orem views the environment as an external source of influence in the internal interaction
of a person’s different aspects. A lot of theories has defined environment as an external factor
but I think in her Self-Care Deficit Nursing Theory, from the word itself “self-care”, which
means it is internal or within thyself. I want to reiterate the internal environment of the client in
which I think is essential in his recovery. By internal environment, I mean the patient’s
willingness to recover, the patient’s perspective on self-care, his perception, whether positive or
negative, can affect one’s prognosis and inner motivation by oneself or by significant others that
is vital in the fast recovery of the patient.

Nursing

Nursing is defined as helping clients to establish or identify ways to perform self-care

activities according to Orem. But I would like to emphasize that the nurses and the significant
others are only there to assist them in the activities of their daily living. Teach them not to rely
on others but help them or teach them how to rely on one self. Another point that I would like to
emphasize the need of the clients for inner motivation because I believe that inner motivation
lasts longer compared to the external motivation influenced by others. Through intrinsic
motivation, the client will be able to condition his self and know the reason behind why does
perform those activities, that is for satisfaction and pleasure. I guess you can say performing one
of these activities is reinforcing in-and-of itself.

SELF-CARE DEFICIT NURSING THEORY

In her theory, she explained that self-care is an activity that promotes a person’s well-
being. I highlighted the word promote because I would like to put emphasis on this word. Self-
care is a necessity but it is not a primary factor in achieving the optimum level of health. Self-
care is not a cure but rather a stepping stone is one’s recovery. Self-care requisites on the other
hand are stated as insights of actions or requirements that a person must be able to meet and
perform in order to achieve well-being. From the term itself, self-care requisites, it provides an
obvious explanation as to what it is. It is further explained that there are two elements which
these so called self-requisites have.

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 First off, is the factor to be controlled or managed to keep aspects of human functioning
and development within the norms compatible with life, health and personal well-being. I think
every theory must somehow have a contingency plan in which one considers some unexpected
turn out of events in which one cannot control or manage. This can also affect the patient and his
recovery in several aspects. For example, like what is currently happening now in the
Philippines, there is a sudden change in the weather. In the morning it is bright and sunny and the
next thing you know, the clouds get gloomy and a sudden gush of heavy rain embraces your
body. Like think what will happen if patients who are unable to walk or uses a wheelchair. What
if they are scheduled everyday supposedly to go out in the open and perform their morning
exercise out on the field whilst making good use of the sunlight and their daily routine suddenly
changes because of the unpredictable weather. I have read that exercising helps you release
endorphins or as what others would call as the happy hormone. Endorphins would make you feel
happy and brighten your mood, thus making the patient feel good about themselves which in turn
aids in their speedy recovery. But if the weather continues to change like crazy, and patients will
not be able to do their morning exercise, they would feel as gloomy as the weather which can
affect their prognosis.

The second element of self-care requisites is said to be the nature of the required action
wherein the patient must be well educated in what he is supposed to do. He should be well
versed in his strengths and limitations as to his capabilities in order to perform self-care and
know appropriate measures with regards to his condition.

According to Orem, there are three types of self-requisites. First is the Universal Health
requisites in which all physiological needs are indicated. This includes the maintenance of a
sufficient intake of air which is vital for our survival. Maintenance of a sufficient intake of food
and water: this part is applicable to almost all patients who are conscious and able but for those
comatose patients who relies on their osterized tube feeding delivered through their nasogastric
tube administered by their nurse or significant other or rather their dependent care agent as
defined by Orem as the one who takes full responsibility of taking a person who are dependent.
There is also the provision of care associated with elimination which is not applicable for
comatose patient and for infants. Comatose patients cannot care for themselves that is why this
theory is mostly not applicable to them. Infants also, being too young, cannot provide care for
themselves given that they cannot even move without assistance or they cannot even verbalize
their concerns, they just cry in order to get their caregiver’s attention and emitting a signal that
something is wrong. Maintenance of balance between activity and rest is also stated under the
universal self-care requisites but is not applicable to paralyzed patients for example patients with
C4, C5 spinal injury. They cannot move from the neck down and although they are being
assisted with passive range of motion (ROM) exercises, they will have to rest more because these
kinds of patients tend to get more exhausted and frustrated so balance between activity and rest
cannot be achieved. The need for balance between solitude and social interaction must also be
achieved but for comatose patients, I do not think that it is applicable. Given that comatose
patients, GCS 3 patients cannot interact. There are also a disease called the “Locked-In”
Syndrome or cerebromedullospinal disconnection wherein their only way of communication is
through the coded messages by blinking or moving their eyes which are not often affected by the
paralysis. But there is also an unfortunate thing such as “Total Locked-In Syndrome” wherein
even their eyes are paralyzed. Unlike the persistent vegetative state, in which the upper portions

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of the brain are damaged and the lower portions are spared, individuals with locked-in syndrome
is caused by a damage to specific portions of the lower brain without any damage on the upper
brain. Individuals with this syndrome lack coordination between breathing and voice. This
prevents them from producing voluntary sounds, though the vocal cords are not paralyzed.
Providing balance between their solitude and social interaction is also not possible because these
patients are often frustrated by the fact that they are not able to communicate although they can
sense and perceive the messages being sent to them. And they also tend to need more rest than
usual. Another universal self-requisite is the prevention of hazards to human life, human
functioning and human well-being and the promotion of human functioning and development. I
do not think this is helpful for patients with late stage Guillain-Barre-Strohl Syndrome because
patients in addition to comatose (GCS 3 or deep coma) patients, infants, patients with C4-C5
spinal damage, patients with “Locked-in or Total Locked-in” Syndrome do not have capability to
take care of themselves. The only thing that they will be able to comply is the maintenance of
sufficient intake of air.

The second type of self-care requisite is the developmental self-care requisite. Among
these, it is said that there are actions to be undertaken that will need to provide developmental
growth of the patients. It is said to be either maturational which is associated with the
developmental process and derived from a specific condition or situational which is associated
with a situation or an event. The degree of maturation differs from each individual. Not all older
people are mature. There are younger ones who are sometimes more mature than their seniors. It
differs because of their experiences, environment where they grew up and their peers which
influence how they behave and how they act, react and perceive things. Also, we should consider
that some situations can also lead to the development of an individual, especially unpredictable
situation. There is a time when a need arises, an individual is sometimes “put on the spot” and
have to decide right then and there regarding a certain situation. Whatever the decision might be,
it would always be a win-win situation because if he comes into a right decision about the matter
at hand, then he wins. However, if things do not go in his favour, then he will realize his mistake
and it will serve as a lesson for him. Either way, the individual will grow no matter which path
he takes. Some may not be able to grow up right away but life is not a race. Try whatever it takes
because no matter how long it takes for you to succeed, what matters is that you have.

The last type of self-care requisite is the health deviation requisite. As per definition in
Orem’s theory, these are the requisites for a person to be considered ill. Now, this is a
contradiction of Orem’s claimed support on World Health Organization’s definition of health. It
was stated in WHO’s definition that health is a state of physical, mental and social well-being
and not merely the absence of disease or infirmity. But in Orem’s theory, these health deviation
requisites are implying that in order for you to be provided with such care, you must be ill. If we
follow her adopted operational definition, there will be an assumption that all clients, sick or
well, should be cared for, regardless if there is a disease or not. Then this theory will be hard to
understand because of the confusing idea that she presented. If we are to apply this theory to
patients with existing illness or diseases, which I think is the main purpose of the theory, it
would contradict the definition of health of the World Health Organization.

This goes against the definition of the World health Organization. An obvious
contradiction between the adopted operational definitions can be seen which is why I would like

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to cite that the researcher should have an operational definition of her own regarding what health
means in her theory.

In her theory, she addresses the demand for therapeutic self-care of the patients which is
defined as the summation of all activities needed to alleviate the existing disease or illness. It
appears yet again as if this theory was created only for individuals with existing illness which
again contradicts her adopted operational definition of health. Among these activities and
definitions is what she called an “agent” and a “dependent care agent” in which in my
perspective, is similar. This is usually the role of the significant others, if not the nurses who is
assigned to take care of the patient. They are the ones who assumes full responsibility in taking
care of the patients who are dependent.

She also pointed out the role of nurses in her theory through what she called as
nursing design. These are said to be the functions that must be performed by the nurse in order to
meet the client’s need. For nursing designed to be materialized, the nurses must possess this
nursing agency which is a set of established capabilities of a nurse who can legitimately perform
activities of care for a client. These capabilities are the essentials for all nurses. One must have
the knowledge, attitude and skills in order for one to be an effective nurse.

ACCEPTANCE OF THE NURSING COMMUNITY

Practice

All of the diseases that had been cited in the researches were all long term or chronic
diseases or the ones needing palliative care such as the geriatrics, cancer patients and patients
with mental illness. Her theory only applicable for patients who are able but with existing illness
or disease who mostly needs palliative care.

Education

This theory has been her legacy in the nursing profession and had been used in some
curriculums which could be a great aid for the aspiring nurses of the future. Perhaps the gaps in
her theory could be refined and be updated in such a way that could be more beneficial to the
nursing community.

Research

A number of theories were conducted which was derived from her theory and its
implication served as a guide in the development of instruments which are used to assess the
patient’s self-care abilities related to the care of the well and the ill.

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ANALYSIS

Simplicity

It is indeed stated in the simplest manner, but sometimes it can be confusing as well. As
you can see through my entire critique, I have mentioned several times about her contradicting
concepts and her adopted operational definition regarding health.

Generality

According to Balita and Octaviano (2010), the theory could assist nurses in different
areas in “any” clinical setting, another point in which I greatly disagree. I do not think that this
theory could be used in any clinical settings because this theory has a lot of limitations. One of
which is the condition of the patients. This theory is not applicable for infants, comatose (GCS 3
or deep coma) patients, patients with C4-C5 spinal injury, patients with Locked-In or
cerebromedullospinal disconnection or Total Locked-In syndrome, late stage Guillain-Barre-
Strohl Syndrome, some post cerebrovascular (CVA) patients or the like. This theory is entitled
self-care theory because the goal is to promote independence among patients to perform their
activities of daily living in which can make them feel useful and lessen their frustrations
regarding being incapacitated or useless. This self-care theory aims to make the prognosis good
and the recovery fast through inculcating the independence of patients.

Empirical Precision

This theory has been used in several researches which have yielded a significant result
regarding its scope, complexity and clinical usefulness. This could serve as an excellent guide in
moving towards the future of empirical based practice.

Derivable Consequences

According to Balita and Octaviano (2010), this theory differentiates nursing from other
disciplines in terms of focus. But although it was first stated that this was a goal-oriented theory,
I still believe that her concepts still points out as to how the patient would take care of himself if
the need arises.

INTEGRATION OF THE 11 KEY AREAS OF RESPONSIBILITIES

A. Safe and quality nursing care

Providing awareness regarding self-care is the most basic foundation for this
theory to be a success. By lending a hand to the patient in performing his activities of
daily living as a way of learning and reiterating the need for the promoting independence
through doing simple and easy tasks first and gradually escalating into more difficult
one’s depending on his prognosis.

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B. Management of resources and environment

Proper use of resources includes the familiarity with the procedures for dealing
with the different concerns of the clients. Considering that the patients who usually has
self-care deficit are the ones who are chronically ill or those needing palliative care.

C. Health education

This is the most crucial part of this theory. Relaying to the patient your
knowledge on how he should care for himself in a way where he can save time and
energy. Ensuring that the patient knows and understands all the teaching conveyed to him
as well as significant others, considering that they are the agents or dependent care agents
who are always taking care of the patient a s stated in Orem’s definition of concepts. Also
making the patient perform return demonstrations as a way of confirming his learning,
clarifying confusing ideas and at the same time evaluating his ability for self-care is the
essence of his theory.

D. Legal responsibility

In Orem’s Self-care deficit theory, one should consider the rights of the patient.
The right of the patient to know and the right for proper information are two of the most
vital rights that need consideration in this theory. The agent or in our case, mostly, the
nurse should be providing the needed information of the patient and answering his
queries about the matter through effective health education. Focusing on the fact that the
patients who have a deficit in their self-care are the ones who can barely move,
chronically ill, old age or those who just finished a major operation or just recovered
from a serious illness are the main recipients of the care, one should consider one’s
preferences because the patient also has the right to refuse. So, coercing the patient into
doing things the ideal way, one should also consider his preferences and the nurse should
adjust and find means inorder to both provide comfort to the patient and at the same time
accomplishing your goals, if in a hospital setting, provide a comprehensive bedside
nursing care.

E. Ethico-moral responsibility

Considering that according to the operational definition of Orem in her theory,

she acknowledges that each person is unique. The agent/nurse should help the client in
promoting independence at the same time respect the differences in perspective of each
individual.

F. Personal and professional development

For personal development, in the client’s perspective, one would be able to do his
daily activities without or with little difficulty after the health teaching has been done.
Knowing on how to take care of his self properly, effectively and efficiently is the main
essence on which we can say that this theory has been successfully applied and carried

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 out effectively. As for the professional development, in the nurse’s perspective, one will
be able to gain new experiences and develop means to render their nursing care with
confidence and a heart reaching out and touching the lives of the patient.

G. Quality improvement

In order for the quality of nursing care to improve, one must first be aware and
acknowledge the patient’s need for “help” then devise a way on how to tackle things
assiduously and assertively. Through knowing the basics and knowing the patient
himself, the care agent would be able to know what goals to set and provide for the
quality care that the client needs.

H. Research

A number of theories were conducted which was derived from her theory and its
implication served as a guide in the development of instruments which are used to assess
the patient’s self-care abilities related to the care of the well and the ill. This theory has
set a standard in promoting independence among sick and well patients.

I. Records management

The care dependent agent or in some cases the nurse, must maintain a simple,
comprehensive and updated record or documentation of the patient’s progress so that she
can track the prognosis of the patient whether recovering or declining and implement
ways in order to address the problem as sooner as possible. This can also be handy in
matters concerning the legalities regarding the care provided to the client just in case
something happened.

J. Communication

One of the most essential elements in achieving an effective health education is

proper communication. Making sure that the patient and the significant others have
received the message that you, the sender, is trying to relay is how you would evaluate
your health education. Using both the verbal and non-verbal way of communication and
also understanding them is vital in relaying information. If one bumps into any sort of
communication barriers along the way, one should be able to find ways in order to ensure
that the message has been conveyed and received and understood by the receiver.

K. Collaboration and teamwork

With regards to collaboration and teamwork, one should be able to establish and
maintain a positive working relationship with the members of the healthcare team.
Through this relationship, it will be easier for the care agent, mostly who are nurses, to
provide a holistic nursing care to the patient.

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 In Orem’s self-care deficit theory, the collaboration and teamwork that is crucial
is that of between the nurse and the patient. Through gaining the rapport of the patient,
the nurse can do her task efficiently without the patient hindering or questioning her
actions or preventing her to do her job. Collaboration with the other members of
healthcare team and the patient is as crucial as that of the nurse and the patient. As it was
reiterated again and again, through this collaboration and teamwork, the patient or in
some cases the significant others could also discover the gravity of his situation and he
will be able to make decisions independently. Also, through this, the constant
monitoring of the patient’s condition could help in gathering information towards
identifying the medical attention that the client needs and implementing it as soon as
possible.

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