Abstract
The purpose of this article is to highlight the relevance of Orem’s Self-Care Deficit Nursing Theory (SCDNT) in contemporary and future practice, explicitly within the global self-care movement and interprofessional healthcare. The authors discuss the relevance and important strengths within Orem’s nursing theory and recommend theoretical refinement within the context of significant societal and healthcare transformation. The constructs of global people-centered care and population health, with related social determinants of health, are identified as critical areas for development if SCDNT is to have continued relevance for nursing practice. Implications for theoretical thinking and nursing education are recommended.
Nursing’s distinctive knowledge is applied within an increasingly complex world of interprofessional and interdisciplinary practice. With the explosion of knowledge in basic sciences, technology, and other healthcare disciplines, nursing’s future theoretical contributions must include concepts and outcomes fully understood and valued by all members of the healthcare team (Meleis, 2018). This includes the nurses who contribute to nursing’s theoretical expansion through practice and inquiry as nursing’s boundaries are understood or expanded. Such development can be facilitated through theoretical explication of concepts and their relationships known to all health professionals as well as the direct recipients and participants in care (Interprofessional Education Collaborative, 2016). One universally accepted concept is self-care.
We posit that Orem’s Self-Care Deficit Nursing Theory (SCDNT; Orem, 2001) has the scientific maturity to contribute to increased interprofessional practice focused on self-care. Further, we believe SCDNT holds promise for consequential knowledge development in nursing during this decade of unprecedented economic, technologic, political, and sociological change. Escalating healthcare costs, growing poverty rates, pressing health and racial inequities, exploding technology, and the global pandemic mandate a clear understanding of nursing’s distinctive identity consistent with worldwide initiatives such as the United Nations’ (2016) 2030 Agenda and the National Academies of Sciences, Engineering, and Medicine’s (2021) Future of Nursing, 2020-2030.
Our purpose is to explicate selected strengths within SCDNT and suggest areas for theoretical refinement and development within the context of significant societal and healthcare transformations and growing complexity of interprofessional practice. We recognize this theoretical development is an ongoing process with continual modification through practice and research and with many potential areas for refinement. After review of major national and international initiatives, we selected two constructs we believe must be addressed for SCDNT to have continued relevance: people-centered care and population health with the latter’s mandate to address social determinants of health (SDOHs). These are necessary if nurses are to have a role in empowering and engaging people in their healthcare, reducing health disparities, and improving healthcare outcomes.
Self-Care: An Overview
Self-care is a ubiquitous term with extensive global application and utility across disciplines (Walker, 2020). The World Health Organization (WHO, 2020) defines self-care as “the ability of individuals, families and communities to promote health, prevent disease, maintain health, and to cope with illness and disability with or without the support of a health-care provider” (para. 1). It is also viewed as a means to address financial pressures on health care systems (The Economist Intelligent Unit, 2019) and inadequacies in health coverage—the latter envisioned by WHO (Narasimhan & Kapila, 2019). With over 50% of the world’s population without access to formal healthcare (WHO, 2017) and over 50% of adults with one or more chronic illnesses (Riegel, Jaarsma, & Stromberg, 2012), self-care is often the only means to promote and maintain health and well-being.
There has been a resurgence of interest in self-care since Levin, Katz, and Hoist (1979) introduced the concept. Over the past decades, the concept has become more abstract and ambiguous (Meleis, 2018). A four-decade content analysis of self-care in lay and healthcare literature revealed 139 definitions, including related concepts such as self-management (Godfrey et al., 2011). Further, Taylor and Renpenning (2011) described an interdisciplinary science of self-care with multiple models used by persons to care for themselves and others. Recently, El-Osta and others (2019) described an acceleration of interest in general self-care primarily to address increased healthcare costs and demands on health and social systems. Their review of academic and lay literature revealed 32 self-care models, theories, and frameworks. Additionally, international collaboration on middle-range self-care theories specific to chronic illnesses has impressive applications for nursing practice and research. For example, Riegel and others’ (2019) research highlights the critical nature of people’s role in self-care to promote increased well-being, decreased mortality and morbidity, and decreased costs. Their extensive research in heart disease stresses the knowledge, skills, confidence, and motivation to engage in self-care, with an emphasis on decision-making. An interprofessional group at the International Center for Self-Care Research described the complexity of self-care (Jaarsma et al., 2020). They further revealed significant gaps in our knowledge, such as the relationship of culture to self-care decision-making and the influence of care partners and health professionals on self-care. Among the various definitions and models across different disciplines and professions, we believe SCDNT provides an ideal formal structure for the nursing role and for development of nursing knowledge for practice now and into the future.
Orem’s Self-Care Deficit Nursing Theory
While the foundation for SCDNT is the science of self-care, Orem’s (2001) early formalization was intended to place self-care structurally and functionally within the framework of nursing practice by expanding the personal, health, and sociocultural features of self-care. She defined self-care as “the practice of activities that individuals initiate and perform on their own behalf in maintaining life, health, and well-being” (p. 43). Throughout five decades, Orem refined the description of nursing for this purpose—to empower patients and their families to care for themselves and to clarify the role of nurses in situations where self-care or care of others was not possible.
Consequently, Orem’s SCDNT provided a structure for nursing’s disciplinary identity within a complex healthcare system and specifically within the broader science of self-care. This provided nurses with their own disciplinary perspective and voice while functioning within self-care practice. Nursing practice, guided by the strong focus of the SCDNT, empowers nurses to bridge boundaries in equal partnership with other health professionals to optimize health outcomes. As Smith (2019) suggested, collaborative teams function more effectively when each profession “can leverage strengths they bring to the persons in their care” (p. 4).
Orem’s theoretical work has successfully been applied throughout the world to nursing practice and administration, verified and refined through nursing research, and used as a framework for nursing curricula at all levels of nursing education (Meleis, 2018). SCDNT’s continued value and efficacy is evident today across continents and throughout clinical settings and patient populations with publications expanding throughout the Middle East and Asia, as well as Europe and the Americas (Gumbs, 2020; Hoojeung & Park, 2019; Khademian, Ara, & Gholamzadeh, 2020). Concepts within this general theory of nursing have been used to derive middle-range and situation-related theories for specific populations (Hartweg, 2020) as diverse as self-care abilities for weight management and nursing management of persons with hypertension (Drevenhorn, 2018; Pickett, Peters, & Jarosz, 2014).
While the suitability of the SCDNT over many years is well-documented, a majority of these practice and research initiatives concentrate on self-care or self-management related to chronic diseases of individuals and families (Hartweg, 2020). This past emphasis reveals the strength of SCDNT and its significant contributions to nursing practice. However, there is also need for refinement and development for utility in contemporary and future practice. We propose such theoretical development must focus on the global people-centered movement and target challenges not only at the individual level but also expand to clarify nursing’s role with populations.
People-Centered Care
The global people-centered initiative provides a framework to empower and engage people in their healthcare to improve health and well-being. People-centered care “consciously adopts individual, carers’, families’ and communities’ perspectives as participants in, and beneficiaries of, trusted health systems that respond to their needs and preferences in humane and holistic ways” (WHO, 2015, p. 7). A fundamental concept is establishing an integrated partnership between the recipient of care and all providers of care that encourages co-designing and delivery of personalized care in an efficient and effective way. The goal is better health and well-being outcomes across levels of care.
Elements of the global people-centered movement, such as empowerment of people through education and self-care, are congruent with strengths of Orem’s SCDNT and provide evidence of its relevance now and into the next decade. For example, Orem (2001) approaches each healthcare situation from a humanistic and holistic perspective with inclusion of well-being as a legitimate outcome of self-care. Viewed as a major strength of SCDNT by Walker (2020), this underemphasized outcome of well-being includes types of affect, spiritual experiences, and life fulfillment (Orem, 2001, p. 186). As a subjective and personal outcome, well-being has been tied to wellness not only in individuals and groups but also at the population level (Fawcett, 2019). Another extant but often overlooked tenet consistent with the people-centered movement is Orem’s emphasis on the person’s perception of the health situation and the right of the individual to make decisions about his or her care (Orem, 2001, pp. 195, 382-383). Understanding the person’s perspective occurs through formation of a care partnership.
Partnership Between Care Recipients and Providers: Theoretical Strengths
Within Orem’s (2001) process of nursing, the development and sustainment of interpersonal relationships are foundational to collaboration and formation of partnerships with recipients of care. Orem identified specific interpersonal and social processes (pp. 290-292) used to legitimize the formal agreement between the recipient and provider on their respective roles in the healthcare situation. This includes formal social interactions or contractual operations that reveal the person’s perspective of their self-care demand/needs and self-care agency/capabilities. Just as scientific evidence prescribes self-care actions that should be taken for life, health, and well-being, these contractual operations guide the nurse and the recipient of care to explore not only “what should be done” from the scientific perspective but also to agree realistically on “what can be done.” This process adjusts the requirements or demand for self-care and the abilities or agency of the recipient within the cultural and environmental context and incorporates the people’s perspective and choice based on values and beliefs. Unlike other nursing conceptual frameworks that emphasize interaction or interpersonal relationships (King, 1981; Orlando, 1961; Peplau, 1952), interpersonal and social/contractual operations are integrated within theoretical constructs such as self-care demand and self-care agency (Orem, 2001, pp. 314-317), the latter essential to empowerment and a key element of the people-centered movement.
Although this current SCDNT structure and interpersonal/social/ contractual operations provide a strong framework for co-designing the plan of care, significant theoretical development is needed to address the variations occurring with changes in healthcare such as the paradigm shift with transition to new healthcare venues (Parse, 2019), the explosion of telehealth technologies (Carroll, 2018), and significant demographic changes of care recipients and providers (Pittman, 2019). Meleis (2018) suggested the need for models that promote the nurse-patient relationship with technology and other variables. All have significant implications for expansion of the concept of nursing agency, or capabilities of the nurse. This suggests the need for theoretical development at the middle-range or situation-specific level to modify interpersonal and social/contractual operations influenced by changes such as technology.
Partnership Across the Healthcare Spectrum: A Need for Development
Another key component of the people-centered movement is the call for integration and coordination of healthcare services among providers, sectors, and programs with the recipient of care (WHO, 2015). This collaboration goes beyond those well-developed methods used for team building within hospitals or specific organizations (Tomasik & Fleming, 2015). Although Orem (2001) and others such as Taylor and Renpenning (2001) suggested SCDNT provides direction for “defining and describing roles and responsibilities of nursing within the interdisciplinary care system” (p. 432), increasing complexity of the social and healthcare system requires further theory development of constructs related to coordination and integration within the broader community and the healthcare sector. This extends the notion of the nursing role directed at the self-care deficit of the individual, groups, or family within healthcare systems to broader platforms.
Such coordination among programs and sectors requires trusted providers with cultural competencies, advanced interpersonal and social/contractual skills, and ability to leverage technology to empower and engage persons in their own decision-making to support sustained self-care. As a means to enhance coordination, Pittman (2019) proposed changes in the core functions of nurses within the complex U.S. system. One core function is to build partnerships within and outside the healthcare arena. Such expectations require nurses to extend boundaries outside the health sectors as “part of the job” (Pittman, 2019, p. 28). Extending Orem’s notion of interpersonal and contractual operations beyond those used in the past with individuals, families, and communities to agents within healthcare and broader social realms also requires advanced knowledge and communication skills for nurses to contribute to improved outcomes.
The strengths of Orem’s SCDNT, with its holistic philosophy, emphasis on well-being as outcome, and the person’s perception of the healthcare situation, are congruent with the contemporary global people-centered initiative and should be emphasized in theoretical self-care nursing practice and research. With improved understanding of the challenges of unmet healthcare needs and the complexity of the healthcare systems, further development of SCDNT must include modification or addition of concepts and variables that clarify the nurse’s role that result in partnerships within and outside the healthcare sector (Pittman, 2019). This is necessary to guide nurses to engage in political and legislative action needed to support nursing practice, education, and research to achieve better healthcare outcomes at the individual, community, and global levels. Such theoretical development requires refinement of Orem’s SCDNT to address population health.
Population Health
In response to the epidemiologic profile of the population worldwide—including declining health indicators and disparity of health outcomes by race and income—a strong focus on population health and a strong focus on population health and social determinants of health (SDOHs) is evolving to improve the health and well-being of all (Houlihan & Leffler, 2019; Pittman, 2019; Storfjell, Winslow, & Saunders, 2017). Population health considers “the health outcomes of groups of individuals, including their distribution,” the SDOHs (upstream conditions), and the “policies and interventions that link them” (Kindig & Stoddart, 2003, p. 380). SDOHs are defined as the long-term conditions in which people are born, grow, live, work, and age that include social norms, social policies, and political systems and have both negative and positive effects on health (WHO, 2008). Scholars of healthcare are increasingly recognizing that SDOHs are a significant contributor to the health and well-being of individuals and the population worldwide, accounting for between 60% and 80% of modifiable health outcomes (Cho & Sonin, 2017; Magnan, 2017). In particular, most believe addressing inequities in SDOHs will create healthy environments, reduce social disparities, and improve health outcomes (Taylor et al., 2016). Historically rooted in population nursing including environmental factors, living conditions, and advocacy, the nursing profession is committed to reducing the disparity in healthcare (American Nurses Association, 2015; Pittman, 2019). While there is general agreement that nursing needs to become refocused on population health to move nursing into the future, limited attention has been paid to developing the nurse’s role in communities/populations within extant grand nursing theories.
Population Health: A Need for Development
One exception is a lesser known extrapolation of the SCDNT begun by Taylor and Renpenning (Taylor & McLaughlin, 1991; Taylor & Renpenning, 2001) that encouraged nurses to think beyond the individual’s self-care agency and self-care demand to multiperson units for the delivery of care that includes communities or populations. Addressing populations and community variables in a comprehensive manner, Taylor and McLaughlin initially examined the theoretical concepts of community and the SCDNT to propose models of community nursing consistent with the philosophical viewpoint of the SCDNT. Their three models for community as a unit of service are detailed in Orem’s (2001) book. Despite the term “community,” the Taylor and Renpenning model is applicable to nurses practicing in population health. It includes representations of health outcome goals, community variables to be assessed, and community systems that can be altered by the nurse. These factors are consistent with the current idea of population health—health outcomes, environmental and SDOHs, and policies and interventions (Kindig & Stoddart, 2003).
Of significance, Taylor and Renpenning (2001) suggested considering the addition of the variable of community as a conditioning factor, recognizing that a community has a responsibility in facilitating the self-care of its members. Community as a conditioning factor is distinct from Orem’s basic conditioning factors (BCFs) that are related to the individual but is similar in function to SDOHs as they include, for example, public policy, community environment, sociocultural values, and community resources. In their model, the nurse examines the healthcare demands of the members of the population, the ability of members to meet the demand, and the community systems’ conditioning effect on the members of the community to achieve their healthcare outcomes (Taylor & Renpenning, 2001). Consistent with the emerging role of the nurse in population health, the goal of the nurse is to alter the community systems that affect outcomes. This is a major change in the nursing role within the SCDNT, as the community becomes the unit of service, not the individual. Similarly, congruent with future trends, the model emphasizes the need for an interdisciplinary health system designed toward the community rather than a nursing system directed to the person and their care needs (Taylor & Renpenning, 2001, p. 418). Modifying the negative conditioning effect of community variables on the person's self-care system requires the nurse's active involvement in resource development, health care system change, and environmental change (upstream interventions), necessitating the nurse’s involvement at the health policy level—all suggested actions of the nurse engaged in population health during the next decade (National Academies of Sciences, Engineering, and Medicine, 2021).
SDOHs and Nursing Assessment: A Need for Refinement
While the imperative to redesign the nursing role in population health is primary, all nurses engaged in patient care have a responsibility to improve population health (Storfjell et al., 2017). Nurses caring for individuals and families make a significant contribution through accurate assessment of health status and healthcare requirements; however, the scope of assessment must be expanded to include information on social needs and SDOHs. As recipients of care move from an acute care setting into the community environment, an understanding of their immediate social needs can assist in interprofessional care coordination to facilitate this transition. On a broader scope, the assessment for the more encompassing SDOHs can provide information about upstream conditions that is essential for the individual’s health planning (Gorski, Polansky, & Swider, 2020). Screening by health professionals for SDOHs at medical centers has proven useful in determining programming, upstream interventions, and individual interventions (Meyer, Lerner, Phillips, & Zumwalt, 2020). Further, Wilson (2019) suggested that information collected by nurses at the individual level contributes to data sets essential in managing population health and identifying effective interventions.
Within the SCDNT, the personal, social, and environmental factors that guide the nurse in structuring the assessment and planning of individuals’ care are 10 BCFs. Age, family system factors, healthcare system factors, sociocultural factors, and patterns of living are representative of the BCFs. Similar to the SDOHs; the BCFs are based on the premise that individuals are members of sociocultural groups and live in a world that alters their circumstances of living (Orem, 2001). The BCFs have been useful in helping nurses determine the individual’s internal and external conditions that modify required care, the person’s ability to engage in care, and the available healthcare resources (Gumbs, 2020; Moore & Pichler, 2000). An analysis of both the BCFs and SDOH reveals commonalities among the named factors/dimensions in that both can influence health in a positive or negative manner and both include circumstances that modify the nursing interventions. In lieu of current trends in the healthcare system, we recommend integrating the terminology of the SDOHs identified in the population health literature within the BCFs to facilitate communication and the sharing of data through standardized data sets. An example would be to expand the BCFs of environment and sociocultural factors to include more emphasis on neighborhood and built environment and community context. This inclusion of more comprehensive factors provides the nurse with information reflecting the degree of discrimination, crime and violence, and social cohesion within the community of residence, providing data essential to improving the individual’s care.
Conversely, in an analysis of the application of the SCDNT to an aggregate in a community, Green (2013) suggested the SDOHs are interchangeable with the concept of BCFs. Within the theoretical conceptualization of the SCDNT, this restricts the nurse’s intervention at the community level. When considering the individual as a unit of service, we prefer to expand the existing BCF categories to maintain the focus on the individual’s need for care and self-care abilities, reserving consideration of SDOHs as an additional variable when assessing populations.
The ideas of community as a unit of service put forth by Taylor and Renpenning (2001) are consistent with the changing demands on the profession to serve the health needs of populations and provide theoretical evidence that Orem’s theory can be expanded to include the nurse’s role in population health. Establishing the expanded role as an integral component of a nursing model will help generate relationships among variables for development of middle-range theories within the context of populations. Equally important the inclusion of the SDOHs as measures of the community variable provides a focus for upstream nursing interventions using terminology prevalent among other health professions. Although the links between SDOHs and population health are established in the public health literature, advancing this work will require persistent effort in both nursing practice and research to determine the precise effectiveness of specific nursing interventions on the SDOHs.
Final Thoughts
Developing nursing knowledge for 21st-century nursing practice calls for a strong theoretical and scientific foundation (Yancey, 2015). Meleis (2018) appealed to a fifth generation of nurse theorists to clarify nursing’s disciplinary identity and promote contemporaneous theoretical thinking. Although we do not consider ourselves those fifth-generation theorists, we strongly believe now more than ever that nurses must be educated to “think nursing” and to navigate in an increasingly interprofessional practice. Nurses must understand their distinctive identity and embrace the need for flexibility as boundaries change and healthcare and social systems become more complex. This is effectively done within a conceptual model of nursing. For us, this model is Orem’s SCDNT consistent with the universal self-care movement.
This ability to “think” nursing within the social and healthcare system begins in basic nursing education. We concur with both Smith (2019) and Meleis (2018) and advocate for a return to integration of nursing theory throughout nursing curricula in both undergraduate and graduate programs. We also advocate for curricula that strengthens knowledge of the context in which nursing is practiced. In addition to knowledge of nursing science and applied sciences, Orem (2001) recognized the importance of other fields of knowledge foundational to nursing. She identified social field, profession-occupation, jurisprudence, history, ethics, and economics as essential knowledge for nurses (p. 469). To these we would add a focus on epidemiology, health policy, and technology. In these unprecedented times of increasing atheoretical nursing and global healthcare challenges, thorough knowledge of nursing’s core context is critically important if nursing is to disempower oppressive social structures and practices and empower clients, families, and communities (Meleis, 2018, p. 423).
With over 40 years of thinking, practicing, teaching, and researching using Orem’s SCDNT framework, we believe Orem’s conceptualizations are more relevant today than ever. Her fundamental definition of self-care is congruent with global definitions and interdisciplinary self-care movements in governments and across professions. Further theoretical concepts and operations are consistent with the international people-centered movement that embraces empowerment and decision-making through partnerships of recipients and providers across the healthcare spectrum. The proposed Taylor and Renpenning (2001) model of nursing in community/populations derived from the SCDNT combined with the inclusion of SDOHs is consistent with movements to reduce health inequities and to improve health outcomes of populations. However, changes must be made. As healthcare delivery moves from acute care to population care, we believe the fifth-generation theorists must develop and refine SCDNT to discover effective approaches and interventions that increase health equity, promote nurses’ engagement in upstream interventions, and take an active role in health policy.
This calls for changes in nursing curricula that emphasize new knowledge and competencies if nurses are to be effective in improving health outcomes as key players in interprofessional and social systems. It is an imperative that all levels of nursing education frame this transformation of the nurses’ role within a nursing model. Unless nursing education programs embrace nursing science, there will be little growth in the advancement of nursing’s knowledge base. Use of SCDNT is particularly appropriate as it articulates the role of the nurse within the global self-care movement and interdisciplinary practice.
Footnotes
Declaration of Conflicting Interest
The authors declared no potential conflicts of interest with respect to the authorship and/or publication of this review.
Funding
The authors received no financial support for the authorship and/or publication of this review.
