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Nursing practice at St. Vincent's Hospital is not based on a specific conceptual theory or model of nursing. Rather, nurses are encouraged to apply the model, most pertinent to the patient/client and their health status at any given time. (Nursing Policy and Procedure Manual, 1988: 43). This paper explores the feasibility of adopting a specific conceptual model - Orem's Model, as a framework for nursing practice. Self-care is the foundation and substance of Orem's model and for this reason it was chosen as self care is a nursing principle currently encouraged in a number of patient care areas in the hospital. Orem's model is briefly described for the purpose of clarity. Selected structural and functional components of the model are than analysed. A critical examination of the effectiveness of the model for nursing care is presented. The paper concludes that major attitudinal and behaviour changes would be required from nurses, patients and society if Orem's model were adopted. This would be an expensive process initially, but it may prove to be cost-effective.
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Marianne Goodwin, RN, CM, BA (Syd), MNA (UNSW). Marianne's nursing experience has included caring for geriatric, neonatal and cardiac patients. She is currently Assistant Director of Nursing, Quality Assurance, at St. Vincent's Hospital, Sydney. |
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Nursing literature is replete with commentary on nursing theory and individuals proffering various theories of nursing. The need for theory does not appear be a matter for debate. Most writers advocate that nursing theory is critical to the advancement of professional nursing.
Ellis (1968: 218) states that nurses should be concerned with theory development because
... theory or theoretical knowledge gives direction to practice... Theory is useful as a framework for storing knowledge available.
Chinn, (1986: 19) states that
Theory will help produce a well-founded basis for the continual description, explanation and prediction of nursing empirics and will help avoid a haphazard approach to practice.
Meleis (1985: 31) succinctly informs us
... theory helps to identify the focus, the means and the goals of practice.
Dorothea Orem has been credited as being one of the first theorists to emphasise nursing's need to develop its own body of knowledge, rather than base its practice and curricula on the models of other disciplines. (Fawcett, 1984: 177).
Orem first introduced her conceptual model in 1959 in Guide For Developing Curricula For the Education of Practical Nurses. Her work has undergone considerable development and refinement since this first publication 30 years ago. The most recent refinements are contained in the 3rd Edition of her book, Nursing: Concepts of Practice, published in 1983.
Orem's model was chosen for this paper because in a number of areas within St. Vincent's Hospital, Sydney, patients are encouraged and educated to care for themselves. This notion of self care is central to Orem's model. Indeed, self care is the foundation and substance of her model.
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Orem's model is centered on the individual and his/her need for self-care. The model is concerned with the provision and management of self-care. A requirement for nursing exists when a person is unable to maintain for him/herself self-care action which is therapeutic in sustaining life and health, recovering from disease and injury or coping with their effects. (Orem, 197 1: 1). This notion of self-care is unique to Orem's model.
The essence of Orem's model is the nurse-patient relationship. This relationship by its very nature is unbalanced with the patient having a need and the nurse the ability to meet that need. (Orem, 1980:18). However, Orem's emphasis is that this relationship is complimentary:
This means that nurses act to help patients assume responsibility for their health-related self-care by:
- making up for existent health-related deficiencies in patient's capabilities for self-care, and
- supplying the necessary conditions for the patients to withhold or to maintain or increase their capabilities for self-care in order to maintain, protect and promote their functioning as human beings.
Orem 1980: 11.
The central focus or concept of her model is the notion of self care and the interrelationship of the basic elements of life and the life cycle:
Self care is a requirement of every person, man women and child. When self care is not maintained, illness, disease or death will occur.
Orem 1980: 6
Another core concept is the notion of a self-care deficit which Orem defines as:
People can benefit from nursing because they are subject to health-related or health-derived limitations that render them incapable of continuous self-care or dependent care, or that result in ineffective care.
Orem 1980: 27
The concept of Nursing Systems according to Orem,
... are formed when nurses use their abilities to prescribe, design and provide nursing for legitimate patients (as individuals or groups) by performing discrete actions and systems of action. These actions or systems regulate the value of or the exercise of, individuals capabilities to engage in self-care and meet the self-care requirements of the individual therapeutically.
Orem 1980: 29
Orem's model adopts a 'Developmental World View', from the identifiable stages she describes in self-care agencies throughout life. The child is viewed as being in a state of dependent care, the healthy adult in a state of total self-care and dependent care and elderly, ill or disabled persons, in a state of dependent care. (Orem, 1980: 35).
Fawcett, (1984: 177) describes Orem's model as being derived from inductive reasoning. The idea of self-care is the result of her own personal and professional experiences. On the other hand, Fawcett, (1984: 178) suggests that Orem's description of the metaparadigm of nursing is derived from deductive reasoning.
Orem's emphasis on self-care is similar to Henderson's:
Nursing is primarily helping people, (sick or well) in the performance of those activities contributing to health or its recovery (or to a peaceful death that they would perform unaided if they had the necessary strength will, or knowledge. It is likewise the unique contribution of nursing to help people to be independent of such assistance as soon as possible.
Henderson 1966: 16
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Orem clearly identifies the four major nursing metaparadigm concepts, viz. The Person receiving nursing, The Environment within which the person exists, The Health-Illness Continuum within which the person falls at the time of the interaction with the nurse and Nursing Actions.
As stated. the individual patient is the primary focus in the model. Orem's definition of the patient, although it does mention family and groups, does not provide a great deal of elaboration on family or groups. Moreover, Orem does not appear to extend her model to address the nurse-society relationship and it is suggested that this model is lacking in the area of public education.
Orem acknowledges self-care requisites to have their origins in human beings and the environmental factors, elements, conditions, etc. She does not define them clearly (Fawcett, 1984: 29).
Orem sees health as an ideal. that is, when living things are structurally and functionally whole, (Orem, 1980: 118). However, as Fawcett (1984: 180) points out, this leaves Orem with the dichotomy of health or not health, wellness or illness.
Orem states her definition of nursing quite clearly. She defines nursing as
... a creative effort of one human being to help another... (Orem 1980: 6)
... action performed by nurses for the benefit of others. (Orem 1980: 92.)
This emphasis on nursing as a 'helping' profession may further perpetuate the 'hand maiden' stereotype image of nursing.
Orem's (1980: 201) nursing process is presented in three stages: diagnosis and prescription, designing and planning and production and management.
Although Orem offers a comprehensive, detailed discussion of nursing actions and the nursing process, she does not delineate the consequences of these actions in detail. Overall, the nurse's actions should be the result of planning and choices in which the patient has played an active part.
Orem seems to 'overlook' the fact that not all patients want to take an active part in this process nor do all patients want to attain or retain a 'a state of wholeness or integrity' (Orem 1980: 118).
Moreover, many patients hold the view that the nurse is 'the expert' and decisions should be left in their 'capable hands'. The study conducted by Anna, et al. (1978), reports that patients were unenthusiastic when the notion of self-care and increased decision making were presented to them. Common replies being,
That's your job... I don't know what to do (Anna, et al., 1978: 10).
However, Orem's concept of self-care is consistent with today's emphasis on patient rights, patient advocacy and better education of health care consumers. But if the model is to be feasible in Australian health services, it would be necessary to place emphasis on 'public education' and attempt to dispel the 'myth' of nurses being 'helpers' or handmaidens. These two ingredients appear to be consistent with Orem's model because she emphasises the individual and a nurse-patient relationship, which is of the 'helping' type and it would be difficult to apply her principle to enhance nurse involvement in public health education. Moreover. as her model is illness oriented, there is little indication of the model's usefulness in enhancing prevention and promoting health and well-being.
Although self-care is the foundation and substance of Orem's model and provides the model with overwhelming consistency, Orem's semantic presentation of the concept is confusing. Anna et al. (1978) reports that post graduate students implementing the model found that:
the stumbling block was not the concept of self-care itself, but rather the words used to describe it. (Anna et al., 1978: 10)
Orem states her assumptions in great detail. Orem's main assumptions relate to 'the person'. There appears to be implications that people are basically 'rational beings who have some 'mastery' over their destiny (self objectification ... can engage in deliberate actions..) People are viewed as a moral beings who are capable of ethical deeds. This implies that humans are basically good. This is an implication that may be questioned. on both philosophic and pragmatic grounds, but it is beyond the scope of this present paper.
Orem seems to imply that it is normal for the person to want to attain optimum levels of self-care. This assumption may require modification if empirically tested. Moreover, such an assumption ignores the possibility of secondary gains a state of unwellness may produce. for example, unwellness with resultant hospitalization may provide a person with shelter, food and clothing. a situation that is not uncommon at St. Vincent's Hospital.
The possibility that the patient may not choose to engage in self care nor the possibility that the nurse may be ineffective or inaccurate in their assessment are possibilities that do not appear to be addressed by Orem.
Finally, Orem's assumption that self-care...is necessary for life itself may produce conflict if patients do not hold this view. This was the experience of Anna et al (1978; 11) who report a Mexican-American whose expectations were in apparent opposition to what is expected of the patient when using Orem's concept.
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Orem's model has been used to guide nursing activities in such settings as ambulatory clinics, a nursing home and a hospice. The most appropriate and widely used application of Orem's model is with the type of patient cared for at St. Vincent's; the adult patient requiring acute care. The usefulness of the model applied to psychiatric patients is questionable.
Orem's model appears consistent with the current principles of the nursing process in use at St. Vincent's. However, patient care plans currently used would have to be changed as well as the wording of all documentation.
The model is particularly compatible with primary nursing as this type of assignment pattern encourages the continuity of care and focuses on individualised care. It is less compatible with patient allocation, based on geographic position, the assignment pattern currently practised at St. Vincent's Hospital.
The introduction of this model into the nursing service at St. Vincent's, or one assumes, anywhere In Australia, would necessitate an extensive educational program for both stair and patients. Major changes would have to be made to all documentation including the Nursing Division's Philosophy, Objectives, Goals, Standards and Care Plans. It would also involve a major educational programme aimed at resocialising staff, patients, their relatives and friends. Such a process would undoubtedly meet with some quite considerable opposition.
With the high rate of nurse turnover currently experienced at St. Vincent's, and indeed by all the ma or N.S.W. teaching hospitals, the on-going educational costs of implementing this model would be enormous.
The lengthy communication process required between patient and nurse as well as the esoteric nature of Orem's terminology would prove to be obstacle's in implementing the model for nursing practice, given the current nursing workload.
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This model would prove costly initially in terms of the time and money involved in changing attitudes and behaviour as well as education.
Adoption of this model may provide a framework for practice at St. Vincent's Hospital by highlighting the focus, the means and the goals of nursing practice. This would encourage continuity of care and enhance patient care by lessening some of the confusion and conflict inherent in the current system. This model would empower the patient and help maintain their dignity.
Ultimately the model has the potential to be cost effective as it encourages a more responsible and independent patient population. This may result in shorter lengths of stay, a reduction in unnecessary utilisation of expensive hospital care and greater emphasis on home care with support systems. This factor may provide stimulus for nursing management to consider the introduction of this model, in times of growing budget restraints and the likelihood of future hospital funding based on case mix and length of stay.
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