NUR 700 Discussion 2.1: Integrative and Transformative Theories in Practice
NUR 700 Discussion 2.1: Integrative and Transformative Theories in Practice
Dorothea Orem’s Self-Care Deficit Nursing Theory
The integrative theory that applies most to my clinical practice would be Dorothea Orem’s Self-Care Deficit Nursing Theory (SCDNT). The SCDNT is commonly seen in rehabilitative nursing because it focuses on teaching patients to care for themselves by giving them the knowledge and means to do so. I currently work in an 80-bed inpatient rehabilitation hospital that is stroke certified through The Joint Commission. This theory applies most to my clinical practice because a large part of my job is treating patients with some form of a self-care deficit. Nursing patients who have been newly affected by a cerebrovascular accident (CVA) or stroke will require teaching and education on new techniques and methods regarding how to care for themselves following a stroke. Patients affected by stroke commonly have to relearn many basic activities of daily living (ADLs). Common ADLs are eating, dressing, getting in or out of bed, toileting, bathing or showering, preparing meals, managing money, shopping, doing housework, using a telephone, etc. Using Orem’s SCDNT as the foundation for nursing interventions geared towards stroke patients helps to empower patients to not only participate in their care but to recognize and respond to potential future strokes (Sposito et al., 2018). The SCDNT is comprised of four concepts (Smith, 2020). The concepts are the Theory of Self-Care, the Theory of Self-Care Deficit, the Theory of Nursing Systems, and finally the Theory of Dependent Care (Irshad-Ali, 2018). The Theory of Self-Care focuses on intentionally performing tasks by one’s self that are necessary for life, human functioning, and health (Smith, 2020). The Theory of Dependent care focuses on the patient being in a dependent position or relationship, like that of a child and a parent (Smith, 2020). The Theory of Self-Care Deficit described why people need nursing such as health-related shortcomings for comprehending, determining, and yielding care to one’s self (Smith, 2020). Finally, the Theory of Nursing Systems encompasses the other three theories and adds the interpersonal relationship between the nurse and the patient (Smith, 2020).
One example of the application of the SCDNT is Ghani et al., (2019) description of a 62-year-old male patient affected by a CVA resulting in left hemiparesis and dysphagia. A holistic approach to the patient’s care was provided using the elements of the SCDNT. The care provided was based on creating a means for the patient to meet his own self-care needs. Using the SCDNT, the nurse was able
to assist and care for the patient while supplying an environment appropriate for enriching the remaining self-care skills and nurturing the development of new ones (Ghani et al., 2019). All of this was achieved through nasogastric tube feeding to prevent dehydration or malnutrition, providing rest breaks during activities to reduce fatigue, checking vital signs frequently, providing aids for communication and means for orientation, teaching affected extremity self-positioning techniques, demonstrating the use of adaptive tools and techniques for ADLs, teaching stroke signs and symptoms, medication management and education, and collaborating with other departments such as physical therapy, occupational therapy, speech therapy, the dietician, and physician (Ghani et al., 2019). Despite attempting to teach stroke patients to care for themselves, some deficits may remain that they are unable to accomplish, which is known as dependency (Sposito et al., 2018). It was concluded that although the patient did not recover fully, he showed remarkable improvement and gradual development of the ability to care for himself, develop new skills, and prevent recurrent stroke (Ghani et al., 2019). This was all achieved through nursing care that was based on Dorothea Orem’s SCDNT.
References
Ghani, N., Suliman, M., & Fatima, A. (2019). Application of Orem’s nursing theory to a stroke patient: A case study. Journal of Saidu
Medical College, 9(2), 273–277. https://doi.org/10.52206/jsmc.2019.9.2.
Irshad-Ali, B. H. (2018). Application of Orem self care deficit theory on psychiatric patient. Annals of Nursing and Practice, 5(1),
1093–1095. https://www.researchgate.net/profile/Bibi-Hajira-Wali/publication/343125237_Central_Bringing_Excellence_in_
Open_Access_Annals_of_Nursing_and_Practice_Application_of_Orem_Self_Care_Deficit_Theory_on_
Psychiatric_Patient/links/5f17bc21a6fdcc9626a685df/Central-Bringing-Excellence-in-Open-Access-Annals-of-
Nursing-and-Practice-Application-of-Orem-Self-Care-Deficit-Theory-on-Psychiatric-Patient.pdf
Smith, M. C. (2020). Nursing theories and nursing practice (5th ed.). F.A. Davis.
Sposito, J., Zipf, A., Alhowaymel, F., Almutairi, M., & Breda, K. (2018). Community-based stroke recognition education and response:
An evidence-based intervention project. Creative Nursing, 24(4), 251–257. https://doi.org/10.1891/1078-4535.24.4.251
Margaret Newman’s Theory of Health as Expanding Consciousness
The transformative and unitary theory that applies to my clinical practice would be Margaret Newman’s Theory of Health as Expanding Consciousness (HEC). As a nurse who works with breast cancer patients, Newman’s HEC theory helps embrace the skills needed to encourage patients and their families to engage openly and have meaningful relationships during their journey. Caring partnerships and relationships enable nurses to identify with cancer patients and helps patients going through the reconstruction process have a purpose during this difficult time. Relationships that are more open, meaningful, loving, caring, peaceful, and connected are expressions of an expanding consciousness (Smith, 2020). The evolution and transformation of patterns occur through the patient-environment interactions and how a patient relates to the environment (Endo, 2017). Newman defines patterns as “information that depicts the whole, understanding of the meaning of all the relationships at once” (Endo, 2017).
Nursing patients and families who have been affected by cancer is emotional, physical, and psychologically challenging. The order and disorder in the patient’s life are part of the expansion of consciousness, and there will be times breast cancer patients will have order in their life, and other times where it will be chaotic. Chemotherapy treatments, radiation, and surgical procedures can bring emotional and physical challenges, like increased weakness, radiation burns, not knowing how many other surgical treatments are in the future, or which surgical option is the best for their situation. Breast reconstruction can be a long process; this is not a one-and-done surgical option for women who choose this route after a mastectomy or lumpectomy. There is autologous-based reconstruction where women use their own body tissue to create a breast instead of expanders or implant base reconstruction. With autologous-based reconstruction, there is not a guarantee that flaps like a transverse rectus abdominis muscle (TRAM) or deep inferior epigastric artery perforator (DEIP) flaps will take. When surgical procedures do not go according to plan, this can become psychologically disappointing. Preparing patients for their breast reconstruction journey involves being present without judgment. I feel this quote by Newman holds true when caring for patients, “caring in its deepest, most respectful sense with a focus on what is important to the patient” (Smith, 2020).
Fujiwara & Endo (2017) chose to look at Newman’s theory of HEC from a unitary perspective based on caring partnership within the client-nurse relationship. This case study looked at a patient (Mrs. A) in her fifties diagnosed with advanced-stage IV cancer who lives with her husband, daughter, and mother-in-law. Unfortunately, treatment did not work, and Mrs. A avoided relating with people, including the nursing staff, and she shared vague information about her cancer diagnosis with her family. Newman’s caring partnership as a nursing intervention presented here provides a potential for connections between the patients and nurses, and at the same time, patients and their families (Fujiwara & Endo, 2017). The nurse senses that Mrs. A has a pattern of “being closed off,” she would find her hiding behind curtains. After developing a trusting partnership between the nurse and patient, Mrs. A began to open up. The key is pattern recognition. In this case study, the pattern was Mrs. A being “closed off.” Pattern recognition comes from within the observer (Fujiwara & Endo, 2017), and because of the benefit of this caring partnership that emerged between the patient and nurse resulted in more insight into the meaning of this patients’ pattern. Newman states, “ultimate consciousness has been equated with love, which embraces all experience equally and unconditionally: pain as well as pleasure, failure as well as success, ugliness as well as beauty, disease as well as nondisease” (Smith, 2020). These interactions that emerge between our patients can change us as nurses, just as nursing touches our patient’s lives.
Reference
Endo, E. (2017). Margaret Newman’s theory of health as expanding consciousness and a nursing
intervention for a unitary perspective. Asia Pacific Journal of Oncology Nursing, 4, 50-50. http://doi.org/10.4103/2347-5625.199076 (Links to an external site.)
Fujiwara, Y., & Endo, E. (2017). A patient with cancer and her family in caring partnership
based on Margaret Newman’s theory of health as expanding consciousness. Asia Pacific Journal of Oncology Nursing, 4, 265-268. http://doi.org/10.4103/apjon_20_17 (Links to an external site.)
Smith, M. C., (2020). Nursing theories and nursing practice (5th ed.). F.A. Davis.
Romina, Cassandra, Michelle, and Airion,
I hope this will answer all your questions. I work in a plastic surgery office for a plastic surgeon whose specialty is breast reconstruction. About 80% of our clients are breast cancer patients getting immediate reconstruction post-mastectomy or lumpectomy, patients seeking reconstruction options years after their cancer treatments for breast cancer, and reconstructive patients needing revisions or second opinions. The other 20% is straight cosmetic. Honestly, cosmetic patients are more challenging to work with than anyone. Nothing you do can please most of these cosmetic patients, and they are the neediest patients you will ever meet.
With my breast reconstruction patients, I am very involved in their care. These patients sometimes are in our office weekly for months, and you develop a close relationship with them and their family members. You figure out which ones need extra support from you as a nurse and which patients have excellent family support. That is why Margaret Newman’s Theory of Health applies so well to breast reconstruction patients and their families because of the meaningful relationships that I built during their journey in our office. I can pick up on patterns and develop a trusting relationship with these patients because of my weekly interactions. About 25 to 50 percent of my patients have my cell phone number, and they do not abuse it; they know that if there is an emergency, they can call. They even will send photos of wounds on their breasts to my phone to expedite their care. By being available for my patients, I hope to give them a sense of meaning and purpose, knowing that I genuinely care about their physical and mental health and wellbeing.
Breast reconstructions and general breast surgeries have a risk for infection and other complications like hematomas which can cause death to the tissue. It is hard for these women to see themselves without a breast or areola and think of themselves as a woman. Helping them cope and trying to explain the reconstruction process clearly is very important. We will often have patients and their families in the office two or three times before their initial surgery so that everyone understands what is to take place. Many breast cancer patients drive one to three hours just to come to their appointments. So by building a trusting relationship where they feel comfortable sending me pictures, we can treat the patient over the phone before coming back to the clinic. I think patients that know that they can trust you and have that personal relationship with their nurse do better healing, and if there are complications, they seem to understand and accept the process better. Even though complications are out of the surgeon’s hand, many people hear plastic surgery and think you can work miracles.
Thanks for all your questions, I hope this helps some.
Shandy
Orem’s Self-Care Deficit Nursing Theory
I believe Orem’s Self-Care Deficit Nursing Theory is most relevant to my nursing practice, specifically when I worked as a surgical nurse on a plastic surgery and colorectal surgery floor. In her theory, Orem describes how those who have a self-care deficit or who are at risk for a self-care deficit are those who require nursing interventions (Simmons, 2009). This can include patients who are “total-care” and are incapable of self-care due to illness, injury, or mental capacity. It can also include patients who are able to perform some level of self-care as they are recovering but still require nursing interventions. It can also include patients who are sufficient in self-care but are in need of additional education or support (Simmons, 2009). I was able to experience caring for this range of patients as they were recovering from surgery. The goal would be to take them from their starting level of self-care and discharge them when they are self-care sufficient with the help of nursing care and interventions. However, this is not always the case due to the patient’s basic conditioning factors (BCFs) such as their age, developmental state, family system factors, and resource availability and adequacy (Smith, 2020). Many times due to the patients self-care deficits they would require longer hospital stays or admission to a rehabilitation facility.
Orem’s SCDNT is utilized in a study done by Zhang & Pan (2021) where they investigated the effect of nursing practice based on Orem’s theory on the recovery of patients after colon cancer surgery. In this study they compared the recovery of patients who received care based on Orem’s self-care model with the control group who received regular nursing care (Zhang & Pan, 2021). Interventions based on Orem’s SCDNT were separated into levels based on self-care ability. This included comprehensive compensatory nursing system, which was for patients during surgery with no self-care capability. In this nursing system, the use of psychological nursing prior to the procedure was implemented where the nurse sat down with the patient and worked through any anxieties the patient may be having prior to surgery. It also included individualized pain management in which the nurse assessed the patient’s pain level and tolerance to ensure proper analgesic effect as well as the use of non-analgesic intervention such as music therapy, massage, and the use of hot and cold compresses. After surgery, most patients had partial self-care capacity and were given a partial compensation nursing system, which included early implementation of physical exercise and diet advancement as early as two days post-op. Finally, by the time of discharge, the majority of patients were self-care sufficient and only required support and education using outlets such as videos and manuals (Zhang & Pan, 2021). After these interventions were implemented, Zhang & Pan compared post-operative recovery between the two groups. Post-operative recovery was based on factors such as the time it took to first ambulate the patient, first return of bowel function, first food intake, the ability to remove the gastric tube from the patient, length of stay, incidence of complications, and pain levels. It was found that nursing practice based on Orem’s SCDNT lead to faster recovery of patients, increased self-care independence and ultimately resulted in improved quality of life for these patients.
References
Simmons L. (2009). Dorthea Orem’s self care theory as related to nursing practice in hemodialysis. Nephrology nursing journal : journal of the American Nephrology Nurses’ Association, 36(4), 419–421.
Smith, M. C. (2020). Nursing Theories and Nursing Practice (5th ed.). F.A. Davis Company.
Zhang, L., & Pan, W. (2021). Effect of a nursing intervention strategy oriented by Orem’s self-care theory on the recovery of gastrointestinal function in patients after colon cancer surgery. American Journal of Translational Research, 13(7), 8010–8020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8340249/