Nursing Theories: Dorothea Orem

Nursing Theories: Dorothea Orem:  Dorothea Orem Date of Birth:  Born in Baltimore, Maryland in 1914.    Education:  Orem started her nursing career at Provid...

Dorothea Orem

 Dorothea Orem

Date of Birth: 

Born in Baltimore, Maryland in 1914.  

Education: 

Orem started her nursing career atProvidence Hospital School of Nursing in Washington D.C., where she received a diploma of nursing in the early 1930’s. Dorothea Orem later completed her Bachelor of Science in Nursing in the Catholic University of America in 1939 and in 1946, she received her Master of Science degree in Nursing Education from the same university. 

A Glimpse of Orem’s Accomplishments and Contributions:

• Dorothea Orem as a member of a curriculum subcommittee at Catholic University recognized the need to continue in developing a conceptualization of nursing.

• Orem’s Nursing: Concept of Practice was first published in 1971 and subsequently in 1980, 1985, 1991, 1995, and 2001.

• Nursing: Concepts of Practice was the original publication of the conceptual framework (Orem, 1971)

• 1949-1957 Orem worked for the Division of Hospital and Institutional Services of the Indiana State Board of Health. Her objective was to improve the quality of nursing in general hospitals and she was able develop the definition of nursing by this time

• 1958-1960 she help publish "Guidelines for Developing Curricula for the Education of Practical Nurses" in 1959.

• Washington D.C. in 1957, Orem further developed her ideas, first as a consultant in the Office of Education where her task was to improve the nursing component of a vocational nursing curriculum.

• Orem’s ideas were further formalized after her participation in the Nursing Development Conference Group (NDCG), the two were committed to the development of structured nursing knowledge and to nursing as a practice discipline” (Hartweg, 1995)

• Continues to develop her theory after her retirement in 1984

• Dr. Orem continues to be active in theory development. She completed the 6th edition of Nursing: Concepts of Practice, published by Mosby in January 2001.

Publication:

Nursing Concepts of Practice

Textbook presents the development of nursing theory and illustrates its relevance to nursing practice. Discusses the foundations of nursing as a field of knowledge and practice and provides an approach to 'knowing and thinking nursing.' Contains five new chapters and three revised chapters. Previous edition: c1995. 

Hardcover: 542 pages 

Publisher: C.V. Mosby; 6th edition (January 15, 2001) 

ISBN: 032300864X 

  

Concepts:

Nursing – is art, a helping service, and a technology

• 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
• Encompasses the patient’s perspective of health condition ,the physician’s perspective , and the nursing perspective
• Goal of nursing – to render the patient or members of his family capable of meeting the patient’s self care needs
• To maintain a state of health
• To regain normal or near normal state of health in the event of disease or injury
• To stabilize ,control ,or minimize the effects of chronic poor health or disability

Health – health and healthy are terms used to describe living things …

• It is when they are structurally and functionally whole or sound … wholeness or integrity. .includes that which makes a person human,…operating in conjunction with physiological and psychophysiological mechanisms and a material structure and in relation to and interacting with other human beings

Environment

• environment components are enthronement factors, enthronement elements, conditions, and developed environment

Human being – has the capacity to reflect, symbolize and use symbols

• Conceptualized as a total being with universal, developmental needs and capable of continuous self care
• A unity that can function biologically, symbolically and socially

MAJOR ASSUMPTIONS:

• People should be self-reliant and responsible for their own care and others in their family needing care
• People are distinct individuals
• Nursing is a form of action – interaction between two or more persons
• Successfully meeting universal and development self-care requisites is an important component of primary care prevention and ill health
• A person’s knowledge of potential health problems is necessary for promoting self-care behaviors
• Self care and dependent care are behaviors learned within a socio-cultural context

Theoretical Assertion: 

Dorothea Orem's Self Care Deficit Theory encompasses all aspect relating to the patient's health, nursing and all the factors that affect which.

The concepts discussed revolve mainly around self care. It is the patient's ability to care for himself and his dependents as well as others as dictated by the environment he lives in that determines health or the need for assistance in maintaining health. On the other hand, the society plays the major role into regulating the nursing care process as to when nursing care is needed and when and how the nursing system is implemented. It is also the environment and the society that directly affect the nurse-patient relationship and self care agency, which are all interconnected into achieving, restoring, and maintaining health.

As shown in the figure below, health can be achieved if the person has knowledge and resources to perform self care activities to meet self care deficits. On the other side, self care deficit results when self care agency (ability to perform self-care) is not adequate to meet the known self care demand and/or the failure to meet the health care requisites (Kozier et.al, 2002) This then warrants the need for nursing intervention through the nursing system, which in turn is empowered by the nurse-patient relationship. The end result of all of this is the maintenance, restoration, or preservation of health. 

Created By: Cheska Uvero

Betty Neuman's Systems Model

Betty Neuman, RN, BSN, MSN, PhD, FAAN

"Health is a condition in which all parts and subparts are in harmony
with the whole of the client.”

BIOGRAPHY

• Born in 1924, in Lowel, Ohio.
• Completed her initial nursing education with double honors at People Hospital School of Nursing (now General Hospital), Akron, Ohio, in 1047.
• Earned a baccalaureate degree in public health and psychology with honors (1957) and a master’s degree in mental health, public health consultation (1966), from the University of California, Los Angeles (UCLA).
• Completed a doctoral degree in psychology from Pacific Western University in 1985 (B. Neuman, personal communication, June 3, 1984)
• Pioneer of nursing involvement in mental health together with Donna Aquilina who first develop the nurse counselor role within community crisis centers in Los Angeles (B. Neuman, personal communication, June 21, 1992)
• Because of her important contributions to the field on Nursing, Dr. Neuman was named Honorary Member of the Fellowship of the American Academy of Nursing in 1993.
• Received an Honorary Doctorate of Science from the Grand Valley State University in Michigan in 1998. For the past years, Dr. Betty Neuman has continuously developed and made famous the Neuman systems model through her work as an educator, author, health consultant.
  

INFLUENCES

Betty Neuman took inspiration in developing her theory from the following theories/ philosophers:

1. Pierre Tielhard deChardin : a philosopher-priest that believed human beings are continually evolving towards a state of perfection – an Omega Point

2. Gestalt Theory : A theory of German origin which proposes that the dynamic interaction of the individual and the situation determines experience and behavior.

3. General Adaptation Syndrome mainly talks about an individual’s reaction to stress on the 3 levels a) alarm b) resistance c) exhaustion

4. General Systems Theory postulates that the world is made up of systems that are interconnected and are influenced by each other.

BASIC ASSUMPTIONS 

• Each client system is unique, a composite of factors and characteristics within a given range of responses contained within a basic structure.
• Many known, unknown, and universal stressors exist. Each differ in it’s potential for disturbing a client’s usual stability level or normal LOD (Line of Defence).
• The particular inter-relationships of client variables at any point in time can affect the degree to which a client is protected by the flexible LOD against possible reaction to stressors.
• Each client/ client system has evolved a normal range of responses to the environment that is referred to as a normal LOD. The normal LOD can be used as a standard from which to measure health deviation.
• When the flexible LOD is no longer capable of protecting the client/ client system against an environmental stressor, the stressor breaks through the normal LOD
• The client whether in a state of wellness or illness, is a dynamic composite of the inter-relationships of the variables. Wellness is on a continuum of available energy to support the system in an optimal state of system stability.
• Implicit within each client system are internal resistance factors known as LOR, which function to stabilize and realign the client to the usual wellness state.
• Primary prevention relates to G.K. that is applied in client assessment and intervention, in identification and reduction of possible or actual risk factors.
•  Secondary prevention relates to symptomatology following a reaction to stressor, appropriate ranking of intervention priorities and treatment to reduce their noxious effects.
•  Tertiary prevention relates to adjustive processes taking place as reconstitution begins and maintenance factors move the back in circular manner toward primary prevention.
• The client as a system is in dynamic, constant energy exchange with the environment.
  

MAJOR CONCEPTS (Neuman, 2002)

Content

• the variables of the person in interaction with the internal and external environment comprise the whole client system

Basic structure/Central core

• The common client survival factors in unique individual characteristics representing basic system energy resources.
• The basis structure, or central core, is made up of the basic survival factors which include: normal temp. range, genetic structure.- response pattern. organ strength or weakness, ego structure.
• Stability, or homeostasis, occurs when the amount of energy that is available exceeds that being used by the system.
• A homeostatic body system is constantly in a dynamic process of input, output, feedback, and compensation, which leads to a state of balance.

Degree to reaction

• the amount of system instability resulting from stressor invasion of the normal LOD.

Entropy

• a process of energy depletion and disorganization moving the system toward illness or possible death.

Flexible LOD

• a protective, accordion like mechanism that surrounds and protects the normal LOD from invasion by stressors.

Normal LOD

• It represents what the client has become over time, or the usual state of wellness. It is considered dynamic because it can expand or contract over time. 

Line of Resistance-LOR

• The series of concentric circles that surrounds the basic structure.
• Protection factors activated when stressors have penetrated the normal LOD, causing a reaction symptomatology. E.g. mobilization of WBC and activation of immune system mechanism

Input- output

• The matter, energy, and information exchanged between client and environment that is entering or leaving the system at any point in time.

Negentropy

• A process of energy conservation that increase organization and complexity, moving the system toward stability or a higher degree of wellness.

Open system

• A system in which there is continuous flow of input and process, output and feedback. It is a system of organized complexity where all elements are in interaction.

Prevention as intervention

• Interventions modes for nursing action and determinants for entry of both client and nurse in to health care system.

Reconstitution

• The return and maintenance of system stability, following treatment for stressor reaction, which may result in a higher or lower level of wellness.

Stability

• A state of balance of harmony requiring energy exchanges as the client adequately copes with stressors to retain, attain, or maintain an optimal level of health thus preserving system integrity.

Stressors

• environmental factors, intra (emotion, feeling), inter (role expectation), and extra personal (job or finance pressure) in nature, that have potential for disrupting system stability.
• A stressor is any phenomenon that might penetrate both the F and N LOD, resulting either a positive or negative outcome.

Wellness/Illness

• Wellness is the condition in which all system parts and subparts are in harmony with the whole system of the client.
• Illness is a state of insufficiency with disrupting needs unsatisfied (Neuman, 2002).

Prevention

• the primary nursing intervention.
• focuses on keeping stressors and the stress response from having a detrimental effect on the body.

• Primary Prevention

• occurs before the system reacts to a stressor.
• strengthens the person (primary the flexible LOD) to enable him to better deal with stressors
• includes health promotion and maintenance of wellness.

• Secondary Prevention

• occurs after the system reacts to a stressor and is provided in terms of existing system.
• focuses on preventing damage to the central core by strengthening the internal lines of resistance and/or removing the stressor.

• Tertiary Prevention
• occurs after the system has been treated through secondary prevention strategies.
• offers support to the client and attempts to add energy to the system or reduce energy needed in order to facilitate reconstitution.

FOUR NURSING PARADIGMS 

PERSON

• Human being is a total person as a client system and the person is a layered multidimensional being.
• Each layer consists of five person variable or subsystems:
• Physiological - Refers of the physicochemical structure and function of the body.
• Psychological - Refers to mental processes and emotions.
• Socio-cultural - Refers to relationships and social/cultural expectations and activities.
• Spiritual - Refers to the influence of spiritual beliefs.
• Developmental - Refers to those processes related to development over the lifespan.

ENVIRONMENT

• "the totality of the internal and external forces (intrapersonal, interpersonal and extra-personal stressors) which surround a person and with which they interact at any given time."
• The internal environment exists within the client system.
• The external environment exists outside the client system.
• The created environment is an environment that is created and developed unconsciously by the client and is symbolic of system wholeness.

HEALTH

• Health is equated with wellness.
• “the condition in which all parts and subparts (variables) are in harmony with the whole of the client (Neuman, 1995)”.
• The client system moves toward illness and death when more energy is needed than is available. The client system moved toward wellness when more energy is available than is needed

NURSING

• a unique profession that is concerned with all of the variables which influence the response a person might have to a stressor.
• person is seen as a whole, and it is the task of nursing to address the whole person.
• Neuman defines nursing as “action which assist individuals, families and groups to maintain a maximum level of wellness, and the primary aim is stability of the patient/client system, through nursing interventions to reduce stressors.’’
• The role of the nurse is seen in terms of degree of reaction to stressors, and the use of primary, secondary and tertiary interventions.

THEORETICAL ASSERTIONS

Theoretical assertions are the relationships among the essential concepts of a model.

• The Neuman model depicts the nurse as an active participant with the client and as “concerned with all the variables affecting an individual’s response to stressors”.
• The client is in a reciprocal relationship with the environment in that “he interacts with this environment by adjusting himself to it or adjusting it to himself”.
• Neuman links the four essential concepts of person, environment, health, and nursing in her statements regarding primary, secondary, and tertiary prevention.
• Earlier publications by Neuman stated basic assumptions that linked essential concepts of the model. These statements have also been identified as propositions and serve to define, describe, and link the concepts of the model.

APPLICATION

Intake Summary

Name: Janina Ples

Age: 35 years old

Sex: Female

Marital Status: Married

Referral Source: Self-referred

A.      Stressors as Perceived by Client:

1.       Major stress areas or areas of concern:

a. Found out 2 weeks ago is 2 months pregnant – here for prenatal visit

b. First child is 11 months old, wants another child, ambivalent about the timing of this pregnancy

2. Life-style patterns

a. Cares for home and daughter

b. Active in church

c. Participates in community groups related to parenting

d. Has supportive family and friends

e. What is different now? – experiencing nausea and fatigue

3. Ever experienced similar problem?

a.The nausea and fatigue are similar to the first pregnancy

b. What helped then – crackers and lying down helped some; primarily just suffered through it

4. Anticipators for the future

a. Concerns about how to maintain a healthy pregnancy and care for an active toddler (concern about grater because first pregnancy resulted in a premature delivery of a small for gestational age baby)

b. Also anticipating the demands of caring for two children under the age of two

5. What is she doing to help herself?

a. Talking with friends and family about their experiences

b. Reading articles and books on childbearing and childrearing

c. “I need to lower my expectations of myself and try not to do so much – for me that’s HARD!”

6. What is expected of others?

a. Family is visiting around the time the baby is due and will help with the children and the house

b. Husband is doing more of the cooking and helping keep the house clean

B. Stressors as Perceived by Caregiver (primary care provider who provided prenatal care with the first pregnancy)

1. Major stess area

a. History of premature delivery

b. Type A personality who has difficulty relaxing

2. Present circumstances differing from usual pattern of living

a. Fatigue and nausea of pregnancy

b. Dealing with anticipation concerns about expanding family

3. Client’s past experience with similar situation?

a. Experienced with nausea and fatigue of pregnancy

b. Not experienced in having 2 children under 2

4. Future anticipations

a. Client is capable of handling the situation – will need support and encouragement to do so

5. What client can do to help herself?

a. Use her support systems

b. Concentrate on getting needed rest

c. Remember that goal is a healthy child and things can be done later

6. Clients expectations of family, friends, and caregivers

a. Accurate information

b. Support and encouragement

c. A listening ear

C. Intrapersonal Factor

1. Physical

a. Height: 5 feet, 5 inches

b. Weight: 12l lbs (no change from pregnancy weight)

c. TPR 98.4 F, 76, 12

d. B/P 118/76

e. Urine negative for sugar and albumin

f. Care – perform all activities of daily living for self and toddler

g. Is current with all immunizations

h. Sleeps 7 to 8 hours per night

i. Does not smoke or ingest alcohol

j. Follows a low fat, balanced diet; usually 3 meals per day

k. Reports experiencing nausea and fatigue – a major stressor at this time

2. Psycho-sociocultural

a. 35-year-old female, married

b. Caucasian

c. Holds a masters degree in communications

d. Sometimes concerned about feeling isolated – likes to have lots of friends and best friend will be moving in 6 to 12 months

e. Knows needs to “slow down” but states that it is hard for her to do , “I plan too much for any given day, I’ve always done this and I don’t really know how to do less. The one good thing is that it doesn’t bother me too much if I don’t get all that I have planned done!”

f. Lives in own home

g. Fluent in English and Spanish

3. Developmental

a. “I have demonstrated my ability to be a good mother – that is reassuring that I can meet this new challenge.”

b. “How am I going to find the time to do everything?”

4. Spiritual belief system

a.This is an area of support, not an area of concern

b. Active at church, regular attendance is important

c. Has personal Bible study daily

D. Interpersonal Factors

1. Has supportive family and friends

2. Often speaks on the phone to family and friends, has lunch with friends regularly

3. Shares toddler play days with friends

4. Concerned about having 2 children under 2 in the house

5. Is working on a project at church to improve the nursery program

6. Cannot rest at with toddler at home – this is different than with first pregnancy so previous coping responses are not as effective

7. Will try to interests toddler in quiet activities on the days she is really tired

8. Husband can work at home some days and help with the toddler

E. Extrapersonal Factors

1. Community lacks good day care programs/facilities for toddlers so there is no real community support for when she needs a respite from child care

2. Health care for all family members is readily available

F. Formulation of a Comprehensive Nursing Diagnosis:

1. Nursing Diagnoses

a. Nausea and fatigue related to pregnancy

b. Lack of knowledge related to parenting two under the age of two

2. Goals (desired outcomes)

a. Manage nausea and fatigue

i. Primary – Normal line of defense has been invaded – is having symptoms

ii. Secondary – Plan daily activities to include rest periods when toddler naps; explore types of foods and eating patterns that decrease nausea

iii. Tertiary – Continue to encourage rest whenever possible; husband helps out as he can; plan daily intake of appropriate nutrients; keep a journal listing daily plans to demonstrate ability to plan less for each day

b. Lack of knowledge about parenting two under two

i. Primary – Discuss current parenting strategies with husband, friends, family, caregiver and explore how these strategies may be adapted caregiver encourages discussion with friend who has two small children and works full time

ii. Secondary and Tertiary – Not needed as yet; flexible and normal lines of defense have functioned effectively

c. Health outcome to the pregnancy

i. The overall desired outcome – preventions as intervention listed in a and b.

4. Evaluation

Janina delivered a healthy 6 pound, 8 ounce girl at 38-weeks gestation after a pregnancy she described as “much better than I thought it would be.” Husband/father and older daughter are delighted with the new baby. Janina states, “I’m still working on not planning too much for each day. Identified outcome was achieved.

CONTRIBUTORS:

Lajom, Elaine Marie S.

Cortes, Renamae

REFERENCES:

Websites:

http://currentnursing.com/nursing_theory/Neuman.html

http://www.neumansystemsmodel.org

http://nursingtheories.blogspot.com/2008/07/betty-neumans.html

Books:

George, Julia B., RN, PhD (2002) Fifth Edition: NURSING THEORIES: The Base for Professional Nursing Practice

Tomey, Ann Marriner, PhD, RN, FAAN & Alligood, Martha Raile, PhD, (2008) RN Sixth Edition: Nursing Theoriests and Their Work