Nursing Theory Application of Orem's Self-Care Deficit Theory to Awakenings

There are several grand theories of nursing, and among them is Dorothea Orem's Self-Care Deficit Theory (SCDT). This theory has established a set of assumptions, including that people are distinct individuals, that they should be self-reliant, that a person's knowledge of potential health problem is necessary for promoting self-care behaviors, and that nursing is a form of action (CurrentNursing.com, 2012). The movie Awakenings (Parkes, Lasker & Marshall, 1990) can be used as an example of how this theory can be applied even to the most difficult of nurse-patient interactions. The focus here will be on the scene where the patients awakened. Dr. Sayer was present, as was the nurse manager and a staff nurse. At this point, there is a transition in the type of care that needs to be provided to the patients from wholly compensatory to partially compensatory.

Background

All individuals need to take care of themselves in one way or the other, depending on their need at any point in time. There will be instances when the assistance that is required is beyond that of the family members or the lay caregivers within the society, thereby requiring the need for specialized caregivers. Hence, from the SCDT perspective, the care of the assistance that is provided by the nurse is associated with the health-related actual or potential healthcare deficits of the persons, individually or collectively (Taylor & Renpenning, 2011).

Orem's SCDT claims that there are three aspects that are basic to nursing practice: self-care, self-care deficits, and the nursing systems (Rice, 2006). In this theory, the main focus is on the families and the individuals to maintain a healthy state of well-being through acquisition of different requirements. She classifies these requirements as being universal, developmental, or health-deviation requisites (Geyer, Mogotlane, & Young, 2009). For the universal requisites, they are those that are universal to every person and basic to daily life functioning such as air, water or food. Developmental requirements are those that arise from the developmental process, and they occur throughout the lifecycle of a person. Finally, the health-deviation requisites are those that arise from the individual's normal structure and integrity of the individual, which inhibits his/her ability to perform self-care. Orem, through the SCDT, aimed at proving that nursing benefits the individual who, for whatever health reasons, cannot adequately provide self-care (Geyer et al., 2009). Hence, the concept of the self-care deficit allows nurses to make specific nursing diagnoses through identification of their patient's self-care deficits with the main objective being the provision of individualized care. Orem lists three levels of care that are provided -- wholly compensatory, partly compensatory, and educational/developmental, depending on the needs of the patient.

The Staff Nurse

The staff nurses under Orem's theory should focus on educating the patient and the patient's family with respect to self-care. Health care in this theory has a strong preventative element, so the nurse must educate patients so that they become more independent, which should improve health outcomes. If the patient is not independent, as is the case in much of the movie where the patients are catatonic, then wholly compensatory care would be provided. In the scene where the patients first awaken, the nurses are still more or less providing wholly compensatory care, but they will soon be shifting to partially compensatory care.

The staff nurse may be limited in the sense that they often do not specialize. When the patients first awaken, the staff nurse continues to play a role in wholly compensatory care. The patients have been asleep for so long that they are initially still dependent on the nurses for their basic needs. More specialized needs such as learning how to re-adapt to the world (self-care) are not relevant at this early stage. The staff nurse instead at the point of awakening must go through the process of Nurse Manager

The nurse manager is responsible for ensuring that the resources are available to staff and advanced practice nurses to perform their educational roles. For example, nurses who educate patients under Orem's theory are going to spend a fair amount of time with each patient. As a result, the nurse manager needs to ensure that this time is available -- otherwise nurses will not be able to genuinely help patients if they are rushed and hurried all the time. Moreover, the nurse manager must be responsible for whatever teaching materials are being used, for ensuring that nurses are properly trained so that they give good advice, and must conduct follow-up as well. The nurse manager therefore plays an important role in removing roadblocks and difficulties that can prevent nurses from educating patients effectively on self-care.

Advanced Practice Registered Nurse (Nurse Practitioner)

The advance practice registered nurse (APRN) has a particular specialty, thus working with patients who have more or less the same condition. This allows the nurse to build a strong body of knowledge with respect to self-care and the different issues that patients face in building their independence. The APRN has power to decide which nurses will perform different forms of interventions and which ones the APRN can do on a personal level. Making such decisions will be based on the personal relationship that the APRN develops with every patient that he/she interacts with. This is a role that is very well suited to the application of SCDT because of the specialization aspect. The APRN will therefore play an important role in guidance and education with respect to dealing with formerly catatonic patients. With little prior body of knowledge on something like re-integrating a person who has been catatonic for decades, the APRN will have to do his/her best to determine a course of action based on what is known. This includes the challenge of bringing families into care, where possible.

The APRN ensures that patients receive the care that they need up until they can take care of themselves. The main objective is to make sure that the patients become self-reliant in doing simple tasks such as self-hygiene or basic chores. For these patients, self-reliance might not be a realistic objective. Through guidance, the APRN ensures that staff nurses provide all patients with the care that they need in a customized manner. The movie highlights a unique situation where the patients move through the different stages of care needs, all the way back to wholly compensatory care. When they first awaken, the key role that the APRN plays is to help determine the nursing system, including working with the staff nurses on its implementation, and handling the evaluation of it as well. The APRN is likely the person who will be responsive to the changes in the patient's conditions as they progress through the awakening, so at this point is managing the transition from wholly compensatory care to partially compensatory as they awaken.

Discussion

Awakenings provides an interesting framework for the SCDT because the patients in the movie are initially catatonic. As such, they are not autonomous beings capable of self-care that Orem assumes patients to be. When they awaken, the nurses, especially the APRN, need to begin Orem's process of going through diagnosis, prescription, designing a nursing system and implementing it. This scene marks a transition for the patients, and therefore a transition in the type of care that they will need. It is not known how much independence they will have, but they will have some, which has implications for the application of Orem's theory.

The shift when the patients awaken is towards partially compensatory care. They will need to be monitored but can perform most basic functions independently, and also as they progress there is a need to incorporate some developmental nursing care as well. For the nurses, this means assisting the patients to engage in some self-care, for example with personal hygiene, as they now have the capability. By helping the patients to become increasingly independent, the nurses are performing a critical transition in Orem's theory. However, the patients begin to regress, and this cuts short the move towards the educational/developmental care that was underway. The nurses have to revert first to partially compensatory and then by the end of the movie to wholly compensatory care again.

By looking at all these instances, the role of the nurses can be applied in different ways. The APRN who in this case is Dr. Sayer can be responsible for managing the entire department by organizing the schedules and how each of these patients can be attended to in…