Theory Application Paper: Orem’s Self Care Deficit Theory in Emergency Department
NU-500-7B: Theoretical Foundations for Nursing
Emergency department (ED) nurses are responsible for education during the discharge process. ED nurses must have a positive attitude about patient education and health promotion in order to communicate to the patient and caregivers at the level they can understand. Health promotion and prevention is essential with the prevalence of increased aging population and increased health care cost. How and why nurses educate depends on the need, the audience, and the situation; therefore, nurses need to be properly prepared to be able to deliver education at any time (McEwen, 2019).
Nurses in the ED are often caring for many patients in short amounts of time. Everyday encounters at the ED includes handling a variety of cases of medical and trauma cases. From a minor injury to large trauma cases and medical emergencies, the nurse is often running from event to event to care for patients. Utilizing Orem’s Self-Care deficit theory (SCDT) in the ED, allows the nurse to care for the patient wholly compensatory, partly compensatory, and supportive-educative (Petiprin, 2016). Orem’s SCDT states that when there is a self-care deficit, educating the patient will bring them back to a self-care state (Orem, 1997).
With regards to education, the nurse in the ED can often cut corners in order to meet demands from management to move the patient out, in order to receive a new patient (Devinney, 2014). Patients seeking medical attention come to the ED with mixed emotions and thoughts. Because of the fast paced, rapid turnover of patients with a chaotic atmosphere, perception of care is lower, and patient education is not received as well (Devinney, 2014). The nurse has little time to build relationships that help foster self-care, leaving patients feeling frustrated and confused how to care for themselves when they leave the hospital.
How does the ED close the gap on lack of education at discharge? A change is needed in the ED. The purpose of this paper is to provide knowledge of Orem’s Self Care Deficit Theory importance in the emergency department, and how the change of discharge education processes in the ED will enhance self-care.
Orem’s Grand theory explains what and why nurses do what they do, and when a nurse is needed. There are six central concepts of SCDNT consisting of self-care, self-care agency, therapeutic self-care demand, self-care deficit, and nursing agency (Petiprin, 2016). As you will see, Orem’s concepts are clearly stated and easily understood.
Self-care focuses on how and why individuals care for themselves. The theory says that self-care, and care of dependents are learned behaviors that purposely regulate human structural integrity, functioning, and development (Nursing Theories, 2012). According to Orem, the requirements of self-care subside in three categories—universal, developmental, and health deviation. Universal requirements relate to meeting common human needs. Second, developmental self-care requisites relate to conditions that promote developmental processes throughout the life cycle. Third, health deviation self-care requisites relate to seeking appropriate medical assistance, and adhering to rehabilitation procedures (Nursing Theories, 2012). Self-care agency is a person’s ability to participate in self-care, and affected by conditioning factors such as age, gender, developmental state, health state, sociocultural factors, health care systems factors, family system factors, pattern of living, environment factors, and availability and adequacy of resources (Nursing Theories, 2012). Opposingly, therapeutic self-care demand involves measuring a person’s ability or inability to meet self-care requisites. When therapeutic self-care demand surpasses self-care agency, there is a self-care deficit.
Self-Care Deficient theory explains when nursing is needed and ways people can be assisted through nursing (Self-Care,2012). When a patient can no longer maintain self-care, nursing steps in to assist. This is achieved through guiding, supporting, teaching, providing a healthy environment, and acts of doing for the patient until self- care is regained (Self-Care,2012).
Orem’s theory of nursing systems is the legitimate nurse and patient relationship that begins when therapeutic self-care demand exceeds available self-care agency (McEwen, 2019). Further classified as wholly compensatory, partly compensatory, and supportive-educative. Wholly compensatory system is where the nurse is in complete control and the patient has no ability to perform self-care. Partly compensatory neither the nurse, nor the patient play a large role in self-care, and can be nurse lead or shared with the patient. Lastly, supportive-education system, self-care is accomplished and the nurse continues to educate the patient (Orem, 1997). This is the time Orem focuses on health promotion and teaching to assist the patient with self-care and continued well-being. By teaching people how self-care can be implemented, it becomes possible to treat illness or disease more effectively. In return, better overall health can be achieved.
Orem’s Self Care Deficient Theory (SCDT) embraces the knowledge that individuals are capable of self-care, which consist of actions that are freely and deliberately initiated by the individual to maintain well-being (Wagnild, 1987). The theory provides a frame of reference about nurses, patients and interactions between them. It is practical and clear to understand. The theory provides communication, structure, links relevant knowledge and gives clear and specific outcomes for nursing to demonstrate the effectiveness of nursing care and nursing actions.
Utilizing Orem’s Self-Care Deficit Theory (SCDT) in the Emergency Department (ED) gives deeper understanding to the nurse what self-care is, and how to help the patient move to a state of self-care. More specifically under the supportive-educative system Orem gives the nurse guidance for supporting and teaching the patient in order to help them achieve self-care. Self-care agency, the power to engage in self-care is developed through a process of learning (Armer, 2009). Nurses may take for granted the patient understands what they are talking about, but most of the time this is not the case. Therefore, patients in the ED return multiple times for the same complaint, because they have never been taught self-care and how to achieve it.
The CDC (2017), National Hospital Ambulatory Medical Care Survey: 2016 Emergency Department Summary Tables, shows ED visit time statistics as follows: Less than 1 hour 17,588 or 12.1%, 1 hour, but less than 2 hours 32,816 or 22.5%, 2 hours, but less than 4 hours 49,128 33.8%, and lastly 4 hours, but less than 6 hours 21,940 or 15.1% (CDC, 2017). The CDC also showed statics on discharge disposition. Return or refer to physician or clinic for follow up 103,713 or 71.2% (CDC, 2017). As you can see by the statistics, the ED sees the largest percentage of patients for 2 hours, but less than 4 hours, and 71.2% of patients are discharged from the ED. If 71.2% of the patients seen in the ED are being discharged to home, it is essential to give thorough discharge education to increase knowledge, adherence, and decrease return visits.
In the ED patient discharge education is rushed in order to turn over beds, and make room for the next patient. In the article, Patient Education in the Emergency Department Devinney notes that over ninety million Americans are unable to fully comprehend how to care for their medical needs (2014). The ED is especially prone to lack of understanding related to limited literacy of many ED patients (Devinney, 2014). This drives the need for increased discharge education for the patient to achieve self-care. Discharge education is one of the most, if not the most important aspects of the ED visit, and there is a disconnect with discharge education in the ED. The ED has barriers to provide adequate discharge instructions, such as lack of time from the nurse to provide adequate discharge information, and educational levels of the patient to comprehend information (Devinney, 2014).
This quantitative study explored health promotion activities of the ED nurses and their attitudes toward working with patients toward health promotion (Devinney, 2014). The findings from the study indicated that nurses felt they had little impact on changing a patient’s lifestyle and that the education performed in the ED had little impact on patients adhering to healthy lifestyle choices. Lastly, lack of time was a barrier that influenced ED discharge education (Devinney, 2014). If the nurse does not see the value in education and feels the patient does not either, then education will not happen. Perceived lack of time may influence the prior feelings. If a patient is to ever move to a state of self-care, education is necessary. Limitations in the study were seen by the limited number of 31 participants. Larger studies are needed to link health promotion in the ED.
With fast turnover, ED nurses will neglect the supportive-education system because of lack of care, feelings of frustration related to time constraints, and perceived feelings that patients are not interested in education. Driven by the need to move more patients to a state of self-care, a total revamp of the discharge process must be done to achieve better patient outcomes and decrease nurse frustration.
Using Orem’s self-care deficit theory, we now have the understanding of what self-care is and need for more enriched education in the emergency department. In order to implant change in the ED, a plan to implement dedicated discharge nurses will increase patient education and adherence to treatment. It will also decrease patient wait times and left without being seen times.
The current discharge process can take upwards to 30 minutes. Currently, the nurse caring for the patient will be given the order for discharge. At this time, the nurse will call and set up follow up appointment, process all discharge paperwork, capture all charges in the system, process charges, and print doctors excuse. The current statistics from (Ochsner/ LSU) ED sees 200 patients per day and 80% of those are discharged (2018). That is 160 patients x 30 minutes, which equals 4800 minutes or 80 hours (Ochsner/LSU, 2018). If there are 16 nurses per shift, that is 5 hours the nurse spends discharging patients. That correlates in longer wait times and greater number of patients left without being seen. If the average ED visit is 2-4 hours, that equates to 20-40 more patients the ED can care for each day once the discharge plan is implemented. If the goal of the ED is to leave no patient unseen, uncared for, and decrease the time it takes to see a practitioner, a better discharge plan is needed. As we look at the patient side of discharge, the plan will foster better understanding of disease, management of disease, medication side effects, where to get medication, how to get medication, and teach back and read back methods to ensure teaching was understood. Orem’s SCDT supports these actions by showing that improved patient education improves the patient’s self-care abilities (Orem, 1997).
The proposed discharge plan process will improve self-care abilities, by providing dedicated discharge nurses to each patient discharged to home from the ED. The discharge process for consideration will be as follows: discharge orders received from MD, nurse caring for patient takes last set of vitals, removes IV, assesses stability of patient for discharge and charts appropriate findings. The nurse care tech then walks the patient and family to designated discharge area. Dedicated discharge nurses, consisting of three full time employed BSN nurses will handle all teaching, which will include teach back and read back methods. These BSN nurses will have at least 5 years’ experience in an ED. The discharge nurse will also assess patient for resources available to buy medication, and help with assistance by calling social worker. Finally, they will obtain a valid phone number from the patient and remind them they will be called in 24 hours for follow-up. One of the three full time employed BSN will handle all call backs to ensure patient safety and answer any questions during a follow up interview. The interview will assess if medication was received, overall health status after ED visit, and reinforce education received the day prior with read back teaching.
As we look even deeper, the discharge plan will enrich patient learning to decrease readmission rates, increase medication adherence rate, and decrease mortality and morbidly due to poor self-control of chronic diseases. This change in discharge process will lead the patient along the continuum to self-care and management. The hospital will decrease left without being seen times, decrease wait times, and increase the number of patients the ER can see per day.
Barriers to Implementation
One barrier noted in the proposed discharge process plan, is the need to build a patient centered relationship. The discharge nurse will not be the nurse that has taken care of the patient. In the ED however, with the known times of 2-4 hours that the nurse cares for the patient, this is a minimal risk to the implementation of dedicated discharge nurses. Discharge nurses must take a caring, nonjudgmental approach in discharge teaching. The need for education to the patient, and discharge nurses, outweighs the need for the discharge nurse to be the same nurse that cared for the patient during their ED visit.
Justification of the need for three full time employees (FTE) is another barrier. Further studies should be done to see the cost effectiveness of the employee’s salaries versus the cost in readmission in less than 30 days. Lastly, a barrier noted is the need for physical space in the ED for implementation of the discharge process plan. Justification of space could be noted by the decrease of left without being seen, decreased wait times, and increased number of patients being seen per day. Space could be small at first, and the ED could utilize some unused space to provide a discharge process room.
Knowing emergency department discharge instructions are an integral part of the care for those patients discharged from the emergency department, some studies have shown that 78% of discharged patients do not have a complete understanding of their discharge instructions (McCarthy, 2012). Workload and lack of time were identified as barriers to proper education and discharge planning in emergency departments in Taiwan (Han, 2009). Time restraints and the nurses lack of care to educate were also seen as barriers to proper discharge education (Devinney, 2014). The implementation of the proposed dedicated discharge nurse, will foster more in-depth, thorough education to the patient and family.
Nurses in the Emergency department are responsible for providing focused care in emergent situations, and providing education to the patient about their disease process upon discharge. With an increase of revisits to the ED, it is imperative the ED nurse communicate health promotion to patients.
Using Dorothea E. Orem’s SCDT in the ED, nurses can provide care during emergent times, and provide an environment for healing. Orem defines nursing as the, “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 (Current Nursing, 2010)”. When self-care regulations can be met, the nurse them uses Orem’s supportive-education system. This is where health promotion and disease prevention education are provided to the patient in order for self-care to be achieved.
As we have seen, the discharge process in the ED needs improvement. Therefore, a change in discharge process should include dedicated nursing staff that educates at discharge and follows up to assist patient to self-care, greater outcomes, which gives the patient feelings of more self-reliance and greater responsibility for their health care outcomes. The dedicated discharge nursing staff will lower patient left without being seen times, decrease ED wait times, and increase the number of patients the ED can see on a daily basis. This discharge process not only assists the patient along the continuum of self-care, but also gives the ED an opportunity to care for more patients in a quicker time period.
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