Theory Application – Orem’s Self-Care Deficit Theory in Emergency Nursing

Theory Application: Orem’s Self-Care Deficit Theory in Emergency Nursing

NU 500 Theoretical Foundations of Nursing

Emergency room (ER) nursing is a multidimensional specialty field that consists of several characteristics including patient assessment, triage and prioritization, stabilization of patients, resuscitation, and crisis intervention all in an unpredictable environment (Emergency Nurses Association, 1999). ER nurses have a broad scope of practice implemented through various roles, such as patient care provider and advocate, educator, mentor, and researcher. When selecting an appropriate theory to guide ER nursing, the theory must also be multidimensional. Dorothea Orem’s self-care deficit theory can apply to any patient condition and used to guide practice toward providing quality care and achieving positive patient outcomes.

Theory Description

Orem’s theory is classified as a grand theory based on human needs and is a conceptual framework for nursing practice, education, and research (McEwan & Wills, 2019, pg 36). The purpose of Orem’s theory emphasizes the importance of the patient having a normal life with the inclusion and responsibility of self-care. The theory’s unique focus identifies the requirements of the nurse when a patient is incapable of effective self-care and involves five different methods of intervention/helping; doing for others, supporting others, providing an environment for personal development, and teaching others (Davidson, 2012). Grand theories, including Orem’s, have a broad scope and apply to all aspects of nursing.

The four metaparadigm concepts of nursing theories, nurse, patient, environment, and health are defined by Orem’s as:

Nursing is seen as an art through which the practitioner of nursing gives specialized assistance to persons with disabilities which makes more than ordinary assistance necessary to meet needs for self-care. The nurse also intelligently participates in the medical care the individual receives from the physician.

Humans are defined as “men, women, and children cared for either singly or as social units,” and are the material object of nurses and others who provide direct care.

Environment has physical, chemical, and biological features. It includes the family culture and community.

Health is being structurally and functionally whole or sound. Also, health is a state that encompasses both the health of individuals and of groups, and human health is the ability to reflect on one’s self, to symbolize experience, and to communicate with others. (Orem, 2001, as cited in McEwen & Wills, 2019, p. 143)

Though there are several other concepts in Orem’s theory, significant concepts include self-care, selfcare deficit, and self-care requisites. Self-care is the patient’s ability to provide/perform self-care activities to maintain one’s health. Self-care deficit refers to a patient being incapable of performing/providing self-care to maintain health; thus, delineating when nursing is needed. Self-care requisite has three subcategories: universal, developmental, and deviation; and is summarized as providing, performing, or obtaining provisions of self-care (McEwen & Wills, 2019).

Rational

Orem’s theory aids in structuring observation and understanding of the nursing practice; and is thoroughly developed, providing a clear explanation of the relationship between the key concepts and the expected outcomes (Nilsen, 2015). The broad scope of the self-care deficit theory makes it easy to apply to the complex and broad requirements of ER nursing. Orem’s theory provides methods to evaluate patient care and the nurse with a rationale for decision making (Davidson, 2012). Patient inability of performing self-care requisites is often a leading cause of emergency room visits. For each requisite deficit, Orem’s theory can be applied to guide the practice of the ER nurse to meet the patient’s needs and increase self-care practices, through care-planning, interdisciplinary consultations, and education.

Patients in the ER often require significant education regarding their condition and how to manage it at home. Orem discusses the importance of the patient regaining independence in their care and returning to as much of a normal life as possible (McEwen & Wills, 2019). Thorough discharge planning and continuing education are imperative to the success of the patient’s self-care. By applying the self-care deficit theory to diagnosis-specific education, the ER nurse can ease the patients transition to becoming a self-care provider. Teaching self-management education involves traditional patient education with the inclusion of self-management skills and promoting self-efficacy thus providing patients with the knowledge and technical and problem-solving skills necessary to achieve their health-care goals (Bodenheimer, Lorig, Holman, & Grumbach, 2002).

The emergency room is often the first line of defense in patient care, emphasizing the importance of utilizing current evidence-based research to implement best practice. The Emergency Nurses Association (1999) details the importance of ongoing research in the emergency department to address common concerns such as the needs of patients, management of care, trends, and alternative modalities of care. Using Orem’s theory as a research framework to obtain theory-guided evidence will provide ER nurses with the knowledge and skills of best practice while also achieving quality outcomes. This concept is supported by evidence obtained in a quasi-experimental, non-randomized study was conducted to examine the satisfaction scores of patients treated by two groups of nursing students. One group was instructed to apply Orem’s theory to their practice, while the other was not. The results showed increased patient satisfaction when care was provided using Orem’s theory (Malekzadeh, Amouzeshi, & Mazlom, 2018).

Implementation Plan

A strategic implementation plan is essential for the success of the application of Orem’s theory to the practice of ER nursing. The plan-do-study-act (PDSA) model is a widely accepted method of implementation and evaluation in healthcare (Taylor, McNicholas, Nicolay, et al., 2014). The PDSA cycle involves planning a change (plan), implementing a change (do), evaluating the outcomes of the change (study), and making necessary adjustments based on the outcomes (act) (Institute for Healthcare Improvement, 2019). Before implementing the PDSA cycle, an interdisciplinary team of ER staff would be established to guarantee representation/participation of the entire department. Presenting the team with education, specific to the details Orem’s theory and the effectiveness of theory-guided evidence-based practice, provides a clear correlation between the application of the theory and intended outcomes. Applying the self-care deficit theory to ER patients presenting with hypertension, the disease affecting most humans worldwide, is suitable for small scale implementation (Ali & Taha, 2015). Researchers in Egypt applied Orem’s theory to the overall treatment of hypertensive patients in a controlled, quasi-experimental study and concluded the self-care deficit theory improved patients self-care practices and provided improved, long-lasting outcomes (Ali & Taha, 2015). If the same success occurs with small scale implementation, then large scale implementation can be planned.

The “plan” for implementation is to apply the self-care deficit theory as a guide to practice in the emergency department. Before implementation, data gathered over the previous six months of patients with presenting complaints of hypertension (HTN) will be evaluated to review the delivery of care, treatment plan, discharge education, documented self-care deficits, and the incidence of return visits. The prediction of implementation is: Improved self-care practices as evidenced by increased patient compliancy and reduced return visits to the ER within six months. After data gathering, implementation will occur using the framework of Orem’s theory.

The “do” phase is the actual “doing” of the plan. The focus of Orem’s theory, to help patients regain self-care (McEwen & Wills, 2019), will be used to create a care plan specific to patients with HTN. Hypertensive patients will be given a comprehensive questionnaire exploring self-care deficits. Based on the deficits determined, the nurse will provide patients with individualized verbal and printed information as a patient guide to HTN, any new medications prescribed, and any dietary changes indicated. The nurse will also teach appropriate use of a sphygmomanometer with a return demonstration by the patient and/or caregiver and instructed to document daily blood pressure readings. After discharge from the hospital, the ER staff will complete a series of follow-up calls to discuss outcomes, compliance, and ability to provide self-care. Calls will take place at one, three, and six weeks post discharge and finalized with re-administration of the initial self-care questionnaire. After six months of implementation, the data will be examined to compare and the incidence of return visits, patient outcomes, and status of self-care practices against the previously gathered data.

Review of the comparative data is the “study” phase of the PDSA cycle. The results of the implementation will be analyzed and compared to the predictive statement in the plan (Institute for Healthcare Improvement, 2019). The data gathered determines the next step in implementation, “act.” Successful implementation data would indicate a decreased number of returned ER visits for HTN and increased patient compliance with improved self-care practices. If the data is supportive of the implementation of Orem’s theory, then large scale implementation could begin, starting with the most common diagnoses presented to the ER. If the evidence showed little to no change, review of the implementation process would need to be evaluated and revised, starting the PDSA cycle over.

Barriers to Implementation

Possible barriers to implementation include poor preparation, lack of education, and lack of staff and/or patient participation. If the team leader fails to prepare adequately, the implementation would not have the framework needed to succeed. A thorough plan with a strong team is invaluable. Providing substantial amounts of research and education to those impacted by the change is necessary for a thorough understanding of Orem’s theory and the implementation plan itself. If the information presented does not provide a clear correlation between the application of Orem’s theory and improved patient self-care practices and outcomes, staff and patients may be reluctant to participate, creating a barrier to implementation. The interdisciplinary team and team leader should discuss possible barriers during the “planning” phase and develop resolutions before the “do” phase occurs.

Conclusion

The complexity and ever-changing dynamic of the emergency department creates a nursing environment that cannot be easily predicted or prepared for. Dorothea Orem’s self-care deficit theory focuses on encouraging patient self-care practices and responsibilities (McEwen & Wills, 2019). Applying Orem’s theory in the emergency department provides a framework through theory-guided practice to the decision making processes, delivery of care, education, and research of ER nurses. Thorough planning of the implementation process and preparation for potential barriers is imperative for the success of the application of the theory. Strong evidence suggests a correlation between Orem’s theory application to guide nursing practice with increased patient self-care practices, positive outcomes, and lasting results. The relationships between the concepts of Orem’s theory are complex and versatile (Hagran, 2015), thus permitting application in various ways to best serve the needs of the emergency department and the patient.

References

Ali, Z., & Taha, N. (2015). Effect of nursing guideline for recently diagnosed hypertensive patients on their knowledge, self-care practice and expected clinical outcomes. Journal of Nursing Education and Practice,5(3), 1-11. doi:10.5430/jnep.v5n3p1

Bodenheimer T, Lorig K, Holman H, Grumbach K. (2002). Patient Self-management of Chronic Disease in Primary Care. Journal of the American Medical Association. 288(19):2469–2475. doi:10.1001/jama.288.19.2469

Emergency Nurses Association. (1999). Scope of Emergency Nursing Practice [PDF]. Retrieved from https://www.nysena.org/library/documents/scopePracticeNursing.pdf

Davidson, S. (2012). Challenging RN-BSN Students To Apply Orem’s Theory To Practice. Self-Care, Dependent-Care & Nursing19(1), 15–19. Retrieved from http://oreminternationalsociety.org/journal

Hagran, A., & Fakharany, E. (2015). Critique of Orem’s Theory. The Journal of Middle East and North Africa Sciences,1(5), 12-17. Retrieved from http://www.jomenas.org

Institute for Healthcare Improvement. (2019). QI Essentials Toolkit: PDSA Worksheet [PDF]. Retrieved from http://www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx

Malekzadeh, J., Amouzeshi, Z., & Mazlom, S. R. (2018). A quasi-experimental study of the effect of teaching Orem’s self-care model on nursing students’ clinical performance and patient satisfaction. Nursing open5(3), 370–375. doi:10.1002/nop2.151

McEwen, M. & Wills, E. (2019). Theoretical basis for nursing (5th). Philadelphia, PA: Lippincott Williams & Wilkins.

Nilsen P. (2015). Making sense of implementation theories, models and frameworks. Implementation science: IS10(53), . doi:10.1186/s13012-015-0242-0

Taylor M, McNicholas C, Nicolay C, et al. (2014). Systematic review of the application of the plan–do–study–act method to improve quality in healthcare BMJ Quality & Safety, 23(4), 290-298. Retrieved from https://qualitysafety.bmj.com/content/23/4/290