Addressing Physical Health Needs of Individuals With Schizophrenia Using Orem’s Theory

Background, Context, and Relevance

For individuals with schizophrenia, physical inactivity and poor dietary intakes are directly associated with weight gain, obesity, and high morbidity (Brown, Birtwistle, Roe, & Thompson, 1999; Henderson et al., 2006). Many individuals with schizophrenia have diets that are high in saturated fats and calories and low in protein, essential vitamins, and minerals (Beebe, 2008; Stokes & Peet, 2004). Research further reveals that individuals with schizophrenia have a sedentary lifestyle (Soundy et al., 2013), with less than 25% engaging in the recommended amount of physical activity of 150 minutes per week (Faulkner, Cohn, & Remington, 2006). Obesity is a risk factor for developing chronic and life-threatening diseases such as diabetes, hypertension, cardiovascular and coronary artery diseases, stoke, and cancer (Happell et al., 2012; Pack, 2009), and is also associated with poor psychosocial functioning and unhealthy coping mechanisms related to negative self-image and self-esteem (Barber, Palmese, Reutenauer, Grilo, & Tek, 2011; Radke, Parks, & Ruter, 2010).

Heavy cigarette smoking is common with 50% to 90% of people with schizophrenia tobacco smokers compared with 25% to 35% of the general population (Schizophrenia Society of Canada, 2012). It is estimated that people with schizophrenia who smoke spend approximately one third of their monthly budget on tobacco products (Steinberg, Williams, & Ziedonis, 2004).

Heavy tobacco use is associated with increased rates of asthma, pneumonia, chronic obstructive pulmonary disease, and lung cancer (National Center for Chronic Disease Prevention and Health Promotion, 2014).

Alcohol and illegal substance abuse is 50% to 70% higher in people with schizophrenia and is associated with aggressive behaviors, relapse, incarceration, suicide, and physical morbidity (Schizophrenia Society of Canada, 2012). The high frequency of substance abuse and unsafe sexual behaviors among individuals with schizophrenia are risk factors associated with viral infections that include hepatitis C and human immunodeficiency virus (HIV; De Hert et al., 2011). The prevalence rate of HIV and hepatitis C is higher in individuals with severe mental illnesses including schizophrenia than the general population, and prevalence rates of hepatitis C are about 20% higher (Leucht et al., 2007; Loftis, Matthews, & Hauser, 2006; Meyer, 2003; Rosenberg et al., 2001; Senn & Carey, 2008). Together, these risk factors contribute to poor physical health that put people schizophrenia at risk for comorbidities and premature death.

Schizophrenia and Social and Physical Health

Mental illness typically has a negative influence on socioeconomical, psychological, and physical health of individuals through its influence on attaining education, financial security, and social and personal relationships (Corrigan & Watson, 2002; Nash & McDermott, 2011). People with schizophrenia have higher than normal rates of unemployment, poverty, social isolation, and lack of knowledge and access to appropriate educational or medical resources (Canadian Mental Health Association [CMHA], 2007, 2014). The initial onset of psychosis generally occurs in early adulthood produces problems with attention and declarative memory that interferes with educational attainment (CMHA, 2015; WHO, 2015). With low educational qualifications, individuals with schizophrenia are at risk for low-income jobs, unhealthy working conditions, unemployment, and poverty (WHO, 2010). For example, in Canada 70% to 90% of individuals with mental illnesses including schizophrenia are unemployed and depend on social services to live (CMHA, 2014). Social assistance recipients live below the poverty line and typically live with inadequate housing, poor nutrition, limited access to resources and programs, and poor physical health (CMHA, 2007).

Psychotropic medications also contribute to compromising physical health in individuals with schizophrenia (Allison et al., 1999; Baptista, Kin, Beaulieu, & de Baptista, 2002; Berkowitz & Fabricatore, 2011). While antipsychotic medications are essential to the management of mental illnesses, they contribute to weight gain and obesity with increased risk of metabolic syndrome, insulin resistance, and dyslipidemia (McIntyre, Mancini, & Basile, 2001; Reist et al., 2007; Wirshing, Pierre, Erhart, & Boyd, 2003). According to Reist et al. (2007), second-generation antipsychotics are associated with a 10% increase in prevalence rates of obesity in individuals with schizophrenia.

Health care disparities that include inadequate access to health care services, insufficient treatment, screening, monitoring, and counseling (Falissard et al., 2011; Kilbourne, Welsh, McCarthy, Post, & Blow, 2008) contribute to increased morbidity and premature mortality in individuals with schizophrenia (De Hert et al., 2011; Mitchell et al., 2009; Osborn, King, & Nazareth, 2003). In a cross-sectional survey and chart audit, Howard and Gamble (2010) identify the practices of nurses in relation to physical health assessment and care management of individuals with a severe mental illness including schizophrenia. Their findings indicated that more than 50% of patients did not have a recorded physical assessment and there was little evidence that dietary intake, physical activity levels, or health promoting activities were evaluated. Similarly, Dean, Todd, Morrow, and Sheldon (2001) found that most mental health nurses were unsure of their role in providing physical health care to patients, focusing predominately on the presenting symptoms of mental illness. The literature indicates that noncomprehensive care by nurses is from a lack of knowledge and skills of how to support the physical health of individuals with mental illness including how to address it from a system level (Dean et al., 2001; Hardy, White, Deane, & Gray, 2011; Nash, 2009). For example, the social determinants of health such as unemployment, poverty, and social isolation should be considered when addressing physical health of people with mental illness. According to the World Federation for Mental Health (2010), failure to provide holistic care that addresses psychosocial and physical needs results in poor health and premature death in individuals with mental illnesses.

The use of theory-based knowledge can support nurses to identify trends, develop interventions, and coordinate resources to provide holistic care for people with schizophrenia. Orem’s SCDNT provides a meaningful and adaptable framework that allows nurses to consider perspectives from interpretive, empirical, and critical theoretical paradigms to enhance the physical as well as psychological health of individuals with schizophrenia.

Overview of Orem’s Self-Care Deficit Nursing Theory

The SCDNT is a grand theory that combines three interrelated theories of self-care, self-care deficit, and nursing system (Orem, 2001). Self-care theory depicts individuals as autonomous and suggests that self-care is performed to regulate functioning and maintain health and well-being (Orem, 2001). The ability of a person to perform self-care, called self-care agency, is affected by basic conditioning factors that include health state, development state, sociocultural orientation, health care system, family system, patterns of living, environment, and resources (Orem, 2001). Through self-care, the ability to address universal, developmental, and deviation in health are met; Orem describes these abilities as self-care requisites (Orem, 2001). Universal self-care requisites are necessary for maintenance of human integrity and include physiological needs such as air, food, water, activity and rest, and social interactions (Orem, 2001). Developmental self-care requisites are associated with developmental stages of life cycle such as adjusting to body changes, whereas the health deviation self-care requisites focus on pathologic conditions, illness, or injury (Orem, 2001).

Self-care deficit theory indicates that people require nursing care when their demands to achieve health outweigh their abilities to execute the necessary activities and processes required for sustaining health (Orem, 2001). Nursing system theory proposes that nurses have the knowledge, ability, and power to act deliberately to assist individuals meet their self-care requisites (Orem, 2001). The nursing system theory explains the necessity of the nurse–client relationship in the preservation of care where nurses assess, diagnose, and develop a plan of care (Orem, 2001). In nursing practice, self-care deficits are continually assessed and nurses help individuals achieve health by acting for, doing for, teaching, supporting, and providing optimal environments (Orem 2001). Nursing actions can be wholly compensatory where a patient’s ability to perform self-care is absent and thus rely fully on nurses. Alternatively, patients and nurses work together to address self-care needs in partly compensatory care, or individuals conduct most of their self-care in supportive-educative care and nurses provide support and resources to guide and monitor their conditions (Orem, 2001). Consistent with the nursing process, it is imperative that nurses evaluate outcomes and adapt their actions accordingly.

Orem subscribes to a moderate realist ideology that is inherent in observed and experienced truths (Taylor, 2006) and the SCDNT assists nurses understand their role in relation to both objective and perceived patient needs (Higgins & Moore, 2012). Fitting readily within the nursing’s metaparadigm of person, health, environment, and nursing and focusing on health through “restoration, stabilization, and regulation of integral functioning” (Orem, 2001, p. 23), Orem’s SCDNT has been adapted and used to guide nursing practice of patients throughout the lifespan in various settings. Orem emphasizes holism, and her theory provides an adaptable structure to integrate interpretive, empirical, and critical paradigmatic perspectives for considering self-care. The ontological and epistemological assumptions of each theoretical paradigm guide the level and focus of inquiry, and thus can determine the direction of nursing action to achieve holistic health.

Implication of Paradigms

Paradigms are belief systems and worldviews that influence one’s understanding and interpretation of experiences and observations and help organize information to guide inquiry and action (Kuhn, 1962; Weaver & Olson, 2006). Interpretive, empirical, and critical theoretical paradigm often explicitly inform nursing research but implicitly apply to practice (Guba & Lincoln, 1994; Weaver & Olson, 2006). The ontological assumption of the interpretive paradigm is that reality is subjective and individually constructed, varies from person to person, and is actively created through interactions with the surrounding social world (Cohen, Manion, & Morrison, 2007; Scotland, 2012). In contrast, the empirical paradigm seeks verifiable evidence to understand reality and takes deductive approaches to reduce complex interaction of variables into correlations and causes (Creswell, 2009; House, 1991). This often involves the systematic testing of interventions using randomization and control group to minimize biases (Cull-Wilby & Pepin, 1987; Watson, 1981). The critical paradigm stems from critical theory and is grounded in the premise that reality is affected by multiple individual and environmental factors such as gender, ethnicity, and sociopolitical, cultural, and economic forces (Guba & Lincoln, 1994). The critical paradigms study power, seek to address injustice, and aim for transformative outcomes (Cohen et al., 2007; Scotland, 2012).

Each of these three paradigms has strengths and limitations for nursing care and research. The interpretive paradigm, for example, allows nurses to understand and explore in depth the circumstances that inform nursing strategies to improve patient outcome. However, the lack of objectivity and limited generalizability from various interpretations limit its application (Gortner, 1993; Weaver & Olson, 2006). Often criticized for not considering social contexts and the complex relationship of unobservable values and truths (Gortner, 1993; Horsfall, 1995), the empirical paradigm has contributed to health promotion and disease and injury prevention in nursing practice (Weaver & Olson, 2006). For example, through an empirical inquiry, Treat-Jacobson and Lindquist (2004) identifying the intensity of exercise required for beneficial results following a coronary bypass surgery. Studying nurse’s knowledge and attitude using an empirical perspective, Walusimbi and Okonsky (2004) also provided a baseline data for educational intervention for nurses who care for patients with HIV/AIDS (Weaver & Olson, 2006). The critical paradigm has provided increased awareness of sociopolitical inequalities among marginalized populations and the need for political action to challenge power imbalances and inequities. Critical paradigms are often considered to be biased to the cultural and social status of the investigated group (Campbell & Bunting, 1991; Weaver & Olson, 2006).

According to Weaver and Olson (2006), “we could not justify choosing one paradigm over others when most can inform different aspects vital to nursing practice” (p. 465). Each paradigm has the potential for noncomprehensive and incomplete approach to clinical decision because of its inherent limitations (Cull-Wilby & Pepin, 1987; Monti & Tingen, 1999). Using a theoretical framework that allows all three paradigms to be considered can help nurses provide effective care to patients while understanding and moving toward influencing the broader social, political, and economic factors that affect people’s abilities to gain control over their lives. Recognizing the epistemic tensions that exist when mixing different theoretical paradigms in inquiry (Guba & Lincoln, 1994), Orem’s SCDNT provides a useful framework for this combined approach as a comprehensive approach to nursing practice.

Nursing Application of Orem’s Theory: Linking Theory and Practice

Individuals with schizophrenia have unique requirements for self-care throughout the continuum of illness and therefore require specific self-care measures to protect against poor physical health, increased morbidity, and premature mortality rates (Werner, 2012). The SCDNT recognizes that behaviors within the self-care process are learned (Orem, 2001), and since mental illness creates deviation from normal, exploring the subjective experience of individuals’ needs for enhanced physical health is crucial (Vandyk & Baker, 2012). The interpretive paradigm emphasizes that the social world is constructed inductively based on personal assumptions, which can only be understood from an individual’s standpoint (Guba & Lincoln, 1994). Using the interpretive paradigm within the SCDNT to understanding physical health needs of individuals with schizophrenia allows nurses to comprehend patient’s realities as perceived by individuals themselves, which may be different from what society considers “normal.” This allows exploring any underlying resistance and barriers to self-care that may be based on social or structural barriers in addition to the mental illness and will help implement interventions that are appropriate to the individual and tailored to their specific social, economical, and environmental conditions. Open-ended questions and focus groups can help nurses see individual’s needs and realities through their lens and assist with self-care actions that are pragmatic and realistic and acceptable to the patient (Bonney & Stickley, 2008; Easton, 1993).

Among the few nursing studies that have explored the physical health of patients with schizophrenia, Vandyk and Baker (2012) investigated the effects of medication-induced weight gain through an interpretive lens with qualitative interviews. This study provides insights into patients’ perspectives of weight, informing nurses of some of the personal challenges these individuals have to addressing healthy weight needs. Participants perceived weight reduction as both important and difficult, identifying lack of energy, loneliness, and insufficient money as major barriers to managing a healthy weight. Understanding realities through the interpretive paradigm demonstrates how incorporating patients’ perspectives into everyday nursing practice will help nurses choose appropriate nursing actions to address physical and mental health self-care needs.

The SCDNT outlines the role nurses have as educators and facilitators to assist individuals meet their self-care needs (Orem, 2001). This requires nurses increase people’s awareness and motivation to actively improve health. An empirical paradigm informs nurses of observable patterns and evidence-based approaches to achieve measurable outcomes and is an explicit approach within the SCDNT (Seed & Torkelson, 2012). Through the empirical paradigm, nurses can draw on observable science and implement evidence-based programs that attend to natural laws and mechanisms based on an individual’s self-care need (Seed & Torkelson, 2012). For example, an 8-month intervention delivered by nurses focusing on healthy lifestyle behaviors to address the physical health needs of people with schizophrenia illustrates application of the empirical paradigm (Klam, McLay, & Brabke, 2006). Participants showed significant weight reduction with improved blood pressure, blood sugar, and lipid levels in addition to enhanced social and psychological functioning (Klam et al., 2006). The empirical approach inherent in the SCDNT allows nurses to provide affective nursing-focused interventions that can result in improved self-care and physical health.

To sustain success at enhancing the physical health of individuals with schizophrenia, the dominant sociopolitical, cultural, and economic factors that affect people’s personal resources and self-care practices at both individual and collective levels must be addressed (Guba & Lincoln, 1994; Weaver & Olson, 2006). The ontological position of the critical paradigm can assist nurses identify and provide optimal environmental conditions for individuals to provide healthy self-care, a concept consistent with Orem’s SCDNT. Recognizing the complexity of change, there is a need for targeting factors such as poverty, lack of social support, and fragmented health care services. By approaching self-care needs through a critical paradigm, nurses can advocate and act for individuals to address the broader sociocultural and political issues that affect people with schizophrenia achieving an optimal environment for self-care. Highlighting health care inequities, political action for emancipator change, and advocacy for programs and policies to help people access healthy food and assist with employment, education, physical activity, and healthy socialization are ways in which the critical paradigm helps guide nursing actions to care for individuals with schizophrenia.

Conclusion

By providing a framework that allows the integration of different paradigms, SCDNT encourages nurses to inquiry beyond the boundaries of particular worldviews to provide a holistic and integrated care that addresses physical as well as mental health conditions of individuals with schizophrenia. Applying the SCDNT allows consideration of interpretive, empirical, and critical paradigms in practice so nurses provide care based on individual’s perceptions and empirical evidence while considering the broader sociopolitical context. This will minimize barriers to care, maximize quality of care, and empower people with schizophrenia to achieve a maximum level of independence in improving their physical health and quality of life.