Nursing Theories & Nursing Practice

80 SECTION II • Conceptual Influences on the Evolution of Nursing Theory

Practice Exemplar

Luciana came into nurse practitioner Janice’s her physical examination, taking care to doc-
office for her annual well-woman examina- ument the extent of her swelling and the size,
tion. A 53-year-old mother of three without shape, smoothness, mobility, and location of
insurance, Luciana had delayed her visit for any lumps palpated during the clinical breast
several months due to lack of money. Despite examination.
a nagging feeling that the pain in her breasts
might be serious, Luciana waited until she Once the examination was finished, Janice
could no longer tolerate the pain and the red- excused herself and sought out the office man-
ness and swelling of the breasts that had since ager. She pulled Sophia aside in private and ex-
developed. plained the situation. They contacted their local
representative from the health department in
When Janice explained to Luciana that she charge of a grant that allocated money for
was a nurse practitioner and would be per- diagnostic mammography and arranged for the
forming her examination today and address- patient to obtain the mammography through
ing any concerns she may have. Luciana sat the program. Janice returned to the examina-
silently, looking slightly below Janice’s eyes as tion room with the referral form, prescription
she spoke. She avoided eye contact until asked for the diagnostic imaging, and contact infor-
if something was wrong. Unable to wait for mation for the program representative. The
Janice to complete the history, Luciana lifted patient began to cry softly as she expressed
her shirt and showed the nurse practitioner concern for her three children and wondered
her erythematous, swollen breasts. The most who would take care of them? Janice hugged
significant swelling noted was located in the Luciana as she cried and shared her story of
upper left quadrant, where Janice’s own working as a stay-at-home mom while her
mother-in-law had experienced her most sig- husband worked for low wages. She felt lonely
nificant swelling and lesions from her breast and missed her family who lived abroad. She
cancer 5 years earlier—a cancer she hid from had not shared her breast pain with any one,
her family until it was too late to intervene. wanting to protect her family from worrying
about her. Tears began to fall from Janice’s
“What do you think this means?” Luciana own eyes, as she remembered her mother-
asked. Stunned by her bluntness, Janice took in-law lying in a hospice bed when she finally
a closer look at the swelling and warm, red shared the gaping wounds where her own
skin across Luciana’s chest. Dread filled breast cancer had eaten away at her skin. Dread
quickly inside Janice. “Do you think this is had filled inside Janice then, too, as she knew
cancer?” she asked. Trying to think back to she was powerless to help her. As Janice
what she had been taught to say in her nursing hugged Luciana, a shimmer of hope radiated
education, her mind drew a blank and honesty from somewhere in that examination room as
was the only thought to come to mind. “Yes,” she realized she could actually do something to
Janice replied softly. “I do.” Tears began to fall help Luciana. Even though she did not have a
from Luciana’s calm face, as though she knew background in oncology, Janice knew how to
she had breast cancer all along. Janice gave her connect her with providers that could further
a big hug and whispered softly into her left ear, evaluate and manage her breast cancer. Janice
“It will be alright. I am going to help you.” Lu- showed Luciana the documents that she had
ciana explained that she did not work carried into the examination room and ex-
and did not have either health insurance or plained how she could obtain the mammogram
Medicaid. Janice explained that programs at no charge. Janice described the program
were available to help provide financial assis- being offered through the health department
tance and that she would help her contact a and gave her the name of the woman who
representative from a state-run breast cancer would now help facilitate the care she needed.
program. Janice carefully finished performing

CHAPTER 6 • Nurse–Patient Relationship Theories 81

Practice Exemplar cont. cues and body language led her to the purpose
of Luciana’s visit and to identify Luciana’s
Luciana looked her in the eyes, hopefully em- fear related to the breast cancer. By identi-
powered by the information Janice had given fying barriers to care and existing sources of
her, and said “thank you.” support for the patient (Concept of Decision-
Making), Janice developed a care plan that in-
Several days later, Janice received the radi- volved a referral to the health department for
ologist’s report from Luciana’s diagnostic access to a state grant available to fund Lu-
mammography. The report confirmed that ciana’s mammogram and to a representative
Luciana did indeed have breast cancer. Fortu- with the state Medicaid program for financial
nately, Sophia, the assistant office manager, assistance with breast cancer treatment (Con-
had spoken with Jan at the health department cept of Action, or Nursing Intervention). By
and learned Luciana had received Medicaid caring for her as a person, Luciana was able to
and was now under the care of an oncologist express her story freely and let go of her feel-
with experience in treating breast cancer. Lu- ings of powerlessness and fear that had built
ciana returned to the clinic a couple weeks up inside her since she first noticed her breast
later and expressed her gratitude for their help pain. The barrier between Janice-as-clinician
in getting her the health care she needed. She and Luciana-as-patient blurred as they con-
had started chemotherapy treatment and her nected in that examination room, their stories
mother had come to stay with her to help take intertwining as they came together as woman-
care of her children. to-woman each affected by breast cancer dif-
ferently and yet somehow the same (concept
Travelbee’s concepts are evident in this of appraisal).
exemplar. Janice, the nurse practitioner, col-
lected the preliminary patient history and ex-
amination findings needed to formulate a
diagnosis during the Stage of Observation.
However, Janice’s interpretation of nonspoken

■ Summary concept of therapeutic use of self to effect
change in patient-centered care. Patients are
Travelbee’s conceptualizations of the human- viewed as unique, and nursing care is delivered
to-human relationship guide the nurse–patient over five stages: observation, interpretation,
interaction with an emphasis on helping the decision making, action (or nursing interven-
patient find hope and meaning in the illness tion), and appraisal (or evaluation).
experience. Scientific knowledge and clinical
competence are incorporated into Travelbee’s

References

Cook, L. (1989). Nurses in crisis: A support group based Travelbee, J. (1963). What do we mean by rapport?
on Travelbee’s nursing theory. Nursing and Health American Journal of Nursing, 63(2), 70–72.
Care, 10(4), 203–205.
Travelbee, J. (1964). What’s wrong with sympathy?
Institute of Medicine. (2001). Crossing the quality American Journal of Nursing, 64(1), 68–71.
chasm: A new health system for the 21st Century.
Available at: www.iom.edu/Reports/2001/Crossing- Travelbee, J. (1966). Interpersonal aspects of nursing.
the-Quality-Chasm-A-New-Health-System-for- Philadelphia, PA: F. A. Davis.
the-21st-Century.aspx
Travelbee, J. (1969). Intervention in psychiatric nursing:
Meleis, A. I. (1997). Theoretical nursing: Development & Process in the one-to-one relationship. Philadelphia:
progress (3rd ed.). New York: Lippincott. F.A. Davis.

Tomey, A. M., & Alligood, M. R. (2006). Nursing theo- Travelbee, J. (1971). Interpersonal aspects of nursing
rists and their work (6th ed.). St. Louis, MO: Mosby (2nd ed.). Philadelphia: F. A. Davis.
Elsevier.
Travelbee, J. (1972). Speaking out: To find meaning in
illness. Nursing, 2(12), 6–8.

82 SECTION II • Conceptual Influences on the Evolution of Nursing Theory

Part Three Ida Jean Orlando’s Dynamic Nurse– direct assistance to individuals in whatever set-
ting they are found for the purpose of avoid-
Patient Relationship ing, relieving, diminishing or curing the
individual’s sense of helplessness (Orlando,
MAUDE RITTMAN AND DIANE GULLETT 1972).

Introducing the Theorist The essence of Orlando’s theory, the dy-
namic nurse–patient relationship, reflects her
Ida Jean Orlando was born in 1926 in beliefs that practice should be based on needs
New York. Her nursing education began at of the patient and that communication with
New York Medical College School of Nursing the patient is essential to understanding needs
where she received a diploma in nursing. In and providing effective nursing care. Following
1951, she received a bachelor of science degree is an overview of the major components of
in public health nursing from St. John’s Orlando’s work:
University in Brooklyn, New York, and in
1954, she completed a master’s degree in nurs- 1. The nursing process includes identifying the
ing from Columbia University. Orlando’s early needs of patients, responses of the nurse,
nursing practice experience included obstetrics, and nursing action. The nursing process,
medicine, and emergency room nursing. as envisioned and practiced by Orlando, is
Her first book, The Dynamic Nurse–Patient not the linear model often taught today
Relationship: Function, Process and Principles but is more reflexive and circular and
(1961/1990), was based on her research and occurs during encounters with patients.
blended nursing practice, psychiatric–mental
health nursing, and nursing education. It was 2. Understanding the meaning of patient be-
published when she was director of the gradu- havior is influenced by the nurse’s percep-
ate program in mental health and psychiatric tions, thoughts, and feelings. It may be
nursing at Yale University School of Nursing. validated through communication between
Ida Jean Orlando passed away November 28, the nurse and the patient. Patients experi-
2007. ence distress when they cannot cope with
unmet needs. Nurses use direct and indi-
Orlando’s theoretical work is both practice rect observations of patient behavior to
and research based. She received funding from discover distress and meaning.
the National Institute of Mental Health to
improve education of nurses about interper- 3. Nurse–patient interactions are unique, com-
sonal relationships. As a consultant at McLean plex, and dynamic processes. Nurses help
Hospital in Belmont, Massachusetts, Orlando patients express and understand the mean-
continued to study nursing practice and devel- ing of behavior. The basis for nursing
oped an educational program and nursing serv- action is the distress experienced and
ice department based on her theory. From expressed by the patient.
evaluation of this program, she published her
second book, The Discipline and Teaching of 4. Professional nurses function in an independ-
Nursing Process (Orlando, 1972; Rittman, ent role from physicians and other health-
1991). care providers.

Overview of Orlando’s Theory Practice Applications
of the Dynamic Nurse–Patient
Relationship Orlando’s theoretical work was based on
analysis of thousands of nurse–patient interac-
Nursing is responsive to individuals who suffer tions to describe major attributes of the rela-
or anticipate a sense of helplessness; it is fo- tionship. Based on this work, her later book
cused on the process of care in an immediate provided direction for understanding and
experience; it is concerned with providing using the nursing process (Orlando, 1972).
This has been known as the first theory of
nursing process and has been widely used in

CHAPTER 6 • Nurse–Patient Relationship Theories 83

nursing education and practice in the United theoretical framework was used to describe the
States and across the globe. Orlando consid- communication among the nursing students,
ered her overall work to be a theoretical frame- homecare nurses, and city residents (Aponte,
work for the practice of professional nursing, 2009, p. 326). Dufault et al. (2010) developed
emphasizing the essentiality of the nurse– a cost-effective, easy-to-use, best practice
patient relationship. Orlando’s theoretical protocol for nurse-to-nurse shift handoffs at
work reveals and bears witness to the essence Newport Hospital, using specific components
of nursing as a practice discipline. of Orlando’s theory of deliberative nursing
process. Abraham (2011) proposed addressing
Orlando’s work has been used as a founda- fall risk in hospitals using Orlando’s concep-
tion for master’s theses (Grove, 2008; Hendren, tualizations. The author asserts that three
2012). Reinforcing Orlando’s theory as a prac- elements (patient’s behavior, nurse’s reaction,
tice and conceptual framework continues to be and anything the nurse does to alleviate the
relevant and applicable to nursing situations in distress) can effectively act as a roadmap for
today’s healthcare environment. decreasing fall risk.

Laurent (2000) proposed a dynamic leader– The New Hampshire Hospital, a university-
follower relationship model using Orlando’s affiliated psychiatric facility, adopted Orlando’s
dynamic nurse–patient relationship. The dy- framework for nursing practice (Potter, Vitale-
namic leader-follower relationship model re- Nolen, & Dawson, 2005; Potter, Williams, &
focuses the nature of “control” through shared Constanzo, 2004). Two nursing interventions
responsibility and meaning making, thereby stemmed directly from the adoption of Or-
granting the employee or patient the ability lando’s ideas. Potter, Williams, and Constanzo
to actively engage in resolving the issue or (2004) developed a structured group curriculum
problem at hand. The emphasis is on recog- for nurse-led psychoeducational groups in an
nizing in both patient care and management inpatient setting. Both nurses and patients
that the person who knows most about the demonstrated improved comfort, active involve-
situation is the person himself or herself. To ment and learning from combining Orlando’s
be truly effective in resolving a problem or dynamic nurse–patient relationship and a psy-
situation involves engaging in a dynamic re- choeducational curriculum with training in
lationship of shared responsibility and active group leadership.
participation on the part of both parties
(i.e., nurse–patient/nurse manager–employee) Potter, Vitale-Nolen, and Dawson (2005)
without which the true nature of the issue at conducted a quasi-experimental study to
hand may go unresolved. Laurant (2000) sug- determine the effectiveness of implementing
gested that engaging in a dynamic relation- a safety agreement tool among patients who
ship with the other provides a means by threaten self-harm. Orlando’s concepts were
which management of care and/or employees used to guide the creation of the safety agree-
becomes a process of providing direction ment. Results demonstrated that RNs per-
rather than control, thereby generating nurs- ceived the safety agreements as promoting
ing leaders in roles of authority rather than a more positive and effective nurse–patient
just nurse managers of care. relationship related to the risk of self-harm
and believed the safety agreements increased
Aponte (2009) employed Orlando’s their comfort in helping patients at risk for
Dynamic Nurse–Patient Relationship as a self-harm. The nurses were divided, however,
conceptual framework for the Influenza Initia- about whether the safety agreements en-
tive in New York City to address the linguistic hanced their relationships with patients, and
disparities within communities. A needs survey the majority did not feel the safety agreements
identified unmet linguistic needs and gaps ex- decreased self-harming incidents. The rate of
isting within the city; nursing students, many self-harm incidents was not statistically sig-
of whom were bilingual, served as translators nificant but the authors report the findings as
for non-English speaking Spanish, Chinese, clinically significant citing no increase in
Russian, and Ukraine residents. Orlando’s

84 SECTION II • Conceptual Influences on the Evolution of Nursing Theory

self-harming rates despite higher acuity levels nursing process. The authors used cognitive in-
and shorter hospital stays during post imple- terviews with a convenience sample of five ex-
mentation stages. perienced nurses to gain insight into the process
of nurse communication with patients and the
Sheldon and Ellington (2008) conducted a strategies nurses use when responding to patient
pilot study to expand Orlando’s process into se- concerns.
quential steps that further define the deliberative

Practice Exemplar

Krystal, a 23-year-old woman with a history hypotheses about the patient. The nurse may
of asthma, presents to the emergency depart- hypothesize that Krystal needs financial assis-
ment with her boyfriend. She states, “I just tance in obtaining her medications and addi-
can’t seem to catch my breath, I just can’t seem tional education about asthma and the role of
to relax”; appearing extremely agitated. Avoid- medications in managing the disease. A nurse
ing eye contact, Krystal fearfully explains to not using Orlando’s theory might administer
the nurse that she has not been able to obtain the necessary asthma medications; provide
any of her regular medications for approxi- asthma education and resources for obtaining
mately 4 months. The nurse obtains vital signs free or low cost medications. A nurse using
including a blood pressure of 113/68; pulse of Orlando’s theoretical framework, however,
98; respiratory rate of 22; an oral temperature understands that no nursing action should be
of 37.0 degrees Celsius; and an oxygen satu- taken without first validating each hypothesis
ration of 95% on room air. Assessment reveals with the patient as a means of determining the
no increased work of breathing with slight, bi- patient’s immediate needs. The nurse in this
lateral, expiratory wheezing. The nurse, em- situation validates with the patient the source
ploying standing orders, places the patient on of her anxiety and inability to catch her breath.
2L of oxygen per nasal cannula and initiates a In doing so, the nurse learns that the patient’s
respiratory treatment. concern now is not with her wheezing or ob-
taining her asthma medication but rather with
Seeking privacy with the patient, the nurse her boyfriend.
kindly asks the boyfriend to wait in the patient
lounge. He becomes argumentative and reluc- The nurse hypothesizes that Krystal is a vic-
tant to leave, the nurse calmly states that she tim of intimate partner violence. Again, the
simply needs to complete her assessment with nurse seeks to validate this with the patient,
the patient and again asks again for him to asking Krystal if her boyfriend is physically or
wait in the lounge; this time he complies. Fur- emotionally harming her. Krystal continues to
ther investigation by the nurse reveals that look fearfully at the door and states, “He is
Krystal normally uses albuterol and Advair to going to kill me if I tell you anything.” The
control her asthma, but she has been unable to nurse assures Krystal that she is in a safe place
obtain her medications over the past 4 months right now, that she is not alone and that there
because of “personal problems.” are safety measures that can be taken to re-
move the boyfriend from the premises if that
In this example, the nurse formulates an would make Krystal feel safer. Krystal requests
immediate hypothesis based on direct and in- the nurse to do this and begins crying, telling
direct observations and attempts to validate the nurse she had a fight with her boyfriend
this hypothesis by collecting additional data today and he hit her. “He always makes sure
(questioning the patient about her normal to hit me where people can’t see, and he is al-
medications, observing the boyfriend’s reluc- ways sorry.” The nurse asks if Krystal is injured
tance to leave the room, assessing the patient’s in any way right now. Krystal pulls up her shirt
agitated state and refusal to make eye contact, to reveal extensive bruising at various stages of
and obtaining vital signs). From the patient healing to her torso and what looks like several
data, the nurse formulates several additional

CHAPTER 6 • Nurse–Patient Relationship Theories 85

Practice Exemplar cont. charted (documentation follows the guidelines
needed to be admissible in a court of law if
fresh cigarette burns to both her breasts. The necessary). The nurse also provides Krystal
nurse asks Krystal if it would be okay to per- with the number for the National Resource
form some additional assessmentsto ensure no Center on Domestic Violence, and with two
further internal injury has occurred. Krystal websites one for Violence Against Women
nods her head yes, and the nurse asks if this Network (www.vawnet.org) and the Florida
has happened before. Krystal tells the nurse Coalition Against Domestic Violence
that these days it happens almost daily but that (www.fcadv.org). The nurse calls the shelter a
she deserves it because she doesn’t have a job few days later to check that Krystal is safe and
and he is the only one who loves her. “I want learns that Krystal will be remaining at the
to leave. I really do, but I am afraid he will kill shelter and has not had any further correspon-
me, and I don’t have anywhere else to go.” The dence with her boyfriend.
nurse acknowledges Krystal’s distress, clarify-
ing that Krystal does not deserve this type of Through mutual engagement, the patient
treatment and that she fears for her safety, and nurse were able to create a dynamic envi-
emphasizing abuse is a crime and only worsens ronment that fostered effective communica-
over time. tion and the ability to address the immediate
needs of the patient. Providing asthma educa-
At this point, the nurse discusses how the tion and financial resources would not have
patient wishes to address this concern ensuring addressed Krystal’s need for physical safety re-
there is a dynamic interaction occurring be- lated to domestic abuse because the plan
tween the patient and the nurse. Offering the would have been based on an invalid hypoth-
patient the resources and opportunity to ex- esis. The nurse in this situation used her
press and understand the meaning of her own perception and knowledge of the nursing
behavior inspires Krystal to find meaning in situation to explore the meaning of Krystal’s
the experience and ownership in the choices behavior. Through communication and vali-
needed to address these concerns. Using her dation with the patient of the nurses’ hypothe-
nursing knowledge of domestic abuse, the ses, perceptions and supporting data, the nurse
nurse engages Krystal in a conversation about was able to elicit the nature of the patient’s
the cycle of violence and empowers Krystal by problem and mutually engage the patient in
providing her with choices and resources to identifying what help was needed. After mutual
address her current situation. After the nurse– decision making, the nurse took deliberative
patient interaction, Krystal decides to go to a nursing actions to meet Krystal’s immediate
local domestic abuse shelter for women (the needs including initiating safety protocols, pro-
nurse makes arrangements by calling the shel- viding resources, gathering additional data, and
ter and providing transportation), to file a po- creating a supportive and encouraging environ-
lice report (the nurse arranges for an officer to ment for the patient.
come to the hospital), and allow for photos
and documentation of her injuries to be

■ Summary

The most important contribution of Orlando’s states what nursing is or should be today.
theoretical work is the primacy of the nurse– Regardless of the changes in the health-care
client relationship. Inherent in this theory is a system, the human transaction between the
strong statement: What transpires between the nurse and the patient in any setting holds the
patient and the nurse is of the highest value. greatest value —not only for nursing, but also
The true worth of her ideas is that it clearly for society at large. Orlando’s writings can

86 SECTION II • Conceptual Influences on the Evolution of Nursing Theory

serve as a philosophy as well as a theory, health care today? The answer to that question
because it is the foundation on which our pro- may lead to reconsideration of the value of
fession has been built. With all of the benefits Orlando’s theory as perhaps the critical link for
that modern technology and modern health enhancing relationships between nursing and
care bring—and there are many—we need to patient today (Rittman, 1991).
pause and ask the question, What is at risk in

References

Abraham, S. (2011). Fall prevention conceptual frame- Orlando, I. J. (1972). The discipline and teaching of nurs-
work. The Health Care Manager, 30(2), 179–184. doi: ing process: An evaluative study. New York: G. P.
10.1097/HCM.0b013e31826fb74 Putnam’s Sons.

Aponte, J. (2009). Meeting the linguistic needs of urban Potter, M. L., Vitale-Nolen, R., & Dawson, A. M.
communities. Home Health Nurse, 27(5), 324–329. (2005). Implementation of safety agreements in an
acute psychiatric facility. Journal of the American
Dufault, M., Duquette, C. E., Ehmann, J., Hehl, R., Psychiatric Nurses Association, 11(3), 144–155. doi:
Lavin, M., Martin, V., Moore, M. A., Sargent, S., 10.1177/1078390305277443
Stout, P., Willey, C. (2010). Translating an evi-
dence-based protocol for nurse-to-nurse shift hand- Potter, M. L., Williams, R. B. & Costanzo, R. (2004).
offs. Worldviews on Evidence-Based Nursing, 7(2), Using nursing theory and structured psychoeduca-
59–75. tional curriculum with inpatient groups. Journal of
the American Psychiatric Nurses Association, 10(3),
Grove, C. (2008). Staff intervention to improve patient 122–128. doi: 10.1177/1078390304265212
satisfaction (master’s thesis). Retrieved from Pro-
Quest Dissertations and Theses database. (UMI Rittman, M. R. (1991). Ida Jean Orlando (Pelletier)—
1454183) the dynamic nurse–patient relationship. In: M.
Parker (Ed.), Nursing theories and nursing practice
Hendren, D. W. (2012). Emergency departments and (pp. 125–130). Philadelphia: F. A. Davis.
STEMI care, are the guidelines being followed? (mas-
ter’s thesis). Retrieved from ProQuest Dissertations Sheldon, L. K., & Ellington, L. (2008). Application
and Theses database. (UMI 1520156) of a model of social information processing to nurs-
ing theory: How nurses respond to patients. Journal
Laurent, C. L. (2000). A nursing theory of nursing lead- of Advanced Nursing 64(4), 388–398. doi:
ership. Journal of Nursing Management, 8, 83–87. 10.111/j.1365-2648.2008.04795.x

Orlando, I. J. (1990). The dynamic nurse–patient relation-
ship: Function, process and principles. New York: Na-
tional League for Nursing New York: G. P.
Putnam’s Sons. (Original work published 1961)

IIISection

Conceptual Models/Grand
Theories in the Integrative-

Interactive Paradigm

87

Section

III

Section III includes seven chapters on the conceptual models or grand theories
situated in the integrative-interactive nursing paradigm. These chapters are
written by either the theorist or an author designated as an authority on the
theory by the theorist or the community of scholars advancing that theory. The-
ories in the integrative-interactive paradigm view persons1 as integrated
wholes or integrated systems interacting with the larger environmental system.
The integrated dimensions of the person are influenced by environmental fac-
tors leading to some change that impacts health or well-being. The subjectivity
of the person and the multidimensional nature of any outcome are considered.
Most of the theories are based explicitly on a systems perspective.

In Chapter 7, Johnson’s behavioral systems model is described. It includes
principles of wholeness and order, stabilization, reorganization, hierarchic in-
teraction, and dialectic contradiction. The person is viewed as a compilation
of subsystems. According to Johnson, the goal of nursing is to restore, maintain,
or attain behavioral system balance and stability at the highest possible level.

Chapter 8 features Orem’s self-care deficit nursing theory, a conceptual model
with four interrelated theories associated with it: theory of nursing systems, theory of
self-care deficit, and the theory of self-care and theory of dependent care. According
to Orem, when requirements for self-care exceed capacity for self-care, self-care
deficits occur. Nursing systems are designed to address these self-care deficits.

King’s theory of goal attainment presented in Chapter 9 offers a view that the
goal of nursing is to help persons maintain health or regain health. This is accom-
plished through a transaction,setting a mutually agreed-upon goal with the patient.

In Chapter 10, Pamela Senesac and Sr. Callista Roy describe the Roy adap-
tation model and its applications. In this model, the person is viewed as a holistic
adaptive system with coping processes to maintain adaptation and promote
person–environment transformations. The adaptive system can be integrated,
compensatory, or compromised depending on the level of adaptation. Nurses
promote coping and adaptation within health and illness.

Lois White Lowry and Patricia Deal Aylward authored Chapter 12 on Neuman’s
systems model. The model includes the client–client system with a basic structure
protected from stressors by lines of defense and resistance. The concern of nursing
is to keep the client stable by assessing the actual or potential effects of stressors
and assisting client adjustments for optimal wellness.

In Chapter 13, Erickson, Tomlin, and Swain’s modeling and role modeling
theory is presented by Helen Erickson. Modeling and role modeling theory pro-
vides a guide for the practice or process of nursing. The theory integrates a holistic
philosophy with concepts from a variety of theoretical perspectives such as adap-
tation, need status, and developmental task resolution.

The final chapter in this section is Dossey’s theory of integral nursing, a relatively
new grand theory that posits an integral worldview and body–mind–spirit connect-
edness. The theory is informed by a variety of ideas including Nightingale’s tenets,
holism, multidimensionality, spiral dynamics, chaos theory, and complexity. It includes
the major concepts of healing, the metaparadigm of nursing, patterns of knowing,
and Wilber’s integral theory and Wilber’s all quadrants, all levels, all lines.

1 Person refers to individuals, families, groups or communities.

88

Dorothy Johnson’s Behavioral 7Chapter
System Model and Its
Applications

BONNIE HOLADAY

Introducing the Theorist Introducing the Theorist
Overview of Johnson’s Behavioral
Dorothy Johnson’s earliest publications per-
System Model tained to the knowledge base nurses needed for
Applications of the Model nursing care (Johnson, 1959, 1961). Through-
Practice Exemplar by Kelly White out her career, Johnson (1919–1999) stressed
that nursing had a unique, independent con-
Summary tribution to health care that was distinct from
References “delegated medical care.” Johnson was one of
the first “grand theorists” to present her views
Dorothy Johnson as a conceptual model. Her model was the first
to provide a guide to both understanding and
action. These two ideas—understanding seen
first as a holistic, behavioral system process me-
diated by a complex framework and second as
an active process of encounter and response—
are central to the work of other theorists who
followed her lead and developed conceptual
models for nursing practice.

Dorothy Johnson received her associate of
arts degree from Armstrong Junior College in
Savannah, Georgia, in 1938 and her bachelor
of science in nursing degree from Vanderbilt
University in 1942. She practiced briefly as a
staff nurse at the Chatham-Savannah Health
Council before attending Harvard University,
where she received her master of public health
in 1948. She began her academic career at
Vanderbilt University School of Nursing. A
call from Lulu Hassenplug, Dean of the
School of Nursing, enticed her to the Univer-
sity of California at Los Angeles in 1949. She
served there as an assistant, associate, and pro-
fessor of pediatric nursing until her retirement
in 1978. Johnson is recognized as one of the
founders of modern systems-based nursing
theory (Glennister, 2011; Meleis, 2011).

89

90 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

During her academic career, Dorothy Johnson Five Core Principles
addressed issues related to nursing practice, ed-
ucation, and science. While she was a pediatric Johnson’s model incorporates five core principles
nursing advisor at the Christian Medical College of system thinking: wholeness and order, stabi-
School of Nursing in Vellare, South India, she lization, reorganization, hierarchic interaction,
wrote a series of clinical articles for the Nursing and dialectical contradiction. Each of these gen-
Journal of India (Johnson, 1956, 1957). She eral systems principles has analogs in develop-
worked with the California Nurses’ Association, mental theories that Johnson used to verify the
the National League for Nursing, and the validity of her model (Johnson, 1980, 1990).
American Nurses’ Association to examine the Wholeness and order provide the basis for con-
role of the clinical nurse specialist, the scope of tinuity and identity, stabilization for develop-
nursing practice, and the need for nursing re- ment, reorganization for growth and/or change,
search. She also completed a Public Health hierarchic interaction for discontinuity, and di-
Service–funded research project (“Crying as a alectical contradiction for motivation. Johnson
Physiologic State in the Newborn Infant”) in conceptualized a person as an open system with
1963 (Johnson & Smith, 1963). The founda- organized, interrelated, and interdependent sub-
tions of her model and her beliefs about nursing systems. By virtue of subsystem interaction and
are clearly evident in these early publications. independence, the whole of the human organism
(system) is greater than the sum of its parts (sub-
Overview of Johnson’s systems). Wholes and their parts create a system
Behavioral System Model with dual constraints: Neither has continuity and
identity without the other.
Johnson noted that her theory, the Johnson be-
havioral system model (JBSM), evolved from The overall representation of the model can
philosophical ideas, theory, and research; her also be viewed as a behavioral system within an
clinical background; and many years of thought, environment. The behavioral system and the
discussions, and writing (Johnson, 1968). She environment are linked by interactions and
cited a number of sources for her theory. From transactions. We define the person (behavioral
Florence Nightingale came the belief that nurs- system) as comprising subsystems and the en-
ing’s concern is a focus on the person rather than vironment as comprising physical, interpersonal
the disease. Systems theorists (Buckley, 1968; (e.g., father, friend, mother, sibling), and soci-
Chin, 1961; Parsons & Shils, 1951; Rapoport, ocultural (e.g., rules and mores of home, school,
1968; Von Bertalanffy, 1968) were all sources for country, and other cultural contexts) compo-
her model. Johnson’s background as a pediatric nents that supply the sustenal imperatives
nurse is also evident in the development of her (Grubbs, 1980; Holaday, 1997; Johnson, 1990;
model. In her papers, Johnson cited developmen- Meleis, 2011). Sustenal imperatives are the nec-
tal literature to support the validity of a behavioral essary prerequisites for the optimal functioning
system model (Ainsworth, 1964; Crandal, 1963; of the behavioral system. The environment must
Gerwitz, 1972; Kagan, 1964; Sears, Maccoby, & supply the sustenal imperatives of protection,
Levin, 1954). Johnson also noted that a number nurturance, and stimulation to all subsystems to
of her subsystems had biological underpinnings. allow them to develop and to maintain stability.
Some examples of conditions that protect, stim-
Johnson’s theory and her related writings ulate, and nurture related to achievement would
reflect her knowledge about both development include encouragement from parents and peers;
and general systems theories. The combination enriched, stimulating environments, awards
of nursing, development, and general systems and recognition; and increased autonomy and
introduces some of the specifics into the rhet- responsibility.
oric about nursing theory development that
make it possible to test hypotheses and con- Wholeness and Order
duct critical experiments.
The developmental analogy of wholeness and
order is continuity and identity. Given the

CHAPTER 7 • Dorothy Johnson’s Behavioral System Model and Its Applications 91

behavioral system’s potential for plasticity, a than a set point. A toddler placed in a body
basic feature of the system is that both conti- cast may show motor lags when the cast is re-
nuity and change can exist across the life span. moved but soon show age-appropriate motor
The presence of or potentiality for at least some skills. An adult newly diagnosed with asthma
plasticity means that the key way of casting the who does not receive proper education until a
issue of continuity is not a matter of deciding year after diagnosis can successfully incorpo-
what exists for a given process or function of a rate the material into her daily activities. These
subsystem. Instead, the issue should be cast in are examples of homeorhetic processes or self-
terms of determining patterns of interactions righting tendencies that can occur over time.
among levels of the behavioral system that may
promote continuity for a particular subsystem What nurses observe as development or
at a given point in time. Johnson’s work im- adaptation of the behavioral system is a product
plies that continuity is in the relationship of of stabilization. When a person is ill or threat-
the parts rather than in their individuality. ened with illness, he or she is subject to biopsy-
Johnson (1990) noted that at the psychological chosocial perturbations. The nurse, according
level, attachment (affiliation) and dependency to Johnson (1980, 1990), acts as the external
are examples of important specific behaviors regulator and monitors patient response, look-
that change over time, although the represen- ing for successful adaptation to occur. If behav-
tation (meaning) may remain the same. Johnson ioral system balance returns, there is no need
stated: “[D]evelopmentally, dependence be- for intervention. If not, the nurse intervenes to
havior in the socially optimum case evolves help the patient restore behavioral system bal-
from almost total dependence on others to a ance. It is hoped that the patient matures and
greater degree of dependence on self, with a with additional hospitalizations, the previous
certain amount of interdependence essential to patterns of response have been assimilated, and
the survival of social groups” (1990, p. 28). In there are few disturbances.
terms of behavioral system balance, this pat-
tern of dependence to independence may be Reorganization
repeated as the behavioral system engages in
new situations during the course of a lifetime. Adaptive reorganization occurs when the behav-
ioral system encounters new experiences in the
Stabilization environment that cannot be balanced by existing
system mechanisms. Adaptation is defined as
Stabilization or behavioral system balance is change that permits the behavioral system to
another core principle of the JBSM. Dynamic maintain its set points best in new situations. To
systems respond to contextual changes by ei- the extent that the behavioral system cannot as-
ther a homeostatic or homeorhetic process. similate the new conditions with existing regu-
Systems have a set point (like a thermostat) latory mechanisms, accommodation must occur
that they try to maintain by altering internal either as a new relationship between subsystems
conditions to compensate for changes in exter- or by the establishment of a higher order or dif-
nal conditions. Human thermoregulation is an ferent cognitive schema (set, choice). The nurse
example of a homeostatic process that is pri- acts to provide conditions or resources essential
marily biological but is also behavioral (turning to help the accommodation process, may impose
on the heater). The use of attribution of ability regulatory or control mechanisms to stimulate
or effort is a behavioral homeostatic process we or reinforce certain behaviors, or may attempt to
use to interpret activities so that they are con- repair structural components (Johnson, 1980). If
sistent with our mental organization. the focus is on a structural part of the subsystem,
then the nurse will focus on the goal, set, choice,
From a behavioral system perspective, or action of a specific subsystem. The nurse
homeorrhesis is a more important stabilizing might provide an educational intervention to
process than is homeostasis. In homeorrhesis, alter the client’s set and broaden the range of
the system stabilizes around a trajectory rather choices available.

92 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

The difference between stabilization and re- physical setting. The person needs to resolve
organization is that the latter involves change (maintain behavioral system balance of) a cas-
or evolution. A behavioral system is embedded cade of contradictions between goals related to
in an environment, but it is capable of oper- physical status, social roles, and cognitive status
ating independently of environmental con- when faced with illness or the threat of illness.
straints through the process of adaptation. The Nurses’ interventions during these periods can
diagnosis of a chronic illness, the birth of a make a significant difference in the lives of the
child, or the development of a healthy lifestyle persons involved because the nurse can help
regimen to prevent problems in later years are clients compare opposing propositions and
all examples in which accommodation not only make decisions. Dealing with these contradic-
promotes behavioral system balance but also tions can be viewed as the “driving force” of de-
involves a developmental process that results velopment as resolution brings about a higher
in the establishment of a higher order or more level of understanding of the issue at hand. This
complex behavioral system. may also alter the persons set, choice and ac-
tion. Behavioral system balance is restored and
Hierarchic Interaction a new level of development is attained.

Each behavioral system exists in a context of Johnson’s model is unique in part because it
hierarchical relationships and environmental takes from both general systems and develop-
relationships. From the perspective of general mental theories. One may analyze the patient’s
systems theory, a behavioral system that has response in terms of behavioral system balance
the properties of wholeness and order, stabi- and, from a developmental perspective, ask,
lization, and reorganization will also demon- “Where did this come from, and where is it
strate a hierarchic structure (Buckley, 1968). going?” The developmental component neces-
Hierarchies, or a pattern of relying on particular sitates that we identify and understand the
subsystems, lead to a degree of stability. A dis- processes of stabilization and sources of distur-
ruption or failure will not destroy the whole bances that lead to reorganization. These need
system but instead will lead to decomposition to be evaluated by age, gender, and culture. The
to the next level of stability. combination of systems theory and develop-
ment identifies “nursing’s unique social mission
The judgment that a discontinuity has oc- and our special realm of original responsibility
curred is typically based on a lack of correlation in patient care” (Johnson, 1990, p. 32).
between assessments at two points of time. For
example, one’s lifestyle before surgery is not a Major Concepts of the Model
good fit postoperatively. These discontinuities
can provide opportunities for reorganization Next, we review the model as a behavioral sys-
and development. tem within an environment.

Dialectical Contradiction Person

The last core principle is the motivational force Johnson conceptualized a nursing client as a
for behavioral change. Johnson (1980) de- behavioral system. The behavioral system is or-
scribed these as drives and noted that these re- derly, repetitive, and organized with interre-
sponses are developed and modified over time lated and interdependent biological and
through maturation, experience, and learning. behavioral subsystems. The client is seen as a
A person’s activities in the environment lead to collection of behavioral subsystems that inter-
knowledge and development. However, by act- relate to form the behavioral system. The sys-
ing on the world, each person is constantly tem may be defined as “those complex, overt
changing it and his or her goals, and therefore actions or responses to a variety of stimuli pres-
changing what he or she needs to know. The ent in the surrounding environment that are
number of environmental domains that the purposeful and functional” (Auger, 1976, p. 22).
person is responding to includes the biological, These ways of behaving form an organized
psychological, cultural, familial, social, and and integrated functional unit that determines

CHAPTER 7 • Dorothy Johnson’s Behavioral System Model and Its Applications 93

Table 7 • 1 The Subsystems of Behavior

Achievement Subsystem

Goal Mastery or control of self or the environment
Function To set appropriate goals
To direct behaviors toward achieving a desired goal
To perceive recognition from others
To differentiate between immediate goals and long-term goals
To interpret feedback (input received) to evaluate the achievement of goals

Affiliative Subsystem

Goal To relate or belong to someone or something other than oneself; to
Function achieve intimacy and inclusion
To form cooperative and interdependent role relationships within human
social systems
To develop and use interpersonal skills to achieve intimacy and inclusion
To share
To be related to another in a definite way
To use narcissistic feelings in an appropriate way

Aggressive/Protective Subsystem

Goal To protect self or others from real or imagined threatening objects, per-
Function sons, or ideas; to achieve self-protection and self-assertion
To recognize biological, environmental, or health systems that are po-
tential threats to self or others
To mobilize resources to respond to challenges identified as threats
To use resources or feedback mechanisms to alter biological, environ-
mental, or health input or human responses in order to diminish threats
to self or others
To protect one’s achievement goals
To protect one’s beliefs
To protect one’s identity or self-concept

Dependency Subsystem

Goal To obtain focused attention, approval, nurturance, and physical assis-
Function tance; to maintain the environmental resources needed for assistance; to
gain trust and reliance
To obtain approval, reassurance about self
To make others aware of self
To induce others to care for physical needs
To evolve from a state of total dependence on others to a state of in-
creased dependence on the self
To recognize and accept situations requiring reversal of self-dependence
(dependence on others)
To focus on another or oneself in relation to social, psychological, and
cultural needs and desires

Eliminative Subsystem

Goal To expel biological wastes; to externalize the internal biological
Function environment
To recognize and interpret input from the biological system that signals
readiness for waste excretion
To maintain physiological homeostasis through excretion
To adjust to alterations in biological capabilities related to waste excre-
tion while maintaining a sense of control over waste excretion
To relieve feelings of tension in the self
To express one’s feelings, emotions, and ideas verbally or nonverbally

Continued

94 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Table 7 • 1 The Subsystems of Behavior—cont’d

Ingestive Subsystem

Goal To take in needed resources from the environment to maintain the in-
Function tegrity of the organism or to achieve a state of pleasure; to internalize
the external environment
To sustain life through nutritive intake
To alter ineffective patterns of nutritive intake
To relieve pain or other psychophysiological subsystems
To obtain knowledge or information useful to the self
To obtain physical and/or emotional pleasure from intake of nutritive or
nonnutritive substances

Restorative Subsystem

Goal To relieve fatigue and/or achieve a state of equilibrium by reestablish-
Function ing or replenishing the energy distribution among the other subsystems;
to redistribute energy
To maintain and/or return to physiological homeostasis
To produce relaxation of the self system

Sexual Subsystem

Goal To procreate, to gratify or attract; to fulfill expectations associated with
Function one’s gender; to care for others and to be cared about by them
To develop a self-concept or self-identity based on gender
To project an image of oneself as a sexual being
To recognize and interpret biological system input related to sexual grat-
ification and/or procreation
To establish meaningful relationships in which sexual gratification
and/or procreation may be obtained

Sources: Based on J. Grubbs (1980). An interpretation of the Johnson behavioral system model. In J. P. Riehl & C. Roy
(Eds.), Conceptual models for nursing practice (2nd ed., pp. 217–254). New York: Appleton-Century-Crofts; D. E. Johnson
(1980). The behavioral system model for nursing. In J. P. Riehl & C. Roy (Eds.), Conceptual models for nursing practice
(2nd ed., pp. 207–216). New York: Appleton-Century-Crofts; D. Wilkie (1987). Operationalization of the JBSM. Unpub-
lished paper, University of California, San Francisco; and B. Holaday (1972). Operationalization of the JBSM. Unpub-
lished paper, University of California, Los Angeles.

and limits the interaction between the person Johnson identified seven subsystems. How-
and environment and establishes the relation- ever, in this author’s operationalization of the
ship of the person to the objects, events, and model, as in Grubbs (1980), I have included
situations in the environment. Johnson (1980, eight subsystems. These eight subsystems and their
p. 209) considered such “behavior to be or- goals and functions are described in Table 7-1.
derly, purposeful and predictable; that is, it is Johnson noted that these subsystems are found
functionally efficient and effective most of the cross-culturally and across a broad range of the
time, and is sufficiently stable and recurrent to phylogenetic scale. She also noted the signifi-
be amenable to description and exploration.” cance of social and cultural factors involved in
the development of the subsystems. She did
Subsystems not consider the seven subsystems as complete,
because “the ultimate group of response systems
The parts of the behavioral system are called to be identified in the behavioral system will
subsystems. They carry out specialized tasks or undoubtedly change as research reveals new
functions needed to maintain the integrity of subsystems or indicated changes in the struc-
the whole behavioral system and manage its re- ture, functions, or behavioral groupings in the
lationship to the environment. Each of these original set” (Johnson, 1980, p. 214).
subsystems has a set of behavioral responses that
is developed and modified through motivation, Each subsystem has functions that serve to
experience, and learning. meet the conceptual goal. Functional behaviors

CHAPTER 7 • Dorothy Johnson’s Behavioral System Model and Its Applications 95

are the activities carried out to meet these behaviors in a situation that will best meet the
goals. These behaviors may vary with each in- goal and attain the desired outcome. The larger
dividual, depending on the person’s age, sex, the behavioral repertoire of alternative behav-
motives, cultural values, social norms, and iors in a situation, the more adaptable is the
self-concepts. For the subsystem goals to be individual. The fourth structural component of
accomplished, behavioral system structural each subsystem is the observable action of the
components must meet functional require- individual. The concern is with the efficiency
ments of the behavioral system. and effectiveness of the behavior in goal attain-
ment. Actions are any observable responses
Each subsystem is composed of at least four to stimuli.
structural components that interact in a spe-
cific pattern: goal, set, choice, and action. The For the eight subsystems to develop and
goal of a subsystem is defined as the desired maintain stability, each must have a constant
result or consequence of the behavior. The supply of functional requirements (sustenal
basis for the goal is a universal drive that can imperatives). The concept of functional re-
be shown to exist through scientific research. quirements tends to be confined to conditions
In general, the drive of each subsystem is the of the system’s survival, and it includes biolog-
same for all people, but there are variations ical as well as psychosocial needs. The prob-
among individuals (and within individuals over lems are related to establishing the types of
time) in the specific objects or events that are functional requirements (universal vs. highly
drive-fulfilling, in the value placed on goal at- specific) and finding procedures for validating
tainment, and in drive strength. With drives the assumptions of these requirements. It also
as the impetus for the behavior, goals can be suggests a classification of the various states or
identified and are considered universal. processes on the basis of some principle and
perhaps the establishment of a hierarchy
The behavioral set is a predisposition to act among them. The Johnson model proposes
in a certain way in a given situation. The be- that for the behavior to be maintained, it must
havioral set represents a relatively stable and be protected, nurtured, and stimulated: It re-
habitual behavioral pattern of responses to par- quires protection from noxious stimuli that
ticular drives or stimuli. It is learned behavior threaten the survival of the behavioral system;
and is influenced by knowledge, attitudes, and nurturance, which provides adequate input to
beliefs. The set contains two components: per- sustain behavior; and stimulation, which con-
severation and preparation. The perseveratory tributes to continued growth of the behavior
set refers to a consistent tendency to react to and counteracts stagnation. A deficiency in any
certain stimuli with the same pattern of behav- or all of these functional requirements threat-
ior. The preparatory set is contingent on the ens the behavioral system as a whole, or the ef-
function of the perseveratory set. The prepara- fective functioning of the particular subsystem
tory set functions to establish priorities for with which it is directly involved.
attending or not attending to various stimuli.
Environment
The conceptual set is an additional com-
ponent to the model (Holaday, 1982). It is a In systems theory, the term environment is de-
process of ordering that serves as the mediat- fined as the set of all objects for which a change
ing link between stimuli from the preparatory in attributes will affect the system as well as
and perseveratory sets. Here attitudes, beliefs, those objects whose attributes are changed by
information, and knowledge are examined the behavior of the system (von Bertalanffy,
before a choice is made. There are three levels 1968). Johnson referred to the internal and
of processing—an inadequate conceptual set, external environment of the system. She also
a developing conceptual set, and a sophisti- referred to the interaction between the person
cated conceptual set. and the environment and to the objects, events,
and situations in the environment. She further
The third and fourth components of each noted that there are forces in the environment
subsystem are choice and action. Choice refers
to the individual’s repertoire of alternative

96 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

that impinge on the person and to which the system balance and stability. Behavioral system
person adjusts. Thus, the JBSM environment balance and stability are demonstrated by ob-
consists of all elements that are not a part of the served behavior that is purposeful, orderly, and
individual’s behavioral system but that influ- predictable. Such behavior is maintained when
ence the system and can also serve as a source it is efficient and effective in managing the
of sustenal imperatives. Some of these elements person’s relationship to the environment.
can be manipulated by the nurse to achieve
health (behavioral system balance or stability) Behavior changes when efficiency and ef-
for the patient. Johnson provided no other spe- fectiveness are no longer evident or when a
cific definition of the environment, nor did she more optimal level of functioning is per-
identify what she considered internal versus ex- ceived. Individuals are said to achieve effi-
ternal environment. But much can be inferred cient and effective behavioral functioning
from her writings, and system theory also pro- when their behavior is commensurate with
vides additional insights into the environment social demands, when they are able to modify
component of the model. their behavior in ways that support biological
imperatives, when they are able to benefit to
The external environment may include peo- the fullest extent during illness from the
ple, objects, and phenomena that can poten- physician’s knowledge and skill, and when
tially permeate the boundary of the behavioral their behavior does not reveal unnecessary
system. This external stimulus forms an organ- trauma as a consequence of illness (Johnson,
ized or meaningful pattern that elicits a re- 1980, p. 207).
sponse from the individual. The behavioral
system attempts to maintain equilibrium in re- Behavior system imbalance and instability
sponse to environmental factors by assimilating are not described explicitly but can be inferred
and accommodating to the forces that impinge from the following statement to be a malfunc-
on it. Areas of external environment of interest tion of the behavioral system:
to nurses include the physical settings, people,
objects, phenomena, and psychosocial–cultural The subsystems and the system as a
attributes of an environment. whole tend to be self-maintaining and
self-perpetuating so long as conditions
Johnson provided detailed information in the internal and external environment
about the internal structure and how it func- of the system remain orderly and pre-
tions. She also noted that “[i]llness or other dictable, the conditions and resources nec-
sudden internal or external environmental essary to their functional requirements are
change is most frequently responsible for sys- met, and the interrelationships among the
tem malfunction” (Johnson, 1980, p. 212). subsystems are harmonious. If these con-
Such factors as physiology; temperament; ego; ditions are not met, malfunction becomes
age; and related developmental capacities, at- apparent in behavior that is in part disor-
titudes, and self-concept are general regulators ganized, erratic, and dysfunctional. Illness
that may be viewed as a class of internalized or other sudden internal or external envi-
intervening variables that influence set, choice, ronmental change is most frequently re-
and action. They are key areas for nursing as- sponsible for such malfunctions. (Johnson,
sessment. For example, a nurse attempting to 1980, p. 212)
respond to the needs of an acutely ill hospital-
ized 6-year-old would need to know some- Thus, Johnson equated behavioral system
thing about the developmental capacities of a imbalance and instability with illness. How-
6-year-old and about self-concept and ego de- ever, as Meleis (2011) has pointed out, we
velopment to understand the child’s behavior. must consider that illness may be separate
from behavioral system functioning. Johnson
Health also referred to physical and social health but
did not specifically define wellness. Just as the
Johnson viewed health as efficient and effective inference about illness may be made, it may
functioning of the system and as behavioral be inferred that wellness is behavioral system

CHAPTER 7 • Dorothy Johnson’s Behavioral System Model and Its Applications 97

balance and stability, as well as efficient and The source of difficulty arises from structural
effective behavioral functioning. and functional stresses. Structural and func-
tional problems develop when the system is un-
Nursing and Nursing Therapeutics able to meet its own functional requirements.
As a result of the inability to meet functional
Nursing is viewed as “a service that is com- requirements, structural impairments may take
plementary to that of medicine and other place. In addition, functional stress may be
health professions, but which makes its own found as a result of structural damage or from
distinctive contribution to the health and the dysfunctional consequences of the behavior.
well-being of people” (Johnson, 1980, p. 207). Other problems develop when the system’s
She distinguished nursing from medicine by control and regulatory mechanisms fail to
noting that nursing views the patient as a develop or become defective.
behavioral system, and medicine views the
patient as a biological system. In her view, Four diagnostic classifications to delineate
the specific goal of nursing action is “to re- these disturbances are differentiated in the
store, maintain, or attain behavioral system model. A disorder originating within any one
balance and stability at the highest possible subsystem is classified as either an insuffi-
level for the individual” (Johnson, 1980, ciency, which exists when a subsystem is not
p. 214). This goal may be expanded to in- functioning or developed to its fullest capacity
clude helping the person achieve an optimal due to inadequacy of functional requirements,
level of balance and functioning when this is or as a discrepancy, which exists when a be-
possible and desired. havior does not meet the intended conceptual
goal. Disorders found between more than one
The goal of the system’s action is behavioral subsystem are classified either as an incompat-
system balance. For the nurse, the area of con- ibility, which exists when the behaviors of two
cern is a behavioral system threatened by the or more subsystems in the same situation con-
loss of order and predictability through illness flict with each other to the detriment of the in-
or the threat of illness. The goal of a nurse’s ac- dividual, or as dominance, which exists when
tion is to maintain or restore the individual’s the behavior of one subsystem is used more
behavioral system balance and stability or to than any other, regardless of the situation or
help the individual achieve a more optimal to the detriment of the other subsystems. This
level of balance and functioning. is also an area where Johnson believed addi-
tional diagnostic classifications would be de-
Johnson did not specify the steps of the veloped. Nursing therapeutics address these
nursing process but clearly identified the role three areas.
of the nurse as an external regulatory force. She
also identified questions to be asked when an- The next critical element is the nature of the
alyzing system functioning, and she provided interventions the nurse would use to respond
diagnostic classifications to delineate distur- to the behavioral system imbalance. The first
bances and guidelines for interventions. step is a thorough assessment to find the source
of the difficulty or the origin of the problem.
Johnson (1980) expected the nurse to base There are at least three types of interventions
judgments about behavioral system balance that the nurse can use to bring about change.
and stability on knowledge and an explicit The nurse may attempt to repair damaged
value system. One important point she made structural units by altering the individual’s set
about the value system is that and choice. The second would be for the nurse
to impose regulatory and control measures. The
given that the person has been provided with nurse acts outside the patient environment to
an adequate understanding of the potential provide the conditions, resources, and controls
for and means to obtain a more optimal level necessary to restore behavioral system balance.
of behavioral functioning than is evident at The nurse also acts within and upon the exter-
the present time, the final judgment of the nal environment and the internal interactions
desired level of functioning is the right of the
individual. (Johnson, 1980, p. 215)

98 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

of the subsystem to create change and restore clinical practice in a variety of ways. The ma-
stability. The third, and most common, treat- jority of the research focuses on clients’ func-
ment modality is to supply or to help the client tioning in terms of maintaining or restoring
find his or her own supplies of essential func- behavioral system balance, understanding the
tional requirements. The nurse may provide system and/or subsystems by focusing on the
nurturance (resources and conditions necessary basic sciences, or focusing on the nurse as an
for survival and growth; the nurse may train the agent of action who uses the JBSM to gather
client to cope with new stimuli and encourage diagnostic data or to provide care that influ-
effective behaviors), stimulation (provision of ences behavioral system balance.
stimuli that brings forth new behaviors or in-
creases behaviors, provides motivation for a Derdiarian (1990, 1991) examined the
particular behavior, and provides opportunities nurse as an action agent within the practice
for appropriate behaviors), and protection domain. She focused on the nurses’ assess-
(safeguarding from noxious stimuli, defending ment of the patient using the JBSM and the
from unnecessary threats, and coping with a effect of using this instrument on the quality
threat on the individual’s behalf). The nurse of care (Derdiarian, 1990, 1991). This ap-
and the client negotiate the treatment plan. proach expanded the view of nursing knowl-
edge from exclusively client-based to knowledge
Applications of the Model about the context and practice of nursing that
is model-based. The results of these studies
Fundamental to any professional discipline is found a significant increase in patient and
the development of a scientific body of knowl- nurse satisfaction when the JBSM was used.
edge that can be used to guide its practice. Derdiarian (1983, 1988; Derdiarian & Forsythe,
JBSM has served as a means for identifying, 1983) also found that a model-based, valid,
labeling, and classifying phenomena important and reliable instrument could improve the
to the nursing discipline. Nurses have used the comprehensiveness and the quality of assess-
JBSM model since the early 1970s, and the ment data; the method of assessment; and the
model has demonstrated its ability to provide quality of nursing diagnosis, interventions,
a medium for theoretical growth; organization and outcome. Derdiarian’s body of work re-
for nurses’ thinking, observations, and inter- flects the complexity of nursing’s knowledge
pretations of what was observed; a systematic as well as the strategic problem-solving capa-
structure and rationale for activities; direction bilities of the JBSM. Her 1991 article in Nurs-
to the search for relevant research questions; ing Administration Quarterly demonstrated the
solutions for patient care problems; and, fi- clear relationship between Johnson’s theory
nally, criteria to determine whether a problem and nursing practice.
has been solved.
Others have demonstrated the utility of
Practice-Focused Research Johnson’s model for clinical practice. Tamilarasi
and Kanimozhi (2009) used the JBSM to de-
Stevenson and Woods (1986) stated: “Nursing velop interventions to improve the quality of
science is the domain of knowledge concerned life of breast cancer survivors. Oyedele (2010)
with the adaptation of individuals and groups used the JBSM to develop and test nursing in-
to actual or potential health problems, the en- terventions to prevent teen pregnancy in South
vironments that influence health in humans African teens. Box 7-1 highlights other JBSM
and the therapeutic interventions that promote research. Talerico (1999) found that the JBSM
health and affect the consequences of illness” demonstrated utility in accounting for differ-
(1986, p. 6). This position focuses efforts in ences in the expression of aggressive behavioral
nursing science on the expansion of knowledge actions in elders with dementia in a way that
about clients’ health problems and nursing the biomedical model has proved unable.
therapeutics. Nurse researchers have demon- Wang and Palmer (2010) used the JBSM to
strated the usefulness of Johnson’s model in a gain a better understanding of women’s toilet-
ing behavior, and Colling, Owen, McCreedy,

CHAPTER 7 • Dorothy Johnson’s Behavioral System Model and Its Applications 99

Box 7-1 Bonnie Holaday’s Research about the links between nursing input and
Highlighted health outcomes for clients. The model has
been useful in practice because it identifies an
My program of research has examined nor- end product (behavioral system balance),
mal and atypical patterns of behavior of chil- which is nursing’s goal. Nursing’s specific ob-
dren with a chronic illness and the behavior jective is to maintain or restore the person’s
of their parents and the interrelationship be- behavioral system balance and stability, or to
tween the children and the environment. My help the person achieve a more optimum level
goal was to determine the causes of instability of functioning. The model provides a means
within and between subsystems (e.g., break- for identifying the source of the problem in
down in internal regulatory or control mecha- the system. Nursing is seen as the external
nisms) and to identify the source of problems regulatory force that acts to restore balance
in behavioral system balance. (Johnson, 1980).

and Newman (2003) used it to study the effec- One of the best examples of the model’s
tiveness of a continence program for frail eld- use in practice has been at the University of
ers. Poster, Dee, and Randell (1997) found the California, Los Angeles, Neuropsychiatric
JBSM was an effective framework to evaluate Institute. Auger and Dee (1983) designed a
patient outcomes. patient classification system using the JBSM.
Each subsystem of behavior was operational-
Education ized in terms of critical adaptive and maladap-
tive behaviors. The behavioral statements were
Johnson’s model was used as the basis for un- designed to be measurable, relevant to the
dergraduate education at the UCLA School of clinical setting, observable, and specific to the
Nursing. The curriculum was developed by the subsystem. The use of the model has had a
faculty; however, no published material is major effect on all phases of the nursing
available that describes this process. Texts by Wu process, including a more systematic assess-
(1973) and Auger (1976) extended Johnson’s ment process, identification of patient strengths
model and provided some idea of the content and problem areas, and an objective means for
of that curriculum. Later, in the 1980s, Harris evaluating the quality of nursing care (Dee &
(1986) described the use of Johnson’s theory Auger, 1983).
as a framework for UCLA’s curriculum. The
Universities of Hawaii, Alaska, and Colorado The early works of Dee and Auger led to
also used the JBSM as a basis for their under- further refinement in the patient classification
graduate curricula. system. Behavioral indices for each subsystem
have been further operationalized in terms of
Loveland-Cherry and Wilkerson (1983) critical adaptive and maladaptive behaviors.
analyzed Johnson’s model and concluded that Behavioral data is gathered to determine the
the model could be used to develop a curricu- effectiveness of each subsystem (Dee, 1990;
lum. The primary focus of the program would Dee & Randell, 1989).
be the study of the person as a behavioral sys-
tem. The student would need a background in The scores serve as an acuity rating system
systems theory and in the biological, psycho- and provide a basis for allocating resources.
logical, sociological sciences, and genetics. The These resources are allocated based on the as-
mapping of the human genome and clinical signed levels of nursing intervention, and re-
exome and genome sequencing has provided source needs are calculated based on the total
evidence that genes serve as general regulators number of patients assigned according to levels
of behavioral system activity. of nursing interventions and the hours of nurs-
ing care associated with each of the levels (Dee
Nursing Practice and Administration & Randell, 1989). The development of this
system has provided nursing administration
Johnson has influenced nursing practice be- with the ability to identify the levels of staff
cause she enabled nurses to make statements needed to provide care (licensed vocational

100 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

nurse vs. registered nurse), bill patients for ac- of the JBSM as a basis for clinical practice
tual nursing care services, and identify nursing within a health care setting. From the findings
services that are absolutely necessary in times of their work, it is clear that the JBSM estab-
of budgetary restraint. Recent research has lished a systematic framework for patient as-
demonstrated the importance of a model- sessment and nursing interventions, provided
based nursing database in medical records a common frame of reference for all practition-
(Poster et al., 1997) and the effectiveness of ers in the clinical setting, provided a frame-
using a model to identify the characteristics of work for the integration of staff knowledge
a large hospital’s managed behavioral health about the clients, and promoted continuity in
population in relation to observed nursing care the delivery of care. These findings should be
needs, level of patient functioning on admis- generalizable to a variety of clinical settings.
sion and discharge, and length of stay (Dee,
Van Servellen, & Brecht, 1998).1 1 For additional information please see the bonus chap-
ter content available at http://davisplus.fadavis.com
The work of Vivien Dee and her colleagues
has demonstrated the validity and usefulness

Practice Exemplar

Provided by Kelly White of smoking three packs per day of cigarettes
for 30 years. He states he quit when he began
During the change-of-shift report that morn- his chemotherapy.
ing, I was told that a new patient had just been
wheeled onto the floor at 7:00 a.m. As a result, Jim, a high school graduate, is married to
it was my responsibility to complete the ad- his high school sweetheart, Ellen. He lives
mission paperwork and organize the patient’s with his wife and three children in their
day. He was a 49-year-old man who was ad- home. He and his wife are currently unem-
mitted through the emergency department to ployed secondary to recent layoffs at the fac-
our oncology floor for fever and neutropenia tory where they both worked. He explained
secondary to recent chemotherapy for lung that Ellen has been emotionally pushing him
cancer. away and occasionally disappears from the
home for hours at a time without explaining
Immediately after my initial rounds, to en- her whereabouts. He informs me that before
sure all my patients were stable and comfort- his diagnosis, they were the best of friends
able, I rolled the computer on wheels into his and inseparable.
room to begin the nursing admission process.
Jim explained to me that he was diagnosed He has tolerated his treatments well until
with small cell lung carcinoma 2 months ear- now, except for having frequent, burning, un-
lier after he was admitted to another hospital controlled diarrhea for days at a time after
for coughing, chest pain, and shortness of his chemotherapy treatments. These episodes
breath. He went on to explain that a recent have caused raw, tender patches of skin
magnetic resonance imaging scan showed around his rectal area that become increas-
metastasis to the liver and brain. ingly more painful and irritated with each
bowel movement.
His past health history revealed that he ir-
regularly visited his primary health care Jim is exceptionally tearful this morning as
provider. He is 6 feet 3 inches tall and weighs he expresses concerns about his own future
168 pounds (76.4 kg). He states that he has and the future of his family. He informs me
lost 67 pounds in the past 6 months. His ap- that Ellen’s mother is flying in from out
petite has significantly diminished because of state to care for the children while he is
“everything tastes like metal.” He has a history hospitalized.

CHAPTER 7 • Dorothy Johnson’s Behavioral System Model and Its Applications 101

Practice Exemplar cont. Jim’s wife, Ellen, is distant these days,
which would have an effect on the
Assessment couple’s intimacy.
The environmental assessment is as follows:
Johnson’s behavioral systems model guided
the assessment process. The significant behav- Internal/external
ioral data are as follows: After the admission process was completed, I
Achievement subsystem
had several concerns for my new patient. I
Jim is losing control of his life and of the re- recognized that Jim was a middle-aged man
lationships that matter most to him as a whose developmental stage was compro-
person—his family. mised regarding his productivity with fam-
ily and career due to his illness. Mental and
He is a high school graduate. physical abilities could be impaired as this
Affiliative protective subsystem disease process advances. In addition, this
may create further strain on his relationship
Jim is married but states that his wife is dis- with his wife, as she attempts to deal with
tancing herself from him. He feels he is her own feelings about his diagnosis. Fam-
losing his “best friend” at a time when he ily support would be essential as Jim’s jour-
really needs this support. ney continued. Lastly, Jim needed to be
educated on the expectations of his diagno-
Aggressive protective subsystem sis, participate in a plan for treatment dur-
ing his hospital stay, and assist in the
Jim is protective of his health now (he quit development of goals for his future.
smoking when he began chemotherapy)
but has a long history of neglecting it Diagnostic Analysis
(smoking for 30 years, unexplained weight
loss for 4 months, irregular visits to his Jim is likely uncertain about his future as a hus-
primary health-care provider). band, father, employee, and friend. Realizing
this, I encouraged Jim to verbalize his concerns
Dependency subsystem regarding these four areas of his life while I
completed my physical assessment and assisted
Jim is realizing his ability to care for self and him in settling into his new environment. At
family is diminishing and will continue to first he was hesitant to speak about his family
diminish as his health deteriorates. He concerns but soon opened up to me after I sat
questions who he can depend on because down in a chair at his bedside and simply made
his wife is not emotionally available to him. him my complete focus for 5 minutes. As a re-
sult of this brief interaction, together we were
Eliminative subsystem able to develop short-term goals related to his
hospitalization and home life throughout the
Jim is experiencing frequent, burning, un- rest of my shift with him that day. In addition,
controlled diarrhea for days at a time he acquiesced and allowed me to order a social
after his chemotherapy treatments. These work consult, recognizing that he would no
episodes have caused raw, tender patches longer be able to adequately meet his family’s
of skin around his rectal area that become needs independently at this time.
increasingly more painful and irritated
with each bowel movement. We also addressed the skin impairment is-
sues in his rectal area. I was able to offer him
Ingestive subsystem ideas on how to keep the area from experiencing
further breakdown. Lastly, the wound care nurse
Jim has lost 67 pounds in 6 months and was consulted.
has decreased appetite secondary to the
chemotherapy side effects. Continued

Restorative subsystem

Jim currently experiences shortness of breath,
pain, and fatigue.

Sexual subsystem

Jim has shortness of breath and possible pain
on exertion, which may be leading to con-
cerns about his sexual abilities.

102 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Practice Exemplar cont. been in months. He stated that they were talk-
ing about the future and that Ellen had ac-
Evaluation knowledged her fears to him the previous
evening. Jim was wheeled out of the hospital
During his 10-day hospitalization, Jim and because he continued to have shortness of
his wife agreed to speak to a counselor regard- breath on extended exertion. As his wife drove
ing their thoughts on Jim’s diagnosis and away from the hospital, Jim waved to me with
prognosis upon his discharge. Jim’s rectal a genuine smile and a sparkle in his eye.
area healed because he did not receive any
chemotherapy/radiation during his stay. He Epilogue
received tips on how to prevent breakdown in
that area from the wound care nurse who took Jim passed away peacefully 3 months later at
care of him on a daily basis. Jim gained 3 home, with his wife and children at his side.
pounds during his stay and maintained that he His wife contacted me soon afterward to let
would continue drinking nutrition supple- me know that the nursing care Jim received
ments daily, regardless of his appetite changes during his first stay on our unit opened the
during his cancer treatment. Jim’s stamina and doors to allow them both to recognize that
thirst for life grew stronger as his body grew they needed to modify their approach to the
physically stronger. As he was being dis- course of his disease. In the end, they flour-
charged, he whispered to me that he was ished as a couple and a family, creating a sup-
thankful for the care he had received while on portive transition for Jim and the entire family.
our floor, and he believed that the nurses had
brought him and his wife closer than they had

■ Summary

The Johnson Behavioral System Model cap- subsystems. For example, a study could examine
tures the richness and complexity of nursing. the way a person deals with the transition from
It also addresses the interdependent functional health to illness with the onset of asthma. There
biological, psychological, and sociological is concern with the relations between one’s bi-
components within the behavioral system and ological system (e.g., unstable, problems breath-
locates this within a larger social system. The ing), one’s psychological self (e.g., achievement
JBSM focuses on the person as a whole, as well goals, need for assistance, self-concept), self in
as on the complex interrelationships among its relation to the physical environment (e.g., aller-
constituent parts. Once the diagnosis has been gens, being away from home), and transactions
made, the nurse can proceed inward to the related to the sociocultural context (e.g., attitudes
subsystem and outward to the environment. It and values about the sick). The study of transi-
also asks nurses to be systems thinkers as they tions (e.g., the onset of puberty, menopause,
formulate their assessment plan, make their di- death of a spouse, onset of acute illness) also rep-
agnosis of the problem, and plan interventions. resents a treasury of open problems for research
The JBSM provides nurses with a clear con- with the JBSM. Findings obtained from these
ception of their goal and of their mission as an studies will provide not only an opportunity to
integral part of the health-care team. revise and advance the theoretical conceptual-
ization of the JBSM, but also information about
Johnson expected the theory’s further devel- nursing interventions. The JBSM approach
opment in the future and that it would uncover leads us to seek common organizational param-
and shape significant research problems that eters in every scientific explanation and does
have both theoretical and practical value to the so using a shared language about nursing and
discipline. Some examples include examining nursing care.
the levels of integration (biological, psycholog-
ical, and sociocultural) within and between the

CHAPTER 7 • Dorothy Johnson’s Behavioral System Model and Its Applications 103

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Dorothea Orem’s Self-Care 8Chapter
Deficit Nursing Theory

DONNA L. HARTWEG

Introducing the Theorist Introducing the Theorist
Overview of the Theory
Applications of the Theory Dorothea E. Orem (1914–2007) dedicated her
life to creating and developing a theoretical
Practice Applications structure to improve nursing practice. As a
Practice Exemplar by Laureen Fleck voracious reader and extraordinary thinker, she
framed her ideas in both theoretical and the
Summary practical terms. She viewed nursing knowledge
References as theoretical, with conceptual structure and
elements as exemplified in her self-care deficit
Dorothea E. Orem nursing theory (SCDNT), and as “practically
practical,” with knowledge, rules, and defined
roles for practice situations (Orem, 2001).

Orem’s personal life experiences, formal
education, employment, and her reading of
philosophers such as Aristotle, Aquinas, Harre
(1970), and Wallace (1983) directed her think-
ing (Orem, 2006). She sought to understand
the phenomena she observed, creating concep-
tualizations of nursing education, disciplinary
knowledge, and finally, a general theory of
nursing or SCDNT.

Orem worked independently and then col-
laboratively until her death at age 93. For a
lifetime of contributions to nursing science and
practice, Orem received honors from organiza-
tions such as Sigma Theta Tau, the American
Academy of Nursing, the National League for
Nursing, and Catholic University of America
as well as four honorary doctorates.

Orem received her initial nursing education
at Providence Hospital School of Nursing
in Washington, DC. After her 1934 gradua-
tion, Orem quickly moved into hospital staff/
supervisory positions in operating and emer-
gency areas. Her BSN Ed from Catholic
University of America (1939) led to a faculty
position there. After completing her MSN Ed
at Catholic University (1946), Orem became

105

106 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Director of Nursing Service and Education conferences encouraged international collabo-
at Provident Hospital School of Nursing in ration among institutions.
Detroit (Taylor, 2007).
In 1991, the International Orem Society
Orem’s early formulations on the nature of (IOS) for Nursing Science and Scholarship was
nursing occurred while she was working for founded by a group of international scholars.
the Indiana State Board of Health between The IOS’s mission is “To disseminate informa-
1949 and 1957 (Hartweg, 1991). She became tion related to development of nursing science
aware of nurses’ ability to “do nursing,” but and its articulation with the science of self-care”
their inability to “describe nursing.” Without (www.scdnt.com). This mission has been real-
this understanding, Orem believed nurses ized through the publication of newsletters
could not improve practice. She made an ini- (1993–2001) and a peer-reviewed journal,
tial effort to define nursing in a report titled Self-Care, Dependent Care & Nursing begun in
“The Art of Nursing in Hospital Service: An 2002 (www.scdnt.com/ja/jarchive.html). Twelve
Analysis” (Orem, 1956). The language of the biennial Orem congresses have been held
patient doing-for-self or the nurse helping to- throughout the world (Berbiglia, Hohmann, &
do-for-self appears in the report as antecedent Bekel, 2012; www.ioscongress2012.lu).
language for the concept of self-care.
In 1995, Orem convened the Orem Study
During her tenure at the Office of Educa- Group. This international group of scholars met
tion, Vocational Section in Washington, DC, regularly at her home in Savannah, GA, for im-
Orem generated a simple yet important ques- mersion in areas of SCDNT needing further
tion: Why do people need nursing? In Guides development. Several publications resulted from
for Developing Curriculum for the Education of this group work (Denyes, Orem, & Bekel,
Practical Nurses (Orem, 1959), she expanded 2001; Taylor, Renpenning, Geden, Neuman, &
the question to what she termed “the proper Hart, 2001). Work groups continue today to re-
object of nursing”: “What condition exists in a fine or develop concepts such as the universal
person when judgments are made that a requisite of normalcy (personal communication,
nurse(s) should be brought into the situation?” Taylor & Renpenning, January, 20, 2014).
(Orem, 2001, p. 20). Her answer was the in-
ability of persons to provide continuously for them- Many of Orem’s original papers are pub-
selves the amount and quality of required self-care lished in Self-Care Theory in Nursing: Selected
because of situations of personal health. Papers of Dorothea Orem (Renpenning &
Taylor, 2003) and are also available in the
Although Orem worked independently, Mason Chesney Archives of the Johns
two groups contributed to the theory’s early Hopkins Medical Institutions for the Orem
development (Taylor, 2007). The first group Collection (www.medicalarchives.jhmi.edu/
was the Nursing Model Committee at papers/orem.html) and in the archives of the
Catholic University of America. In 1968, the IOS website. Audios and videos of the theo-
Nursing Development Conference Group rist’s lectures are available through the Helene
(NDCG) was formed and continued the work Fuld Health Trust (1988) and the National
of the Nursing Model committee. The collab- League for Nursing (1987). Self-Care Science,
orative process and outcomes were published Nursing Theory, and Evidence-based Practice
in Concept Formalization: Process and Product (Taylor & Renpenning, 2011) is the most
(NDCG, 1973, 1979), edited by Orem. Con- recent theory development and practice publi-
current with group work, Orem published the cation. Orem’s 50-year influence on nursing
first of six editions of Nursing: Concepts of science and practice is also summarized in
Practice (1971), which has been translated into recent works by Clarke, Allison, Berbiglia, and
many languages. Taylor (2009) and by Taylor (2011).1

By 1989, the global impact of Orem’s work 1For additional information please see the bonus chapter
was evident when the First International self- content available at http://davisplus.fadavis.com
care deficit nursing theory Conference was
held in Kansas City (Hartweg, 1991). These

CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 107

Overview of the Theory presents the general focus of the theory, the
presuppositions are assumptions specific to this
As noted earlier, Orem’s general theory of theory, and the propositions are statements
nursing is correctly referred to as self-care about the concepts and their interrelationships.
deficit nursing theory. Orem believed a general The propositions have changed over time with
model or theory created for a practical science SCDNT refinement. These occurred in part
such as nursing encompasses not only the through theory testing that validated or inval-
What and Why, but also the Who and How idated hypotheses generated from the relation-
(Orem, 2006). This action theory therefore in- ships. As Orem used terminology at various
cludes clear specifications for nurse and patient levels of abstraction within constituent theo-
roles. The grand theory originally comprised ries, the reader is advised to thoroughly study
three interrelated theories: the theory of self- SCDNT concepts, including the synonyms.
care, the theory of self-care deficit, and the For example, agency is also called capability,
theory of nursing systems. A fourth, the theory ability and/or power.
of dependent care, emerged over time to ad-
dress the complexity not only of the individual 1. Theory of Self-Care (TSC)
in need of care but also of the caregivers whose
requisites and capabilities influence the design The central idea describes self-care in contrast
of the nursing system (Taylor & Renpenning, to other forms of care. Self-care, or care for
2011). The building blocks of these theories oneself, must be learned and be deliberately
are six major concepts, with parallel concepts performed for life, human functioning, and
from the theory of dependent care, and one well-being. Six presuppositions articulate
peripheral concept. The following is a brief Orem’s notions about necessary resources, ca-
overview of each theory and concept. Readers pabilities for learning, and motivation for self-
are encouraged to study relevant sections in care. However, there are situational variations
Orem’s Concepts of Practice (2001) or other that affect self-care such as culture.
citations to enhance understanding.
Orem (2001) expanded two sets of propo-
Foundational to learning any theory is explo- sitions from previous writings. She introduced
ration of its underlying assumptions, the key to requirements necessary for life, health, and
conceptual understanding. Many principles well-being and explained the complexity of a
emerged from Orem’s independent work as well self-care system. A person performing self-care
as from discussions within the Nursing Develop- must first estimate or investigate what can and
ment Conference Group and the Nursing Study should be done. This is a complex action of
Group. Five general assumptions/principles knowing and seeking information on specific
about humans provided guidance to Orem’s care measures. The self-care sequence contin-
conceptualizations (Orem, 2001, p. 140). When ues by deciding what can be done and finally pro-
thinking about humans within the context of the ducing the care (see Orem, 2001, pp. 143–145).
theory, Orem viewed two types: those who need
nursing care and those who produce it (Orem, 2. Theory of Dependent Care
2006). In the simplest terms, this is the patient
and the nurse, respectively. These assumptions Taylor and others (2001) formalized the the-
also reveal human powers and properties neces- ory of dependent care as a corollary theory to
sary for self-care. Consistent with most Orem the theory of self-care. Concepts within the
writings, the term patient is used to refer to the theory of dependent care (TDC) parallel those
recipient of care. in the theory of self-care. Assumptions relate
to the nature of interpersonal action systems
Four Constituent Theories Within and social dependency. Within a particular so-
Self-Care Deficit Nursing Theory cial unit such as a family, the self-care agent
(the patient) is in a socially dependent rela-
Each theory includes a central idea, presuppo- tionship with the person or persons providing
sitions, and propositions. The central idea care, such as a parent (the dependent-care
agent). The presence of a self-care deficit of

108 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

the dependent also gives rise to the need for (Orem, 2001, p. 147). Although much of the
nursing (Taylor & Renpenning, 2011; Taylor, theory relates to diagnosis, actions, and out-
Renpenning, Geden, Neuman, & Hart, 2001). comes based on a deficit relationship between
self-care capabilities and self-care demand,
3. Theory of Self-Care Deficit Orem also presents theoretical work related to
the interpersonal relationship between nurse
The central idea describes why people need nurs- and person(s) receiving nursing and a social
ing (Orem, 2001, pp. 146–147). Requirements contract between the nurse and patient(s)
for nursing are health-related limitations for (Orem, 2001, pp. 314–317). These compo-
knowing, deciding, and producing care to self. nents are often overlooked when studying the
Orem presents two sets of presuppositions that SCDNT and are important antecedents and
articulate this theory with the theory of self- concurrent actions in the process of nursing.
care and what she calls the idea of social de-
pendency. To engage in self-care, persons must The theory of nursing systems includes
have values and capabilities to learn (to know), seven propositions related to most SCDNT
to decide, and to manage self (to produce and concepts but adds nursing agency (capabilities
regulate care). The second set presents the con- of the nurse) and nursing systems (complex ac-
text of nursing as a health service when people tions). Nursing agency and nursing systems are
are in a state of social dependency. linked to the concepts of the person receiving
care or dependent care, such as self-care capa-
The theory of self-care deficit (TSCD) in- bilities (agency), self-care demands (therapeu-
cludes nine propositions called principles or tic self-care demand), and limitations (deficits)
guides for future development and theory test- for self-care. Through this, the general theory
ing. These statements are essential ideas of the or SCDNT becomes concrete to the practicing
larger, SCDNT. Orem describes the situations nurse. Although the language is implicit,
that affect legitimate nursing. Nursing is legit- Orem proposes that nursing systems are deter-
imate or needed when the individual’s self-care mined by the person’s (or dependent-care
capabilities and care demands are equal to, less agent’s) self-care limitations (capabilities in
than, or more than at a point in time. With the relationship to health-related self-care or
existence of this inequity, a self-care deficit ex- dependent-care demand). Nursing systems
ists, and nursing is needed. In a dependent- therefore vary by the amount of care the nurse
care system, a self-care deficit exists in the must provide, such as a total care system, or
patient as well as a dependent-care deficit in a wholly compensatory system (e.g., unconscious
caregiver. The latter is an inequity between the critical care patient); partial care, or partially
dependent-care demand and agency (abilities) compensatory system (e.g., patient in rehabil-
to care for the person in need of health care. itation); or supportive-educative system (e.g.,
Legitimate nursing also occurs when a future patient needing teaching).
deficit relationship is predicted such as an up-
coming surgery. Theoretical development by Orem scholars
and others continues as nursing practice
4. Theory of Nursing Systems evolves. The addition of the theory of depend-
ent care is a major example and extends basic
The fourth theory, the theory of nursing sys- concepts, such as adding “dependent-care sys-
tems (TNS), encompasses the three others. tem” (Taylor & Renpenning, 2011). Other
The central focus is the product of nursing, concepts such as self-care and self-care requi-
establishing both structure and content for sites, their processes and core operations, con-
nursing practice as well as the nursing role (see tinue to be explicated (Denyes, Orem & Bekel,
Orem, 2001, pp. 111, 147–149). The four pre- 2001). Some researchers or theorists develop
suppositions direct the nurse to major com- the subconcepts of basic concepts such as self-
plexities of nursing practice. For example, care agency through exploration of congruent
Orem stated that “Nursing has results-achieving theories. For example, Pickens (2012) proposed
operations that must be articulated with the in- exploration of motivation, a foundational
terpersonal and societal features of nursing”

CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 109

capability and power component of self-care another on whom the person is socially de-
agency, through examination of several theories pendent (dependent-care agent). Orem also
including self-determination theory (Ryan, addresses multiperson situations and multi-
Patrick, Deci, & Williams, 2008). Others cre- person units such as entire families, groups,
ate new concepts, such as spiritual self-care or communities.
(White, Peters, & Schim, 2011) or extend gen-
eral concepts such as environment (Banfield, Each concept is defined and presented with
2011). levels of abstraction. Varied constructs within
each concept allow theoretical testing at the
Concepts level of middle-range theory or at the practice
application level whether with the individual
SCDNT is constructed from six basic con- or multiperson situations. All constructs and
cepts and a peripheral concept. Four concepts concepts build on decades of Orem’s inde-
are patient related: self-care/dependent care, pendent and collaborative work. A “kite-like”
self-care agency/dependent-care agency, ther- model provides a visual guide for the six con-
apeutic self-care demand/dependent-care de- cepts and their interrelationships (Fig. 8-1).
mand, and self-care deficit/dependent-care For a model of concepts and relationships of
deficit. Two concepts relate to the nurse: dependent care, the reader is referred to Taylor
nursing agency and nursing system. Basic and Renpenning (2011, p. 112). For a model
conditioning factors, the peripheral concept, of multiperson structure, the reader is referred
is related to both the self-care agent (person to Taylor and Renpenning (2001).
receiving care)/dependent-care agent (family
member/friend providing care) and also to Basic Conditioning Factors
the nurse (nurse agent). Orem defines agent
as the person who engages in a course of action A peripheral concept, basic conditioning factors
or has the power to do so (Orem, 2001, (BCFs), is related to three major concepts. For
p. 514). Hence there is a self-care agent, a simplicity, only the patient component is pre-
dependent-care agent, and a nurse agent. sented rather than the parallel dependent-care
The unit of service is a person(s), whether components. In general, basic conditioning fac-
that is the individual (self-care agent) or tors relate to the patient concepts (self-care
agency and therapeutic self-care demand) and

Conditioning R Self-care R Conditioning
factors R factors
Self-care Self-care
agency demands

Deficit R
R

Conditioning Nursing
factors agency

Fig 8 • 1 Structure of SCDNT.

110 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

one nurse concept (nursing agency). These capabilities (self-care agency; Taylor et al.,
conditioning factors are values that affect the 2001; Taylor & Renpenning, 2011).
constructs: age, gender, developmental state,
health state, sociocultural orientation, health- Although the practice of maintaining life is
care system factors, family system factors, pat- self-explanatory, Orem (2001) viewed outcomes
tern of living, environmental factors, and of health and well-being as related but different.
resource availability and adequacy (Orem, 2001, Health is a state of physical–psychological,
p. 245). For example, the family system factor structural–functional soundness and wholeness.
such as living alone or with others may affect In contrast, well-being is conceived as experi-
the person’s ability (self-care agency) to care ences of contentment, pleasure, and kinds of happi-
for self after hospital discharge. The self-care ness; by spiritual experiences; by movement toward
demand (care requirements) of a person taking fulfilment of one’s self-ideal; and by continuing
insulin for type 2 diabetes will vary based personalization (Orem, 2001, p. 186). Self-care
on availability of resources and health system performed deliberately for well-being versus
services (e.g., access to medications and care structural–functional health was conceptualized
services). These same BCFs apply to nursing and developed as health promotion self-care by
agency, such as health state. A nurse with recent Hartweg (1990, 1993) and Hartweg and
back surgery may have limitations in nursing Berbiglia (1996). Exploration of the relation-
capabilities (nurse agency) in relationship to ship between self-care and well-being was later
specific care demands of the patient. conducted by Matchim, Armer, and Stewart
(2008).
These BCF categories have many subfactors
that have not been explicitly defined and con- Key to understanding self-care and depend-
tinue in development. For example, sociocul- ent care is the concept of deliberate action, a
tural orientation refers to culture with its voluntary behavior to achieve a goal. Deliberate
various components such as values and prac- action is preceded by investigating and deciding
tices. Sociocultural includes economic condi- what choice to make (Orem, 2001). In practice,
tions as well as others. The BCFs related to the nurse’s understanding of each of these
nursing agency include those such as age but phases of investigating, deciding, and produc-
expand to include nursing experience and ed- ing self-care is essential for positive health
ucation. A clinical specialist in diabetes usually outcomes. Take two situations: A pregnant
has more capabilities in caring for the self-care woman avoids alcohol for her fetus’s health
agent with type 2 diabetes than one without and a woman with breast cancer requires
such credentials. All these affect the parame- chemotherapy for life and health. Each woman
ters of the nurse’s capability to provide care. must first know and understand the relation-
ship of self-care to life, health, and well-being.
Self-Care (Dependent Care) Decision making follows, such as deciding to
avoid alcohol or choosing to engage in
Orem (2001) defined self-care as the practice of chemotherapy. Finally, the individual must
activities that individuals initiate and perform on take action, such as not drinking when offered
their own behalf in maintaining life, health, and alcohol or accepting chemotherapy treatment.
well-being (p. 43). Self-care is purposeful ac- Without each phase, self-care does not occur.
tion performed in sequence and with a pattern. The pregnant woman may know the dangers to
Although engagement in purposeful self-care her fetus and decide not to drink but engage in
may not improve health or well-being, a posi- drinking when pressured to do so. The woman
tive outcome is assumed. Dependent care is with cancer may understand the health out-
performed by mature, responsible persons on come without treatment, decide to have
behalf of socially dependent individuals or self- treatment, then not follow through because
care agents such as an infant, child, or cognitively transportation to chemotherapy sessions dis-
impaired person. The purpose is to meet the rupts her husband’s employment. Because each
person’s health-related demands (dependent- phase of the action sequence has many compo-
care demand) and/or to develop their self-care nents, nurses often provide partial support to

CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 111

patients and self-care action does not occur. If Capabilities
skills related to the operation to avoid alcohol for self-care
when pressured or the operations necessary for operations
transportation to a cancer center are not antic-
ipated by the nurse for these patients, the self- Power components
care action sequences may not be completed. (enabling capabilities
Then outcomes related to life, health, and well-
being are affected. for self-care)

Self-Care Agency (Dependent Foundational capabilities
Care Agency) and disposition

Orem (2001) defined self-care agency (SCA) Fig 8 • 2 Structure of self-care agency.
as complex acquired capability to meet one’s con-
tinuing requirements for care of self that regulates are abilities related to perception, memory,
life processes, maintains or promotes integrity of and orientation. One example is the deliberate
human structure and functioning [health] and act of repairing a car. One must have perception
human development, and promotes well-being of the concept of the car and its parts, memory
(p. 254). Capability, ability, and power are all of methods of repair, and orientation of self to
terms used to express agency. Self-care agency the equipment and vehicle. If these founda-
is therefore the mature or maturing individ- tional abilities are not present, then actions
ual’s capability for deliberate action to care for cannot occur.
self. Dependent care agency is a complex ac-
quired ability of mature or maturing persons to Power Components
know and meet some or all of the self-care requi-
sites of persons who have health-derived or health At the midlevel of the hierarchy are the power
associated limitations of self-care agency, which components, or 10 powers or types of abilities
places them in socially dependent relationships for necessary for self-care. Examples are the valu-
care (Taylor & Renpenning, 2011, p. 108). ing of health, ability to acquire knowledge
Viewed as the summation of all human capabil- about self-care resources, and physical energy
ities needed for performing self-care, these range for self-care. At a very general level, these ca-
from a very basic ability, such as memory, to pabilities relate to knowledge, motivation, and
capability for a specific action in a sequence to skills to produce self-care. If a mature person
meet a specific self-care demand or require- becomes comatose, the abilities to maintain at-
ment. At this concrete level, the capabilities of tention, to reason, to make decisions, to phys-
knowing, deciding, and acting or producing ically carry out the actions are not functioning.
self-care are necessary. If these capabilities do The self-care actions necessary for life, health,
not exist, then the abilities of others are nec- and well-being must then be performed by the
essary, such as the family member or the nurse. dependent-care agent or the nurse agent.
A three-part, hierarchical model of self-care
agency provides a visualization of this structure Capabilities for Estimative,
(Fig. 8-2). Understanding these elements is Transitional, and Productive
necessary to determine the self-care agent role, Operations
dependent-care agent role, and the nurse role.
The most concrete level of self-care agency is
Foundational Capabilities one specific to the individual’s detailed com-
and Dispositions ponents of self-care demand or requirements.
Capabilities related to estimative operations
Foundational capabilities and dispositions are are those necessary to determine what self-care
at the most basic level (Orem, 2001, pp. 262–
263). These are capabilities for all types of
deliberate action, not just self-care. Included

112 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

actions are needed in a specific nursing situa- nurse agent must provide care. Similar varia-
tion at one point in time—in other words, ca- tions of development and operability occur
pabilities of investigating and estimating what with dependent-care agency and must be con-
needs to be done. This includes capabilities of sidered by the nurse when developing the self-
learning in situations related to health and care or dependent-care system.
well-being. For example, does the person
newly diagnosed with asthma have the capa- Therapeutic Self-Care Demand
bility to learn about regular exercise activities (Dependent-Care Demand)
and rescue medication? Does the person know
how to obtain the necessary resources? Tran- Therapeutic self-care demand (TSCD) is a
sitional operations relate to abilities necessary complex theoretical concept that summarizes
for decision making, such as reflecting on the all actions that should be performed over time
course of action and making an appropriate for life, health, and well-being. When first de-
decision. The patient may have the capabilities veloped, the concept was referred to as action
to learn and obtain resources but not the ability demand or self-care demand (Orem, 2001).
to make the decision. The asthma patient has Readers will therefore see these terms used in
the capability to learn about exercise and med- Orem’s writings and in the literature. Dependent
ication but not the capability to make the care demand is the summation of all care actions
decision to follow through on directions. for meeting the dependent caregiver’s therapeutic
Capabilities for productive operations are self-care demand when his or her agency is not ade-
those necessary for preparing the self for the quate or operational (Taylor & Renpenning,
action, carrying out the action, monitoring the 2011, p. 108).
effects, and evaluating the action’s effective-
ness. If the person decides to use the inhaler, The word therapeutic is essential to one’s un-
does the person have the ability to take time to derstanding of the concept. Consideration is
engage in the necessary self-care, to physically always on a therapeutic outcome of life, health,
push the device, to monitor the changes, and and well-being. A Haitian mother in a remote
determine the effectiveness of the action? Just village may expect to apply horse or cow dung
as the action sequence is important in the self- to the severed umbilical cord to facilitate dry-
care concept, these types of capabilities reveal ing, a culturally adjusted self-care measure for
the complexity of human capability. a newborn. With horse/cow dung as the major
carrier of Clostridium tetanus, this dependent-
At the concrete practice level, self-care care action may lead to disease and infant
agency also varies by development and oper- death, not a therapeutic outcome.
ability. For example, the nurse must determine
whether capabilities for learning are fully de- Constructing or calculating a TSCD re-
veloped at the level necessary to understand quires extensive nursing knowledge of evi-
and retain information about the required ac- denced-based practice, communication, and
tions. For example, a mature adult with late interpersonal skills. Both scientific nursing
stage Alzheimer’s disease is not able to retain knowledge and knowledge of the person and
new information. The self-care agency is there- environment are merged to formulate what
fore developed but declining, creating the possi- needs to be done in a particular nursing situation
ble need for dependent-care agency or nursing (NDCG, 1979). The process of calculating the
agency. A second determination is the oper- TSCD includes adjusting values by the basic
ability of agency. Is agency not operative, par- conditioning factors. For example, a mental
tially operative, or fully operative? A comatose health patient will have different needs based
patient may have fully developed capabilities on the type of mental health condition (health
before a motor vehicle accident, but the trauma state), family system factors, and health-care
results in inoperable cognitive functioning. resources.
SCA is therefore developed, but not operative at
that moment in time. In this situation, the Self-Care Requisites

To provide the framework for determining the
TSCD, Orem developed three types of self-care

CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 113

requisites (or requirements): universal, develop- hazards to ingestion of food such as avoiding
mental, and health deviation. These are the pur- pesticides.
poses or goals for which actions are performed for
life, health, and well-being. The individual Developmental Self-Care Requisites
sleeps once each day and engages in daily activ-
ities to meet the requisite or goal of maintaining Orem (2001) identified three types of devel-
a balance of activity and rest. Without rest, a opmental self-care requisites (DSCRs). The
human cannot survive. Therefore, these are gen- first refers to actions necessary for general
eral statements within a three-part framework human developmental processes throughout
that provide a level of abstraction similar to the the life span. These requisites are often met by
power components of self-care agency. Denyes dependent-care agents when caring for devel-
et al. (2001) explicated the self-care requisite to oping infants and children or when disaster and
maintain an adequate intake of water. Their work serious physical or mental illness affects adults.
demonstrates the complexity of actions neces- Engagement in self-development, the second
sary to meet a basic human need. Without con- DSCR, refers to demands for action by indi-
sideration of this complexity, analysis and viduals in positive roles and in positive mental
diagnosis of patient requirements is not com- health. Examples include self-reflection,
plete. This scholarly contribution by Denyes and goal-setting, and responsibility in one’s roles.
others (2001) can serve as a model for structur- The third DSCR, interferences with develop-
ing information regarding all other requisites ment, expresses goals achieved by actions that
(personal communication, Dr. Susan G. Taylor, are necessary in situational crises such as loss
March 12, 2013). of friends and relatives, loss of job, or terminal
illness. Originally subsumed under USCRs,
Universal Self-Care Requisites Orem created the developmental self-care
requisite category to indicate the importance
The eight universal self-care requisites (USCR) of human development to life, health, and
are necessary for all human beings of all ages well-being.
and in all conditions, such as air, food, activity
and rest, solitude, and social interaction. The Health Deviation Self-Care Requisites
BCFs influence the quality and quantity of the
action necessary to achieve the purpose. Ac- Health deviation self-care requisites (HDSCR)
tions to be performed over time that meet the are situation-specific requisites or goals when
requisite, prevention of hazards to human life, people have disease, injuries, or are under pro-
human functioning, and human well-being (the fessional medical care. These six requisites
purpose), will vary for an infant (e.g., keeping guide actions when pathology exists or when
crib rails up) versus an adult (e.g., ambulation medical interventions are prescribed. The first
safety). Some requisites are very general yet HDSCR refers in part to a patient purpose: to
provide important concepts necessary for all seek and secure appropriate medical assistance for
humans. One example is the concept of nor- genetic, physiological, or psychological conditions
malcy, the eighth USCR. The goal is promotion known to produce or be associated with human
of human functioning and development within pathology (Orem, 2001, p. 235). For a person
social groups in accord with human potential, with history of breast cancer, seeking regular
human limitations, and the human desire to be diagnostic tests is a goal to preserve life, health,
normal (Orem, 2001, p. 225). Practice exam- and well-being. A teenager in treatment for se-
ples in the literature have emerged, such as the vere acne takes action to meet HDSCR 5: to
importance of normalcy to individuals with modify the self-concept (and self-image) in ac-
learning disabilities (Horan, 2004). These two cepting oneself as being in a particular state of
requisites, prevention of hazards and promo- health and in need of a specific form of health care
tion of normalcy, also relate to the other six (Orem, p. 235).
USCRs. For example, when maintaining a
sufficient intake of food, one must consider Each TSCD, through the three types of
self-care requisites, is individualized and ad-
justed by the basic conditioning factors (BCFs)

114 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

such as age, health state, and sociocultural ori- meet the therapeutic self-care demand? If ade-
entation. Once adjusted to the specific patient quate, there is no need for nursing.
in a unique situation, the purposes are specific
for the patient or type of patient. These are A dependent-care deficit is a statement of
called “particularized self-care requisites.” the relationship between the dependent-care
Dennis and Jesek-Hale (2003) proposed a list demand and the powers and capabilities of the
of particularized self-care requisites for a nurs- dependent-care agent to meet the self-care
ing population of newborns. Although created deficit of the socially dependent person, the
for nursery newborns, a group particularized self-care agent (Taylor & Renpenning, 2011).
by age, the individual patient adjustments are When this deficit occurs, then a need for nurs-
then made. For example, a newborn’s sucking ing exists. When a parent has the capabilities
needs may vary, necessitating variation in feed- to meet all health-related self-care requisites
ing methods. More recent nursing literature of an ill child, then no nursing is needed.
continues to expand the types of requisites var-
ied by specific diseases or illnesses that provide When an existing or potential self-care deficit
a basis for application to specific patients and is identified and legitimate nursing is needed, an
caregivers. analysis by the nurse/patient/dependent-care
agents results in identification of types of limi-
Self-Care Deficit (Dependent-Care tations in relationship to the particularized self-
Deficit) care requisites. These are generally described as
limitations of knowing, limitations or restric-
As a theoretical concept, self-care deficit ex- tions of decision-making, and limitations in
presses the value of the relationship between ability to engage in result-achieving courses of
two other concepts: self-care agency and ther- action. Orem classified these into sets of limi-
apeutic self-care demand (Orem, 2001). When tations (Orem, 2001, pp. 279–282).
the person’s self-care agency is not adequate to
meet all self-care requisites (TSCD), a self- Nursing System (Dependent-Care
care deficit exists. This qualitative and quanti- System)
tative relationship at the conceptual level of
abstraction is expressed as “equal to,” “more Orem describes a nursing system as an “action
than,” or “less than” (see Fig. 8-1). A deficit system,” an action or a sequence of actions per-
relationship is also described as complete or formed for a purpose. This is a composite of all
partial; a complete deficit suggests no capabil- the nurse’s concrete actions completed or to be
ity to engage in self-care or dependent care. completed for or with a self-care agent to pro-
An example of a complete deficit may exist in mote life, health, and well-being. The compos-
a premature infant in a neonatal intensive care ite of actions and their sequence produced by
unit. A partial self-care deficit may exist in a the dependent-care agent to meet the thera-
patient recovering from a routine bowel resec- peutic dependent self-care demand is termed
tion 1 day after surgery. This person is able to a dependent-care system (Taylor et al., 2001).
provide some self-care. These actions relate to three types of subsys-
tems: interpersonal, social/contractual, and
Understanding self-care deficit is necessary professional-technological.
to appreciate Orem’s concept of legitimate nurs-
ing. If a nurse determines a patient has self-care The interpersonal subsystem includes all
agency (estimative, transitional, and productive necessary actions or operations such as enter-
capabilities) to carry out a sequence of actions ing into and maintaining effective relation-
to meet the self-care requisites, then nursing is ships with the patient and/or family or others
not necessary. A self-care deficit or anticipated involved in care. The social/contractual subsys-
self-care deficit must exist before a nursing sys- tem relates to all nursing actions/operations to
tem is designed and implemented. The nurse reach agreements with the patient and others
reflects with the patient: Is self-care agency related to information necessary to determine
(and/or dependent-care agency) adequate to the therapeutic self-care demand and self-care
agency of an individual and caregivers. Within
this subsystem, the nurse, in collaboration with

CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 115

the patient or dependent-caregiver, determines With determination of a real or potential
roles for all care participants (Orem, 2001). self-care deficit or dependent-care deficit, the
These are based on social norms and other nurse develops one of three types of nursing
variables such as basic conditioning factors. systems: wholly compensatory, partly compen-
Although other nursing theories emphasize in- satory, or supportive-educative (developmen-
terpersonal interactions, Orem’s general theory tal). The nurse then continues the query: Who
clearly specifies details of interpersonal and can or should perform actions that require move-
contractual operations as necessary antecedents ment in space and controlled manipulation?
and concurrent components of care. This ele- (Orem, 2001, p. 350). If the answer is only the
ment of Orem’s model is often overlooked and nurse, then a wholly compensatory system is
clarifies the decision-making process and col- designed. If the patient has some capabilities
laborative relationship within the nurse– to perform operations or actions, then the
patient–family/multiperson roles. nurse and patient share responsibilities. If the
patient can perform all actions that control
The professional–technological subsystem movement in space and controlled manipula-
comprises actions/operations that are diagnostic, tion, but nurse actions are required for support
prescriptive, regulatory, evaluative, and case (physical or psychological), then the system is
management. The latter involves placing all supportive–educative. Note, in all systems, the
operations within a system that uses resources self-care deficit is the necessary element that
effectively and efficiently with a positive pa- leads to the design of a nursing system. Using
tient outcome. Orem views the professional– the interpersonal and social–contractual oper-
technological subsystem as the process of ations, the nurse first enters into an interper-
nursing, a nonlinear one that integrates all sonal relationship and an agreement to
operations of this subsystem with those of the determine a real or potential self-care deficit,
interpersonal and the social–contractual. This prescribe roles, and implement productive
involves collecting data to determine existing operations of self-care and/or dependent
and projected universal, developmental, and care. Regulation or treatment operations are
health-deviation self-care requisites, and meth- designed or planned and then produced or
ods to meet these requisites as adjusted by the performed. Control operations are used to
basic conditioning factors. Using the interper- appraise and evaluate the effectiveness of
sonal and social–contractual subsystems, the nursing actions and to determine whether
nurse incorporates modifications of her or his adjustments should be made. These ap-
diagnosis and prescriptions in collaboration with praisals emphasize validity of operations or
the patient and family on what is possible. The actions in relationship to standards. Selecting
nurse also identifies the patient’s usual self-care valid operations in the plan and in evaluation
practices and assesses the person’s estimative, incorporate evidence-based practices. These
transitional, and productive capabilities for processes, including diagnosis, prescription,
knowledge, skills, and motivation in relationship designing, planning, regulating, and control-
to the known self-care requisites. That is, are the ling, can be viewed as elements of Orem’s
capabilities (self-care agency/dependent-care steps in the process of nursing (Fig. 8-3).
agency) needed to meet the self-care requisites
developed, operable, and adequate? Are there Orem’s language of the nursing process
limitations in knowing, deciding, or producing varies from the standard language of assess-
self-care? If no limitations exist, then there is no ment, diagnosis, planning, implementation,
need for nursing and no nursing system is devel- and evaluation. The interaction of the three
oped. If there is a self-care deficit or dependent- aforementioned subsystems creates a model for
care deficit, then the nurse and patient or true collaboration with the recipient of care or
caregivers reach agreement about the patient’s the caregiver.
role, the family’s role, and/or the nurse’s role.
Orem (2001) charted the progression of these The three steps of Orem’s process of nurs-
steps by subsystems (pp. 311, 314–317). ing are as follows: (1) diagnosis and prescrip-
tion, (2) design and plan, and (3) produce and

116 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Accomplishes patient’s (capabilities)? What, if any, are limitations
therapeutic self-care for deliberate action related to the estimative
(investigative–knowing), transitional (decision
Nurse Compensates for patient’s making), and productive (performing) phases
action inability to engage in of self-care? (Orem, 2001, p. 312). The nurse
self-care collects information, analyses it, and makes
judgments about the information within the
Supports and protects limits of nursing agency (capabilities of the
patient nurse, such as expertise).

Wholly compensatory system Orem describes nursing as a specialized
helping service and identifies five helping
Performs some self-care methods to overcome self-care limitations or
measures for patient regulate functioning and development of pa-
tients or their dependents. Nurses employ one
Compensates for self-care or more of these methods throughout the
limitations of patient process of nursing, including acting for or
doing for another, guiding another, supporting
Nurse Assists patient as required another, providing for a developmental envi-
action ronment, and teaching another (Orem, 2001,
pp. 56–60). Acting for or doing for another in-
Performs some self-care cludes physical assistance such as positioning
measures the patient. Assuming self-care agency that is
developed and operable, the nurse replaces this
Regulated self-care Patient method with others that focus on cognitive de-
agency action velopment, such as guiding and teaching.
These methods are not unique to nursing, but
Accepts care and are used by most health professionals. Through
assistance from nurse their unique role functions, nurses perform a
specific sequence of actions in relationship to
Partly compensatory system the identified patient and/or dependent-care
agent’s self-care limitations in combination
Nurse Accomplishes self-care Patient with other health professionals to meet the
action action self-care requirements.
Regulates the exercise
and development of Although comparisons are made between
self-care agency these steps and those of the general nursing
process, Orem’s complexity is unique in ad-
Supportive-educative system dressing an integration of interpersonal, social–
Fig 8 • 3 Basic nursing system. contractual, and professional–technological
subsystems. The intricacy of her steps is also ev-
control. For example, Orem considers the term ident in the complexity of the diagnostic and
“assessment” too limiting. Within Orem’s prescriptive components. The practice exemplar
process, assessments are made throughout the in this chapter provides one simplified example
iterative social–contractual and professional- of this process.
technological operations. During the first step
of diagnosis, data are collected on the basic Nursing Agency
conditioning factors and a determination is
made about their relationship to the self-care Nursing agency is the power or ability to nurse.
requisites and to self-care agency. How does The agency or capabilities are necessary to know
health state (e.g., type 2 diabetes) affect the and meet patients’ therapeutic self-care demands
individual’s universal, developmental, and and to protect and to regulate the exercise of devel-
health-deviation self-care requirements? How opment of patient’s self-care agency (Orem, 2001,
does the basic conditioning factor, or health
state, affect the individual’s self-care agency

CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 117

p. 290). Nursing agency is analogous to self- groups, and communities, where the recipient
care agency but with capabilities performed on of nursing care is more than a single individual
behalf of “legitimate patients.” Similar to self- with a self-care deficit. They distinguished
care agency, nursing agency is affected by basic among types of multiperson units, such as
conditioning factors. The nurse’s family system, community groups and family or residential
as well as nursing education and experience, group units. These authors present categories
may affect his or her ability to nurse. of multiperson care systems, create family and
community as basic conditioning factors, and
Orem categorizes nursing capabilities present a model of community as aggregate.
(agency) as interpersonal, social–contractual, This model appropriately incorporates addi-
and professional-technological. That is, the tional basic conditioning factors such as public
nurse must have capabilities within each of the policy, health-care system changes, and com-
subsystems described in the nursing system. munity development. Other frameworks such
Capabilities that result in desirable interper- as a community participation model have been
sonal nurse characteristics include effective developed (Isaramalai, 2002).
communication skills and ability to form rela-
tionships with patients and significant others. Community groups have a selected number
Social–contractual characteristics require of common self-care requisites and/or limita-
the ability to apply knowledge of variations in tions of knowledge, decision making, and pro-
patients to nursing situations and to form con- ducing care. These can be based on requirements
tracts with patients and others for clear of entire communities, groups within the com-
role boundaries. Desirable professional– munities, or to other situations when groups
technologic characteristics require the ability have common needs. For example, the focus of
to perform techniques related to the process of a student health nurse at a university may be a
nursing: diagnosis of therapeutic self-care de- group of first-year students and the self-care req-
mand of an assigned patient with considera- uisite, prevention of the hazards of alcohol poi-
tion of all self-care requisites (universal, soning. The self-care limitations of the group
developmental, and health deviation) and a may be knowledge of binge drinking outcomes
concomitant diagnosis of a patient’s self-care and the skills to resist peer pressure at parties.
agency. Other desired nurse characteristics in- This environment and situation, the college mi-
clude the ability to prescribe roles: Assuming lieu and new independence, creates the common
a self-care deficit (and therefore a legitimate set of self-care requisites. The action system de-
patient), what are the roles and related respon- signed by the college health nurse is to develop
sibilities of the nurse, the patient, the aide, and the knowledge, decision-making, and result-
the family? Nurses must also have the ability producing skills of new students collectively so
to know and apply care measures such as gen- life, health, and well-being are enhanced for the
eral helping techniques (teaching, guiding) and group, as well as the college community.
specialized interventions and technologies
such as those identified with evidence-based Family or others in a communal living
practice. These necessary nursing capabilities arrangement are another type of multiperson
also have implications for nursing education unit of service. Because of the interrelationship
and nursing administration. Knowledge of all of the individuals in the living unit, the purpose
components of nursing agency will direct nurs- of nursing varies from that for a community
ing curricula for successful development of group. In this situation, the focus is often an
nursing abilities. Likewise, knowledge related individual, as well as the family as a unit. The
to nursing administration is critical to oper- health-related requirements of one individual
ability of nursing agency (Banfield, 2011). trigger the need for nursing but also affect the
unit as a whole. In one situation, an elderly par-
Multiperson Situations and Units ent moves into the family home. Not only is
the therapeutic self-care demand of the parent
Taylor and Renpenning (2001) extended ap- involved, but also the needs of family members
plication of Orem’s concepts to families, as it affects their self-care requisites. The health

118 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

of the unit is therefore established and main- Child and Adolescent Self-Care Performance
tained by meeting the therapeutic self-care de- Questionnaire (Jaimovich, Campos, Campos
mands of all members and facilitating the & Moore, 2009); The Nutrition Self-Care
development and exercise of self-care agency Inventory (Fleck, 2012); and Self-Care
for each group member (Taylor & Renpen- Outcomes (Valente, Saunders, & Uman,
ning, 2011). 2011).

Applications of the Theory A few Orem scholars continue with devel-
opment of theoretical elements through well-
Nursing Education Applications designed programs of research with specific
populations. For example, Armer et al. (2009)
Many educational programs used Orem’s con- studied select power components (elements
ceptualizations to frame the curriculum and to of self-care agency) to describe those important
guide nursing practice (Hartweg, 2001; Ransom, in developing supportive-educative nursing
2008). Taylor and Hartweg (2002) found systems with postmastectomy breast cancer
Orem’s conceptualization was the most fre- patients. A secondary analysis of this study
quently used nursing theory in U.S. programs. contributed to identification of the types of
Examples of Orem-based schools included self-care limitations experienced by this popula-
Morris Harvey College in Charleston, West tion. The results have potential to promote effec-
Virginia, Georgetown University, the University tive nursing interventions (Armer, Brooks, &
of Missouri—Columbia, and Illinois Wesleyan Steward, 2011). Research is needed on actions
University (Taylor, 2007). Current application and methods to meet health deviation self-care
of Orem’s theory in nursing education ranges requisites in a variety of specific health situations
from application to pedagogy in a hybrid (Casida, Peters, Peters, & Magnan, 2009).
RN-BSN course in the United States (Davidson,
2012) to use as a general framework for nursing Many studies use SCDNT as a framework
education in Germany (Hintze, 2011). for research and reference select concepts but
with limited application (Lundberg & Thrakul,
Research Applications 2011). For example, Carthron and others
(2010) used Orem’s SCDNT to guide research
The use of SCDNT as a framework for re- related to specific concepts such as therapeutic
search continues to increase with application self-care demand and self-care agency. How-
to specific populations and conditions. Studies ever, a family system factor (the primary care
range from those with general reference to role of grand-mothering) on type 2 diabetes
Orem’s theory to more sophisticated explo- self-management was the primary emphasis
ration of concepts and their relationships. within the study. Other studies combine ele-
Early Orem studies concentrated on theory ments from SCDNT with other theories with-
development and testing, including creation of out consideration of the congruence of
theory-derived research instruments (Gast et al., underlying assumptions. For example, Single-
1989), a necessary process in theory building. ton, Bienemy, Hutchinson, Dellinger, and
Examples of widely used concept-based instru- Rami (2011) framed their study in part within
ments include those by Denyes (1981, 1988) Orem’s theory of self-care as well as in the
on self-care practices and self-care agency. The health belief model and the concept of self-
Appraisal of Self-care Agency (ASA scale) was efficacy. This combination of concepts and
an early tool used in international research (van theories in research studies is common. Fur-
Achterberg et al., 1991) and later modified for ther, Klainin and Ounnapiruk (2010) summa-
specific populations (West & Isenberg, 1997). rized research findings from 20 studies of
More recent instruments derive from structural Thai elderly guided by Orem’s SCDNT. Al-
components of SCDNT but are applicable in though their analysis revealed two of six major
more specific situations: Self-Care for Adults concepts and one peripheral concept were
on Dialysis Tool (Costantini, Beanlands, & evident in the research, many studies explored
Horsburgh, 2011); Spanish Version of the other non–SCDNT-specific concepts such as

CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 119

self-concept, self-efficacy, and locus of control. Table 8-1 provides examples of domestic
The authors suggest that SCDNT should be and international theory development and
revisited to include additional concepts to practice-related research conducted in the past
strengthen the theory. 5 years at the time of this writing.

Table 8 • 1 Examples of Research Applications

Author (Year), Purpose Population/ SCDNT Results
Country Settings Concept(s) Methods
Identified types
Armer, Brooks, & To examine Breast cancer SCA, Secondary of self-care limi-
Steward (2011), patient per- survivors, tations in rela-
USA ceptions of postsurgery especially analysis of tionship to sets
SC limitations (N = 14) of limitations,
Arvidsson, to meet TSCD estimative, qualitative e.g., “know-
Bergman, to reduce Rheumatic ing.” Most limi-
Arvidsson, lymphedema disease transi- data from tations were not
Fridlund, & Tops patients related to lack
(2011), Sweden To describe (N = 12) tional, and pilot study of knowledge
the meaning but to energy,
of health- productive (Armer patterns of liv-
promoting ing, etc. Em-
SC in pa- phases of et al., phasized the
tients with “supportive”
rheumatic self-care 2009) element in this
diseases nursing system.
necessary Perspectives re-
vealed that SC
to de- requires dia-
logues with the
crease body and envi-
ronment, power
risk of lym- struggles with
the disease,
phedema; and making
choices to fight
supportive- the disease. SC
was viewed as
educative a way of life.
SCA predicted
nursing SC. Education,
employment,
system and health sta-
tus facilitated
Health- Phenome- SC practices;
smoking and
promoting nology chronic condi-
tions were
SC barriers.
Before and
Burdette (2012), To examine Rural midlife BCFs, Predictive after beginning
USA relationship SCA, and correla- caregiving:
among SCA, women SC prac- tional GMs were sta-
SC, and (N = 224) tices; com- design tistically differ-
obesity plemented was used. ent with fewer
with rural days of eating
nursing
theory Continued

Carthron, To compare African BCF (fam- Nonexper-
Johnson, Hubbart, diabetes self- American ily system imental,
Strickland, & management GMs with factor of compara-
Nance (2010), activities of type 2 grand- tive design
USA primary care- diabetes mother
giving grand- (N = 68, 34 role;
mothers (GM) per group) patterns of

120 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Table 8 • 1 Examples of Research Applications—cont’d

Author (Year), Purpose Population/ SCDNT Methods Results
Country Settings
before and Concept(s) a healthy diet
after begin- and fewer per-
ning caregiv- living); formed self-
ing activities; TSCD; management
to compare SCA, blood glucose
these GMs’ especially tests. Fewer self-
self-manage- power management
ment activi- compo- blood glucose
ties with nents tests and fewer
those of GMs eye examina-
not providing tions were per-
primary care formed by GMs
providing pri-
Kim (2011), To determine Prostate can- SCA; Quasi- mary care to
Korea effectiveness quality experimen- grandchildren.
of a program cer patients of life tal; non- Significant dif-
to develop (N = 69) equivalent ference was
SCA based control found between
on SC needs group using self-care
specific to pre–post agency and
prostatectomy test design quality of life in
treatment
Lundberg & To explore Thai Muslim Orem’s Ethno- group vs con-
Thrakul (2011), Thai Muslim women living SCDNT graphic trol group at
Sweden & women’s self- in Bangkok was used study using 8 weeks after
Thailand management (N = 29) as frame- participant prostatectomy.
of type 2 work observation Four themes
diabetes emerged on self-
management:
Ovayolu, To explore re- Turkish pa- SCA; Cross- daily life prac-
Ovayolu, & lationship tients with Factors re- sectional; tices (dietary, ex-
Karadag (2011), among SCA, rheumatoid lated to descriptive– ercise, medicine,
Turkey disability lev- arthritis (RA) health- correla- doctor follow-up,
els, and other (N = 467) care, such tional blood sugar
factors as pain self-monitoring,
and dis- use of herbal
ability remedies), af-
level. fect of illness,
family support
and need for
everyday life
as before
diagnosis (e.g.,
maintaining
religious prac-
tices during
Ramadan).
For patients
with RA, pa-
tients with
higher disabil-
ity and pain
had lower self-
care agency.
The potential for
development of

CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 121

Table 8 • 1 Examples of Research Applications—cont’d

Author (Year), Purpose Population/ SCDNT Methods Results
Country Settings Concept(s)
Quasi- knowledge,
Rujiwatthanakorn, To examine Thais with SC de- experimen- skills, and re-
Panpakdee, effectiveness essential mands, tal sources neces-
Malathum, & of a SC man- hypertension self-care sary for SC
Tanomsup (2011), agement (N = 96) ability Descriptive were identified.
Thailand program and case study Patients in treat-
blood ment group
pressure Descriptive/ had higher
control compara- knowledge of
tive self-care de-
Surucu & Kizilci To explore Type 2 dia- TSCD, mands and self-
(2012), Turkey the use of betes patients HDSCR, care ability
SCDNT in di- regarding med-
abetes self- SCA ication, dietary,
management physical activity,
education self-monitoring.
Both systolic
Thi (2012), South To describe Hepatitis B in- SCA (SC and diastolic
Vietnam levels of SC patients and knowl- readings of
knowledge in outpatients edge), treatment group
patients (N = 230) SCR, were lower
BCFs than control
group.
Demonstrated
improvement in
health indica-
tors after design
of a nursing sys-
tem directed at
deficits in SCA
related to
HDSCR.
51% of patients
had the re-
quired hepatitis
B SC knowl-
edge, espe-
cially need for
exercise, rest,
and methods of
prevention of
transmission
through sexual
activity. There
was a knowl-
edge deficit re-
lated to diet and
management/
monitoring of
disease.
Level of educa-
tion, type of
occupation,
previous health
education, and

Continued

122 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Table 8 • 1 Examples of Research Applications—cont’d

Author (Year), Purpose Population/ SCDNT Methods Results
Country Settings Concept(s)
health-care set-
Wilson, To determine Urban radia- SCA: SC Nonexperi- ting affected
Mood, whether tion oncology knowledge mental, levels of SC
Nordstrom reading low clinic pa- of radia- exploratory knowledge.
(2012), USA literacy pam- tients, tion side Knowledge
phlets on (N = 47) effects about radiation
radiation side effect man-
side effects agement var-
affect patient ied by literacy
knowledge level despite
low literacy
level of pam-
phlets. Sup-
ported premise
that founda-
tional capaci-
ties for self-care
include skills
for reading,
writing, com-
munication per-
ception and
reasoning.

Note. BCF = basic conditioning factors; HDSCR = health deviation self-care requisites; SC = self-care or self-care practices;
SCA = self-care agency; SCDNT = self-care deficit nursing theory; SCR = self-care requisites; TSCD = therapeutic self-care demand.

Practice Applications Table 8-2 provides examples of specific prac-
tice applications in the past 5 years at the
Nursing practice has informed development time of this writing.
of SCDNT as SCDNT has guided nursing
practice and research. Biggs (2008) con- One theoretical application to nursing prac-
ducted a review of nursing literature from tice exemplifies the continued scholarly work
1999 to 2007. The results revealed more necessary for practice models and addresses
than 400 articles, including those in Inter- one deficit area noted by Biggs (2008). Casida
national Orem Society Newsletters and Self- and colleagues (2009) applied Orem’s general
Care, Dependent-Care, and Nursing, the theoretical framework to formulate and de-
official journal of the International Orem velop the health-deviation self-care requisites
Society. Although Biggs noted a tremendous of patients with left ventricular assist devices.
increase in publications during that period, This article specifies not only the self-care
the author observed that SCDNT research requisites for this population but also the nec-
has not always contributed to theory progres- essary subsystems unique to practice applica-
sion and development or to nursing practice. tions. This work illustrates the complexity of
She identified deficient areas such as those SCDNT and also the utility of SCDNT for
related to concepts such as therapeutic self- patients with all types of technology assisted
care demand, self-care deficit, nursing sys- living.
tems, and the methods of helping or
assisting. Recent publications on Orem based One change in the past few years has been
practice address areas identified by Biggs. an emphasis on self-management rather than or
in conjunction with self-care (Ryan, Aloe, &

CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 123

Table 8 • 2 Examples of Practice Applications

Patient or Practice

Author (Year), Health or SCDNT Focus (Selected
Country Illness Focus Concept(s)
Alspach Hypertension/ Settings SC Examples) Other
(2011), USA heart failure Critical care
in elderly unit HDSCR, in- Development Editorial
Casida, Acute care cluding SC of checklist demonstrating
Peters, Peters, Left-ventricular systems tool to meas- use of theoreti-
& Magnan assist devices School setting ure SC at cal framework
(2009), USA (LVAD) SCR; SCD; home after to design a
Acute care BCF; SCA; critical care brief checklist
Green Children with settings DCA; SCS discharge
(2012), USA special needs Reformulation An exemplar
Community SCDNT of HDSCR for the six HD-
Hohdorf Hospitalized dialysis unit common to SCRs specific
(2010), patients SCDNT as patients with health situation
Germany framework; LVAD using and model for
Adults with all concepts five guidelines developing
Hudson & hemodialysis including NA described by other condi-
Macdonald arteriovenous Orem (2001) tions using
(2010), fistula self- to validate multifaceted
Canada cannulation form and technological
adequacy care
Demonstration An example of
of utility of types of nurs-
SCDNT ing systems
through two
case studies: One hospital’s
wholly com- goal to im-
pensatory sys- prove quality
tem for child care and de-
with cerebral crease length
palsy; partly of stay by mov-
compensatory ing to theory
for child with based practice
asthma; and An example of
supportive- application or
educative sys- SCDNT to ar-
tem for diabetic. teriovenous
Exemplified fistula SC
change of
focus to
theory-based
nursing
practice

Demonstration
of SCDNT as
guide to de-
velop and
update patient-
teaching re-
sources in
preparation for
home care; as-
sisted nurses
with role
clarification

Continued

124 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Table 8 • 2 Examples of Practice Applications—cont’d

Patient or Practice

Author (Year), Health or SCDNT Focus (Selected
Country Illness Focus Concept(s)
Pickens Adults with Settings Examples) Other
(2012), USA schizophrenia Psychiatric
nursing care SCA: Explored vari- Theoretical
Seed & Acute psychi- motivation ous theories paper incorpo-
Torkelson atric care Recovery component of motivation rating elements
(2012), USA principles to develop of other theo-
Use of SCDNT con- SCDNT’s ries to expand
Surucu & SCDNT in University set- cepts in align- foundational supportive-
Kizilci, type 2 dia- ting; diabetes ment with capability developmental
(2012), betes self- education recovery can and power technologies in
Turkey management center be used to component of patients with
Swanson & education structure inter- motivation serious mental
Tidwell Integration Orem’s self- ventions and illness
(2011), USA model of care deficit research in SCDNT pro- Demonstrates
shared gover- theory as acute psychi- vided a com- use of SCDNT
Wanchai, nance using general prac- atric settings prehensive toward partner-
Armer, & magnet com- tice frame- framework based relation-
Stewart ponents to work BCFs; SCA; for delivering ships for
(2010), USA, promote pa- SCD; TSCD, interventions recovery from
Canada, tient safety Multiple with empha- that empower mental illness
Germany settings sis on HDSCR individuals to
Breast cancer based on make choices This case study
survivors review of 11 SCA; SCD; in care and provides an ex-
studies from helping treatment emplar for self-
1990 methods through part- management of
through nerships and type 2 diabetes
2009 SCA education
Implemented SCDNT as
steps of gen- component of
eral nursing health system
process using practice model
Orem-specific
concepts
Demonstrates
incorporation
of SCDNT as
the theoreti-
cal guide to
professional
practice at
one institution
and its com-
bination
shared gover-
nance to en-
hance patient
safety
SC agency
enhancement
through use
of comple-
mentary or
alternative
therapies to
meet HDSCR,
specifically to

CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 125

Table 8 • 2 Examples of Practice Applications—cont’d

Patient or Practice

Author (Year), Health or SCDNT Focus (Selected
Concept(s)
Country Illness Focus Settings Examples) Other

maintain
physical and
emotional
well-being
and to man-
age side ef-
fects of
treatment

BCFs = basic conditioning factors; DCA = dependent-care agency; HDSCR = health deviation self-care requisites; NA =
nursing agency; SC = self-care; SCA = self-care agency; SCD = self-care deficit; SCR = self-care requisites; SCS = self-care
systems; TSCD = therapeutic self-care demand.

Mason-Johnson, 2009; Sürücu & Kizilci, In addition to creating models for specific
2012; Swanlund, Scherck, Metcalfe, & Jesek- health-care conditions, Orem’s SCDNT is
Hale, 2008; Wilson, Mood, & Nordstrom, also used as a general framework for nursing
2012). Orem (2001) introduced the term practice in health care institutions. For ex-
self-management in her final book, defining the ample, Cedars Sinai Medical Center in Los
concept as the ability to manage self in stable or Angeles, California, integrates SCDNT with
changing environments and ability to manage one’s its shared governance model to promote pa-
personal affairs (p. 111). This definition relates tient safety (Swanson & Tidwell, 2011).
to continuity of contacts and interactions one However, most practice applications use the
would expect over time with nursing, especially general theory or elements of the theory with
when caring for people with chronic conditions specific populations. Table 8-2 includes di-
such as diabetes. By nature, chronic disease vari- verse examples from English publications.
ations over time are collaboratively managed However, the reader is also directed to non-
by the self-care agent, dependent-care agent, English publications including examples
the nurse agent, and others. The dependent- from practitioners or researchers in Brazil
care theory enhances the self-management (Herculano, De Souse, Galvão, Caetano, &
component, a uniqueness of SCDNT (Casida Damasceno, 2011) and China (Su & Jueng,
et al., 2009). With increases in chronic illness 2011).
and treatment, especially in relationship to
allocation of health-care dollars, countries such To further develop the sciences of self-
as Thailand now emphasize self-management care related to specific self-care systems and
versus self-care in health policy decisions to nursing systems for diverse populations
(personal communication, Prof. Dr. Somchit around the globe, collaboration will be nec-
Hanucharurnkul, January 15, 2013). Taylor and essary between reflective practitioners and
Renpenning (2011) presented diverse perspec- scholars (Taylor & Renpenning, 2011).
tives on self-management, describing it first Orem’s wise approach to theory develop-
as a subset of self-care with emphasis on creat- ment, combining independent work with
ing a sense of order in life using all available formal collaboration among practitioners,
resources, social and other. Another perspective administrators, educators, and researchers
relates to controlling and directing actions in will determine the future of self-care deficit
a particular situation at a particular time. This nursing theory. The International Orem So-
includes incorporating standardized models for ciety for Nursing Science and Scholarship
self-management in specific health situations continues as an important avenue for collab-
such as diabetes. orative work among expert and novice
SCDNT scholars around the globe.

126 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Practice Exemplar

Provided by Laureen M. Fleck, PhD, worships in a community-based black church,
FNP-BC, CDE a source of spiritual strength and social support.
Marion has a high school education.
Marion W. presents to a primary care office
seeking care for recent fatigue. She is assigned Questions about health state and health
to the nurse practitioner. The nurse explains system reveal Marion has type 2 diabetes that
the need for information to determine what was diagnosed more than 5 years ago. Except
needs to be done and by whom to promote for periodic fatigue, she believes she has man-
Marion’s life, health, and well-being. Infor- aged this chronic condition by following the
mation regarding Marion is gathered in part treatment plan, faithfully taking oral medica-
using Orem’s conceptualizations as a guide. tion, and checking blood sugar once per day.
First, the nurse introduces herself and then de- The morning reading was 230 mg/dL. Al-
scribes the information she will seek to help though the family has no health insurance,
her with the health situation. Marion agrees Marion has access to the community health
to provide information to the best of her care clinic and free oral medications. There is
knowledge. As the nurse and Marion have en- a small co-pay for her blood glucose testing
tered into a professional relationship and strips, which is now a concern. The children
agreed to the roles of nurse and patient, the receive health care through the State Chil-
nurse initiates the three steps of Orem’s dren’s Health Insurance Program. The neigh-
process of nursing: borhood Marion lives in has a safe, outdoor
environment. The latter has been a comfort
Step 1: Diagnosis and Prescription because she works as a crossing guard and
I. Basic Conditioning Factors walks her children to school. Although she en-
joys this exercise, her increasing fatigue dis-
As basic conditioning factors affect the value courages additional exercise.
of therapeutic self-care demand and self-care
agency, the nurse seeks information regarding When asked about her perception of her
the following: age, gender, developmental current condition, Marion expressed concern
state, patterns of living, family system factors, for her weight and considers this a partial ex-
sociocultural factors, health state, health-care planation for the fatigue. She desires to lose
system factors, availability and adequacy of re- weight but admits she has no willpower,
sources, and external environmental factors snacks late at night, and finds “healthy foods”
such as the physical or biological. too expensive. At 205 lbs (93 kg) and 5 feet
3 inches (1.6 m), Marion is classified as obese
Marion is 42, female, in a developmental with a body mass index of 38 kg/m2.
stage of adulthood where she carries out tasks II. Calculating the Therapeutic Self-Care Demand
of family and work responsibilities as a produc-
tive member of society. The history related to With Marion, the nurse identifies many ac-
patterns of living and family system reveals em- tions that should be performed to meet the
ployment as a school crossing guard, a role that universal, developmental, and health devia-
allows time after school with her children, ages tion self-care requisites. Her health state and
5, 7, and 9. Her husband works for “the city” health system factors (including previous
but recently had hours cut to 4 days per week. treatment modalities) are major conditioners
Therefore, money is tight. They pay bills on of two universal self-care requisites: maintain
time, but no money remains at the end of the a sufficient intake of food and maintain a
month. She has learned to stretch their money balance between activity and rest. Throughout
by shopping at the local discount store for the interview, the nurse determines that
clothes and food and cooking “one-pot meals” Marion is clear about her chronic condition
so that they have leftovers to stretch through- and has accepted herself in need of continued
out the week. As an African American, she monitoring and care, including quarterly

CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 127

Practice Exemplar cont. 4. Seek assistance from health professional
when levels are below 60 mg/dL and not
hemoglobin A1C and lipid blood tests responsive to sugar intake or higher than
(American Diabetes Association [ADA], 300 mg/dL with feelings of fatigue, thirst,
2013) or visual disturbances.

Two health deviation self-care requisites also 5. Adjust activity and meal planning/portion
emerge as the primary focus for seeking helping sizes when levels are not within parameters.
services: being aware and attending to effects
and results of pathological conditions; and B. Make healthy food choices.
effectively carrying out medically prescribed
diagnostic and therapeutic measures. Without 6. Seek knowledge of healthy food choices
additional self-care actions beyond the pre- for family meal planning from dietitian at
scribed medication, short walks, and daily blood clinic.
glucose testing, the risks of uncontrolled dia-
betes may lead to diabetic retinopathy, 7. Review family expenses with health pro-
nephropathy, neuropathy, and cardiovascular fessional to adjust grocery budget to pur-
disease (ADA, 2013). chase affordable but healthy foods.

One particularized self-care requisite 8. Eat three balanced meals per day including
(PSCRs) is presented as an example, with midmorning, afternoon, and evening
the related actions Marion should perform to snack as desired. These meals and snacks
improve her health and well-being. Once the will have portion sizes established between
actions to be performed and concomitant meth- Marion and the nurse.
ods are identified, then the nurse determines
Marion’s self-care agency: the capabilities of 9. All meals will have a selection of protein,
knowing (estimative operations), deciding fats, and carbohydrates, and the snacks
(transitional operations), and performing these will be limited to 15 grams of carbohy-
actions (productive operations). drate or less (ADA, 2013).

PSCR: Reduce and maintain blood glucose C. Increase physical activity to 150 minutes/
level within normal parameters through in- week of moderate intensity exercise (ADA,
creased blood glucose monitoring, appropriate 2013).
healthy food choices, and increased activity. If
this PSCR is achieved, Marion’s weight will be 10. Gain knowledge regarding step-walking
decreased, a related purpose that provides mo- program to increase activity. Discuss
tivation to engage in self-care. The methods to community options for safe walking areas.
achieve the PSCR include detailed actions:
A. Increase blood glucose monitoring to twice 11. Explore budget to include properly fitting
per day; set goals for 100–110 mg/dL fasting footwear. Tennis shoes with socks are to
and <140 mg/dL at 2 hours after a main meal. be worn for each walk. Obtain free pe-
dometer from clinic to measure perform-
1. Obtain discounted glucose monitoring ance of steps and walking.
strips from ABC drug company.
12. Review pedometer measures three times a
2. Obtain assistance from community clinic week. Increase steps by 10% each week if
for monthly replacement request to ABC natural increase in steps has not occurred.
drug company. For example, if walking 2000 steps/walk
increase next walk by 200 steps as a goal.
3. Monitor glucose level through testing two Maintain goals until 10,000 step/day is
times per day, with one test before break- achieved (ADA, 2013).
fast and one test 2 hours after a main meal.
Add more testing when needed for symp- III. Determining Self-Care Agency
toms of high or low blood sugar (ADA, The nurse and Marion then seek information
2013). about self-care agency or the capabilities
related to knowledge, decision making, and

Continued

128 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm

Practice Exemplar cont. performing the necessary actions is intact
to meet the particularized self-care requi-
performance necessary to meet this PSCR. site, maintain blood glucose level at 100–
This includes the ability to seek and obtain re- 110 mg/dL fasting and <140 mg/dL at
quired resources important to each action. 2 hours after a main meal.
What capabilities are necessary to increase 2. Dietary practices: The nurse seeks infor-
blood glucose testing? Does Marion have the mation from Marion on her knowledge of
knowledge about access to drug company re- effective dietary practices and healthy
sources (testing strips) available to persons foods, including flexibility in the family
with their income level? Does she have the budget, shopping practices, and family
communication skills to seek resources from cultural practices that may influence her
the community center? Does she have the food purchases. The nurse learns Marion
knowledge regarding blood glucose parame- has misinformation about her selected
ters and methods to adjust exercise and diet to foods and is aware of resources, such as the
maintain the levels? The nurse and Marion to- local health department that offers free
gether determine capabilities for each of these classes by a registered dietitian. However,
components of each action necessary to meet transportation to dietary classes is not pos-
her particularized self-care requisite. sible because her husband uses the only car
to drive to work. Although Marion under-
After collecting and analyzing data about stands the relationship of her high blood
her abilities in relationship to the required glucose levels to the resulting fatigue, she
actions, the nurse determines the absence or seems to focus on losing weight, a possible
existence of a self-care deficit—that is, is self- motivational asset. Marion maintains the
agency adequate to meet the therapeutic self- ability to shop, cook, use the stove safely,
care demand? The nurse quickly determines and ingest all food types.
throughout the data collection period that 3. The nurse assesses that Marion enjoys
Marion’s foundational and disposition capa- walking and generally feels safe in the sur-
bilities (necessary for any deliberate action) rounding environment. She also has time
and the power components (necessary for self- while the children are at school to take
care) are developed and operable. The question walks. The nurse discovers that Marion is
is the adequacy of self-care agency in relation- not aware of proper foot care or the step
ship to this PSCR. program for increasing exercise. Marion
does not believe the family budget can
1. Blood glucose monitoring: The nurse manage both changes in food purchases as
learns that Marion possesses necessary ca- well as the purchase of good walking shoes.
pabilities of knowing, deciding, and per-
forming to obtain additional testing strips IV. Self-Care Limitations
from ABC drug company and to increase
her blood glucose testing to two times per Marion has self-care limitations in the area of
day. After questioning, the nurse deter- knowledge and decision making about re-
mines Marion is aware of norms and in quired dietary actions. The limitations of
general the effect of food and exercise. In knowing are related to healthy dietary prac-
addition to verbalizing available time for tices. This includes the use of carbohydrate
testing, Marion also recalls that the school counting. She lacks knowledge about purchas-
nurse where she works agreed to be a re- ing options for healthier foods and methods to
source if blood glucose readings are not incorporate these into her meal effort. Al-
within the required range. She agreed to though interested, she is unable to enroll in di-
seek out this resource if adjustment in ex- etary classes at the health department due to
ercise or food intake is needed. The nurse transportation issues. Marion has knowledge
practitioner concludes Marion’s self-care
capabilities of knowing, deciding, and

CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 129

Practice Exemplar cont. goal is to maintain blood glucose levels at
100–110 mg/dL fasting and <140 mg/dL at
and decision-making authority for managing 2 hours after a main meal, the priority actions
the family budget but has no experience incor- relate to dietary changes, followed by slow,
porating healthier foods into the planning. incremental changes in activity. The nurse
Marion also has self-care limitations in rela- expects it will take 1 month to obtain the
tionship to knowledge of the step program, necessary footwear. Objectives will be re-
proper footwear, and related foot care. No re- viewed at 1 month. Marion knows that
sources exist to purchase the necessary walking weight loss is her objective, but she must
shoes. Major capabilities include Marion’s start changes in dietary practices. The goal
ability to learn, availability of time, and her for weight loss will be set at the first
motivation to lose weight, and hence have less month’s meeting after attendance at the di-
fatigue. If Marion decides to make healthier etary sessions and initial experience with
food choices that are affordable and also in- changing the family’s food purchases and
crease her general activity, she will need mon- meal planning. Marion and the nurse prac-
itoring, counseling, and support from a health titioner begin implementing their roles as
professional related to the blood glucose levels, prescribed.
access to resources for classes, budgeting, and Step 3: Treatment, Regulation, Case Management,
purchase of equipment. Control/Evaluation

With analysis of self-care agency in rela- Marion and the nurse begin implementing
tionship to the particularized self-care requi- their agreed-on actions as they collaborate
site, the nurse and patient establish the within the nursing system. The nurse practi-
presence of a self-care deficit. Now that legit- tioner maintains contact via phone with Marion
imate nursing has been established, a nursing as she completes actions, such as seeking
system is designed. resources for the dietary classes and footwear.
Step 2: Design and Plan of Nursing System Marion contacts the school nurse where she
works to see if she will be a resource for
Now that the self-care limitations of knowing weekly reports on blood glucose levels. She
are identified, the nurse will use helping also seeks out additional testing strips and
methods of guiding and supporting by de- calls the clinic to obtain the routine forms for
signing a supportive-educative nursing sys- monthly renewal requests. They proceed
tem. The design involves planning Marion’s through each of these actions as agreed on as
activities to meet the particularized self-care social–contractual operations. Throughout
requisite with nurse guidance and monitoring this step, the interpersonal operations are
and also to establishing the nurse’s role. essential as the nurse evaluates Marion’s
Together they agree on communication progress and new roles are determined and
methods to work together to monitor progress agreed on. This continues over time, with
as Marion attends classes to learn healthy continued review of the design, the role pre-
dietary practices and increase activity. Marion scriptions, until Marion’s therapeutic self-
agrees to share information related to blood care demand is decreased or self-care agency
glucose testing with the school nurse and the is developed so no self-care deficit exists, and
pharmacist at the community clinic when nursing is no longer required.
refilling medication and supplies.
Throughout the process, nursing agency
The nurse agrees to seek out resources for was evident. The capabilities related to inter-
transportation to the health department for personal, social–contractual, and professional–
dietary classes, purchase of footwear, assis- technological operations were evident.
tance to fill out forms, and also to meet with
Marion every 2 weeks to review food con-
sumption and activity records. Although the