CH A P T ER

14

Dorothea E. Orem
1914 to 2007

Self-Care Deficit Theory of Nursing

Violeta A. Berbiglia and Barbara Banfield

“Nursing is practical endeavor, but it is practical endeavor engaged in by

persons who have specialized theoretic nursing knowledge with developed
capabilities to put this knowledge to work in concrete situations of nursing
practice”
(Orem, 2001, p. 161).

Orem’s early nursing experiences included operat-

Credentials and Background of the
ing room nursing, private duty nursing (home and
Theorist hospital), hospital staff nursing on pediatric and
Dorothea Elizabeth Orem, one of America’s adult medical and surgical units, evening
foremost nursing theorists, was born in Baltimore, supervisor in the emergency room, and biological
Maryland, in 1914. She began her nursing career science teaching. Orem held the directorship of
at Providence Hospital School of Nursing in both the nursing school and the Department of
Washington, DC, where she received a diploma Nursing at Providence Hospi- tal, Detroit, from
of nursing in the early 1930s. Orem received a BS 1940 to 1949. After leaving Detroit, she spent 8
in Nursing Education from Catholic University of years (1949 to 1957) in Indiana working at the
America (CUA) in 1939, and she received an MS in Division of Hospital and Institutional Services of
Nursing Education from the same university in the Indiana State Board of Health. Her goal was
1946. to upgrade the quality of nursing in general
hospitals

Photo credit: Gerd Bekel Archives, Cloppenburg, Germany.

Previous authors: Susan G. Taylor, Angela Compton, Jeanne Donohue Eben, Sarah Emerson, Nergess N. Gashti, Ann
Marriner Tomey, Margaret J. Nation, and Sherry B. Nordmeyer. Sang-arun Isaramalai is acknowledged for research and editorial
assistance in a previous edition.

240
 CHAPTER 14 Dorothea E. 241
Orem
throughout the state. During this time, Orem devel- American Academy of Nursing, 1992. She was
oped her definition of nursing practice (Orem, awarded the Doctor of Nursing Honoris Causae
1956). from the University of Missouri in 1998.
In 1957, Orem moved to Washington, DC, to
take a position at the Office of Education, U.S.
Department of Health, Education, and Welfare, as
a curriculum consultant. From 1958 to 1960, she
worked on a proj- ect to upgrade practical nurse
training. That project stimulated a need to
address the question: What is the subject matter
of nursing? As a result, Guides for Developing
Curricula for the Education of Practical Nurses was
developed (Orem, 1959). Later that year, Orem
became an assistant professor of nursing edu-
cation at CUA. She subsequently served as
acting dean of the School of Nursing and as
associate profes- sor of nursing education. She
continued to develop her concepts of nursing and
self-care at CUA. Formal- ization of concepts
sometimes was accomplished alone and
sometimes with others. Members of the Nursing
Models Committee at CUA and the Improve- ment
in Nursing Group, which later became the
Nursing Development Conference Group
(NDCG), all contributed to the development of
the theory. Orem provided intellectual leadership
throughout these collaborative endeavors.
In 1970, Orem left CUA and began her own
con- sulting firm. Orem’s first published book was
Nursing: Concepts of Practice (Orem, 1971). She
was editor for the NDCG as they prepared and
later revised Concept Formalization in Nursing:
Process and Product (NDCG, 1973, 1979). In 2004, a
reprint of the second edition was produced and
distributed by the International Orem Society for
Nursing Science and Scholarship (IOS).
Subsequent editions of Nursing: Concepts of
Practice were published in 1980, 1985, 1991, 1995,
and 2001. Orem retired in 1984 and continued
working, alone and with colleagues, on the
development of the Self-Care Deficit Nursing
Theory (SCDNT).
Georgetown University conferred on Orem the
honorary degree of Doctor of Science in 1976.
She received the CUA Alumni Association
Award for Nursing Theory in 1980. Other
honors received in- cluded Honorary Doctor of
Science, Incarnate Word College, 1980; Doctor of
Humane Letters, Illinois Wesleyan University,
1988; Linda Richards Award, National League for
Nursing, 1991; and Honorary Fellow of the
 CHAPTER 14 Dorothea E. 242
At age 92, Dorothea Orem’s life ended after a Orem
(2001) thinking was, “What con- dition exists in a
period of being bedridden. She died Friday, person when judgments are made that a nurse(s)
June 22, 2007, at her residence on Skidaway should be brought into the situation?”
Island, Georgia. Survivors were her lifelong
friend, Walene Shields of Savannah, and her
cousin Martin Conover of Minneapolis,
Minnesota. Tributes by Orem’s close colleagues
were featured in the IOS official journal, Self-
Care, Dependent- Care & Nursing (SCDCN).
Orem’s many papers and presentations
provide insight into her views on nursing
practice, nursing education, and nursing
science. Some of these papers are now available
to nursing scholars in a compilation edited by
Renpenning and Taylor (2003). Other pa- pers
of Orem and scholars who worked with her in
the development of the theory can be found
in the Orem Archives at The Alan Mason
Chesney Medical Archives of the Johns
Hopkins Medical Institutions.

Orem (2001) stated, “Nursing belongs to the Theoretical Sources

family of health services that are organized to
provide direct care to persons who have
legitimate needs for differ- ent forms of direct
care because of their health states or the nature
of their health care requirements” (p. 3). Like
other direct health services, nursing has social
features and interpersonal features that
characterize the helping relations between
those who need care and those who provide
the required care. What dis- tinguishes these
health services from one another is the helping
service that each provides. Orem’s SCDNT
provides a conceptualization of the distinct
helping service that nursing provides.
Early on, Orem recognized that if nursing
was to advance as a field of knowledge and as
a field of prac- tice, a structured, organized body
of nursing knowledge was needed. From the
mid-1950s, when she first put forth a definition
of nursing, until shortly before her death in
2007, Orem pursued the development of a
theoretical structure that would serve as an
organizing framework for such a body of
knowledge.
The primary source for Orem’s ideas about
nursing was her experiences in nursing. Through
reflection on nursing practice situations, she
was able to identify the proper object, or focus,
of nursing. The question that directed Orem’s
(p. 20). The condition that indicates the need for philosophical system of moderate realism. Banfield
nursing assistance is “the inability of persons to (1998, 2008, 2011)
pro- vide continuously for themselves the amount
and quality of required self-care because of
situations of personal health” (Orem, 2001, p. 20).
It is the proper object or focus that determines
the domain and boundaries of nursing, both as a
field of knowledge and as a field of practice. The
specification of the proper object of nursing
marks the beginning of Orem’s theoretical work.
The efforts of Orem, work- ing independently as
well as with colleagues, resulted in the development
and refinement of the SCDNT. Consisting of a
number of conceptual elements and theories that
specify the relationships among these concepts,
the SCDNT is a general theory, “one that is
descriptively explanatory of nursing in all types of
practice situations” (Orem, 2001, p. 22). Originally,
three specific theories were articulated, the theory
of nursing systems, the theory of self-care deficits,
and the theory of self-care. An additional theory,
the theory of dependent care, has been articulated.
This theory is regarded as being parallel with the
theory of self-care and serves to illustrate the
ongoing devel- opment of the SCDNT.
In addition to her experiences in nursing
practice situations, Orem was well versed in
contemporary nursing literature and thought. Her
association with nurses over the years provided
many learning experi- ences, and she viewed her
work with graduate students and her collaborative
work with colleagues as valuable endeavors. Orem
cited many other nurses’ works in terms of their
contributions to nursing, including, but not limited
to, Abdellah, Henderson, Johnson, King, Levine,
Nightingale, Orlando, Peplau, Riehl, Rogers, Roy,
Travelbee, and Wiedenbach.
Orem’s familiarity with literature was not limited
to nursing literature. In her discussion of various
topics related to nursing, Orem cited authors from
a number of other disciplines. The influence of
scholars such as Allport (1955), Arnold (1960a,
1960b), Barnard (1962), Fromm (1962), Harre
(1970), Macmurray
(1957, 1961), Maritain (1959), Parsons (1949, 1951),
Plattel (1965), and Wallace (1979, 1996) can be seen
in Orem’s ideas and positions. Familiarity with
these sources helps to promote a comprehensive
under- standing of Orem’s work.
Foundational to Orem’s SCDNT is the
conducted philosophical inquiries to explicate does not negate the position that human beings
the metaphysical and epistemological are unitary beings (Orem, 1997, p. 31).
underpinnings of Orem’s work. These inquiries The view of person-as-agent is central to the
revealed consistency between Orem’s views SCDNT. Self-care, which refers to those actions
regarding the nature of reality, human beings, in which a person engages for the purpose of
the environment and nursing as a sci- ence; pro- moting and maintaining life, health, and
ideas and positions associated with the philoso- well-being, is conceptualized as a form of
phy of moderate realism. Taylor, Geden, deliberate action.
Isaramalai, and Wongvatunyu (2000) have also
explored the philo- sophical foundations of
the SCDNT.
According to the moderate realist position,
there is a world that exists independent of the
thoughts of the knower. Although the nature
of the world is not determined by the thoughts
of the knower, it is pos- sible to obtain
knowledge about the world.
Orem did not specifically address the nature
of real- ity; however, statements and phrases
that she uses reflect a moderate realist position.
Four categories of postulated entities are
identified as establishing the on- tology of the
SCDNT (Orem, 2001, p. 141). These four
categories are (1) persons in space-time
localizations,
(2) attributes or properties of these persons, (3)
motion or change, and (4) products brought
into being.
With regard to the nature of human beings,
“the view of human beings as dynamic,
unitary beings who exist in their
environments, who are in the pro- cess of
becoming, and who possess free-will as well
as other essential human qualities” is
foundational to the SCDNT (Banfield, 1998, p.
204). This position, which reflects the
philosophy of moderate realism, can be seen
throughout Orem’s work.
Orem (1997) identified “five broad views of
human beings that are necessary for developing
understand- ing of the conceptual constructs of
the SCDNT and for understanding the
interpersonal and societal as- pects of nursing
systems” (p. 28). These are the view of person,
agent, user of symbols, organism,and object.
The view of human beings as person reflects
the philosophical position of moderate
realism; it is this position regarding the nature
of human beings that is foundational to
Orem’s work. She made the point that taking a
particular view for some practical purpose
 “Deliberate action refers to actions performed by action, and (3) the science of human assistance for
indi- vidual human beings who have intentions persons with health-associated self-care deficits. In
and are conscious of their intentions to bring relation to this proposed structure of nursing
about, through their actions, conditions or states
of affairs that do not at present exist” (Orem, 2001,
pp. 62–63). When engaging in deliberate action,
the person acts as an agent. The view of person-as-
agent is also reflected in the SCDNT’s conceptual
elements of the nursing care and dependent care.
In relation to the view of person- as-agent and the
idea of deliberate action, Orem cited a number of
scholars, including Arnold, Parsons, and Wallace.
She identified seven assumptions regard- ing human
beings that pertain to deliberate action (Orem, 2001,
p. 65). These explicit assumptions, while
addressing deliberate action, rest upon the
implicit assumption that human beings have free
will.
The SCDNT represents Orem’s work regarding the
substance of nursing as a field of knowledge and
as a field of practice. She also put forth a position
regard- ing the form of nursing as a science,
identifying it as a practical science. In relation to
her ideas about the form of nursing science,
Orem cites the work of Maritain (1959) and
Wallace (1979), philosophers who were
associated with the moderate realist tradi- tion, .
In practical sciences, knowledge is developed for
the sake of the work to be done. In the case of
nursing, knowledge is developed for the sake of
nursing practice. Two components make up the
prac- tical science: the speculative and the
practical. The speculatively practical component is
theoretical in nature, while the practically
practical component is directive of action. The
SCDNT represents specula- tively practical
knowledge. Practically practical nurs- ing science is
made up of models of practice, standards of
practice, and technologies.
Orem (2001) identified two sets of speculatively
practical nursing science: nursing practice sciences
and foundational nursing sciences. The set of nursing
practice sciences includes (1) wholly
compensatory nursing science, (2) partly
compensatory nursing science, and (3)
supportive developmental nurs- ing science.
The foundational nursing sciences are
(1) the science of self-care, (2) the science of the
development and exercise of the self-care agency in
the absence or presence of limitations for deliberate
sciences, Orem stated, “the isolation, naming, From Orem, D. E. (2001). Nursing: Concepts of practice (6th ed.).
and description of the two sets of sciences St. Louis: Mosby.
are based on my understanding of the
nature of the practical sciences, on my
knowledge of the organization of subject
matter in other practice fields, and on my
understanding of components of curricula for
edu- cation for the professions” (pp. 174–
175).
In addition to the two components or types
of prac- tical science, scientific knowledge
necessary for nurs- ing practice includes sets of
applied sciences and basic non-nursing
sciences. In the development of applied
sciences, theories from other fields are used to
solve problems in the practice field. These
applied nursing sciences have yet to be
identified and developed. Box 14–1 depicts
the structure of nursing science.
Orem’s articulation of the form of nursing
science provided the framework for the
development of a body of knowledge for the
education of nurses and for the provision of
nursing care in concrete situations of nursing
practice. The SCDNT with its conceptual
elements and four theories identifies the
substance or content of nursing science.

BOX 14-1Speculatively Practical

Nursing Science
Nursing Practice Sciences
Wholly Compensatory Nursing Partly
Compensatory Nursing Supportive-
Developmental Nursing

Foundational Nursing Sciences

The Science of Self-Care
The Science of the Development and Exercise of
Self-Care Agency in the Absence or Presence of
Limitations for Deliberate Action
The Science of Human Assistance for Persons
with Health-Associated Self-Care Deficits

Applied Nursing Sciences Basic Non-

Nursing Sciences Biological
Medical
Human Environmental
MAJOR CONCEPTS & DEFINITIONS
The self-care deficit nursing theory is a general
theory composed of the following four related Accomplishes patient’s
theories: therapeutic self-care
1. The theory of self-care, which describes Compensates for patient’s
why and how people care for Nurse inability to engage
action in self-care
themselves.
2. The theory of dependent-care, which explains Supports and protects
how family members and/or friends patient
provide dependent-care for a person who
is socially dependent. Wholly compensatory system
3. The theory of self-care deficit, which
describes and explains why people can be Performs some self-care
helped through nursing measures for patient
4. The theory of nursing systems, which Compensates for self-care
describes and explains relationships that must limitations of patient
be brought about and maintained for nursing
to be produced The major concepts of these Assists patient as required
Nurse
theories are identi- action
fied here and discussed more fully in Orem Performs some self-care
(2001), measures
Nursing: Concepts of Practice (see Figure 14–1). Patient
Regulates self-care agency
action
Self-Care Accepts care and assistance
Self-care comprises the practice of activities that from nurse
ma- turing and mature persons initiate and
Partly compensatory system
perform, within time frames, on their own behalf
in the interest of maintaining life, healthful
functioning, continuing personal development, Accomplishes self-care
and well-being by meeting known requisites for Patient
functional and developmental regulations (Orem, action
Nurse Regulates the exercise and
2001, p. 522). action development of
self-care agency
Dependent Care
Supportive-educative system
Dependent care refers to the care that is
provided to a person who, because of age or
related factors, is unable to perform the self-care
needed to maintain life, healthful functioning,
continuing personal
development, and well-being. 1. The factor to be controlled or managed to keep an
aspect(s) of human functioning and development
Self-Care Requisites
A self-care requisite is a formulated and
expressed insight about actions to be
performed that are known or hypothesized to
be necessary in the regu- lation of an aspect(s)
of human functioning and development,
continuously or under specified con- ditions and
circumstances. A formulated self-care requisite
names the following two elements:
FIGURE 14-1 Basic nursing systems. (From Orem, D. E.
[2001]. Nursing: Concepts of practice [6th ed., p.
351]. St. Louis: Mosby.)

within the norms compatible with life,

health, and personal well-being
2. The nature of the required action
Formulated and expressed self-care
requisites constitute the formalized purposes
of self-care. They are the reasons for which
self-care is undertaken; they express the
intended or desired result—the goal of self-
care (Orem, 2001, p. 522).
MAJOR CONCEPTS & DEFINITIONS— These self-care requisites exist for persons
cont’d who are ill or injured, who have specific
forms of pathologi- cal conditions or
Universal Self-Care Requisites disorders, including defects and disabilities,
Universally required goals are to be met through and who are under medical diagnosis
self- care or dependent care, and they have their
origins in what is known and what is validated, or
what is in the process of being validated, about
human structural and functional integrity at
various stages of the life cycle. The following eight
self-care requisites common to men, women, and
children are suggested:
1. Maintenance of a sufficient intake of air
2. Maintenance of a sufficient intake of food
3. Maintenance of a sufficient intake of water
4. Provision of care associated with elimination
processes and excrements
5. Maintenance of balance between activity and
rest
6. Maintenance of balance between solitude and
social interaction
7. Prevention of hazards to human life,
human functioning, and human well-
being
8. Promotion of human functioning and
devel- opment within social groups in
accordance with human potential, known
human limita- tions, and the human
desire to be normal. Normalcy is used in
the sense of that which is essentially
human and that which is in
accordance with the genetic and constitutional
characteristics and talents of individuals
(Orem, 2001, p. 225).
Developmental Self-Care Requisites
Developmental self-care requisites (DSCRs) were
separated from universal self-care requisites in
the second edition of Nursing: Concepts of
Practice (Orem, 1980). Three sets of DSCRs have
been iden- tified, as follows:
1. Provision of conditions that promote
development
2. Engagement in self-development
3. Prevention of or overcoming effects of
human conditions and life situations that can
adversely affect human development (Orem,
1980, p. 231)
Health Deviation Self-Care Requisites
 Therapeutic self-care demand consists of the
sum- mation of care measures necessary at
and treatment. The characteristics of health devia- specific times or over a duration of time to meet
tion as conditions extending over time determine the all of an individ- ual’s known self-care requisites,
types of care demands that individuals experi- ence particularized for existent conditions and
as they live with the effects of pathological circumstances by methods appropriate for the
conditions and live through their durations. following:
Disease or injury affects not only specific struc- n Controlling or managing factors identified in

tures and physiological or psychological mechanisms, but the requisites, the values of which are regulatory
also integrated human functioning. When inte- grated of human functioning (sufficiency of air, water,
functioning is affected seriously (severe mental and food)
retardation and comatose states), the individual’s n Fulfilling the activity element of the

developing or developed powers of agency are seri- requisites (maintenance, promotion,

ously impaired, either permanently or temporarily. In prevention, and pro- vision) (Orem, 2001, p.
abnormal states of health, self-care requisites arise from 523)
both the disease state and the measures used in its Therapeutic self-care demand at any time
diagnosis or treatment. (1) describes factors in the patient or the
Care measures to meet existent health deviation self- environment that must be held steady within a
care requisites must be made action components of an range of values or brought within and held
individual’s systems of self-care or dependent care. The within such a range for the sake of the patient’s
complexity of self-care or dependent care systems is life, health, or well-being, and
increased by the number of health deviation requisites (2) has a known degree of instrumental
that must be met within specific time frames. effectiveness derived from the choice of
technologies and specific techniques for using,
Therapeutic Self-Care Demand changing, or in some way con- trolling patient
or environmental factors.
Continued
MAJOR CONCEPTS & DEFINITIONS— self-care demands and to regulate the
cont’d development or exercise of their self- care
agency (Orem, 2001, p. 518). Nursing agency
Dependent-Care Demand
The summation of care measures at a specific point
in time or over a duration of time for meeting
the dependent’s therapeutic self-care demand when
his or her self-care agency is not adequate or
operational. (Taylor, Renpenning, Geden, et al,
2001, p. 40).

Self-Care Agency
The self-care agency is a complex acquired ability
of mature and maturing persons to know and
meet their continuing requirements for deliberate,
purpo- sive action to regulate their own human
functioning and development (Orem, 2001, p.
522).

Dependent-Care Agency
Dependent-care agency refers to the acquired ability
of a person to know and meet the therapeutic
self-care demand of the dependent person and/or
regulate the development and exercise of the
dependent’s self-care agency.

Self-Care Deficit
Self-care deficit is the relation between an
individual’s therapeutic self-care demands and his
or her powers of self-care agency in which the
constituent-developed self-care capabilities within
self-care agency are in- operable or inadequate
for knowing and meeting some or all
components of the existent or projected
therapeutic self-care demand (Orem, 2001, p. 522).

Dependent-Care Deficit
Dependent-care deficit is a relationship that
exists when the dependent care provider’s
agency is not adequate to meet the therapeutic
self-care demand of the person receiving
dependent care.

Nursing Agency
Nursing agency comprises developed capabilities
of persons educated as nurses that empower
them to represent themselves as nurses and within
the frame of a legitimate interpersonal
relationship to act, to know, and to help persons
in such relationships to meet their therapeutic
also incorporates the capabilities of nurses to assist
persons who provide dependent care to regulate the
development or exercise of their dependent-care
agency.

Nursing Design
Nursing design, a professional function performed
both before and after nursing diagnosis and pre-
scription, allows nurses, on the basis of reflective
practical judgments about existent conditions, to
synthesize concrete situational elements into or-
derly relations to structure operational units. The
purpose of nursing design is to provide guides for
achieving needed and foreseen results in the pro-
duction of nursing toward the achievement of
nursing goals; these units taken together constitute
the pattern that guides the production of nursing
(Orem, 2001, p. 519).

Nursing Systems
Nursing systems are series and sequences of deliber-
ate practical actions of nurses performed at times in
coordination with the actions of their patients to
know and meet components of patients’ therapeutic
self-care demands and to protect and regulate the
exercise or development of patients’ self-care agency
(Orem, 2001, p. 519).

Helping Methods
A helping method from a nursing perspective is a
sequential series of actions that, if performed, will
overcome or compensate for the health-associated
limitations of individuals to engage in actions to
regulate their own functioning and development or that
of their dependents. Nurses use all methods,
selecting and combining them in relation to the
action demands on individuals under nursing care
and their health-associated action limitations, as
follows:
n Acting for or doing for another
n Guiding and directing

n Providing physical or psychological support

n Providing and maintaining an environment that

supports personal development

n Teaching (Orem, 2001, pp. 55–56)
 MAJOR CONCEPTS & DEFINITIONS—cont’d
Basic Conditioning Factors n Developmental state
Basic conditioning factors condition or affect the n Health state
value of the therapeutic self-care demand and/or n Pattern of living
the self-care agency of an individual at particular n Health care system factors
times and under specific circumstances. The n Family system factors
following ten factors have been identified: n Socio-cultural factors
n Age
n Availability of resources
n Gender
n External environmental factors

Use of Empirical Evidence felt were de- scriptive of nursing and would contribute
As a practical science, nursing knowledge is to nursing
devel- oped to inform nursing practice. Orem
(2001) stated that, “nursing is practical endeavor,
but it is practical endeavor engaged in by persons
who have special- ized theoretic nursing
knowledge with developed capabilities to put this
knowledge to work in concrete situations of
nursing practice” (p. 161). The provision of
nursing care occurs in concrete situations. As
nurses enter into nursing practice situations,
they use their knowledge of nursing science to
assign meaning to the features of the situation,
to make judgments about what can and should be
done, and to design and implement systems of
nursing care. From the perspective of the SCDNT,
desired nursing outcomes include meeting the
patient’s therapeutic self-care demand and/or
regulating and developing the patient’s self-care
agency.
The conceptual elements and the specific theories
of the SCDNT are abstractions about the features
com- mon to all nursing practice situations. The
SCDNT was developed and refined through the use
of intellectual processes that focused on nursing
practice situations. For example, Orem reflected on
her nursing practice experiences to identify the
proper object of nursing. In their work related to
the SCDNT, the Nursing Development Conference
Group (1979) engaged in analysis of nursing cases
and in processes of analogical reasoning. In a
tribute to Orem, Allison (2008) talks about the
Nursing Development Conference Group, saying
that “these nurses came together because they were
interested in and willing to commit themselves to
examining nursing situations in order to
formalize ways of thinking about nursing that they
knowledge” (p. 50). Since the SCDNT was first
pub- lished, extensive empirical evidence has
contributed to the development of theoretical
knowledge. Much of this is incorporated into
continuing refinement of the theory; however,
the basics of the theory remain unchanged. The
theory of dependent care represents a major
advancement in terms of the development of
the SCDNT. “The increased need in societies
for dependent-care indicates the importance for
nurses of understanding dependent-care and their
relationships to dependent-care agents”
(Orem, 2001, p. 286).

Assumptions basic to the general theory were Major Assumptions

formal- ized during the early 1970s and were first
presented at Marquette University School of
Nursing in 1973. Orem (2001) identifies the
following five premises underlying the
general theory of nursing:
1. Human beings require continuous,
deliberate inputs to themselves and their
environments to remain alive and
function in accordance with natural
human endowments.
2. Human agency, the power to act
deliberately, is exercised in the form of care
for self and others in identifying needs
and making needed inputs.
3. Mature human beings experience privations
in the form of limitations for action in care
for self and others involving making of
life-sustaining and function-regulating
inputs.
4. Human agency is exercised in discovering,
devel- oping, and transmitting ways and
means to identify needs and make inputs to
self and others.
5. Groups of human beings with structured
relation- ships cluster tasks and allocate
responsibilities for
 providing care to group members who experience is that the requirements of persons for nursing are
privations for making required, deliberate input
to self and others (p. 140).
Orem stated pre-suppositions and propositions for
the theory of nursing systems, the theory of self-
care deficit, and the theory of self care. These
constitute the expression of the theories and are
summarized below.

Theoretical Assertions
Presented as a general theory of nursing, one
that represents a complete picture of nursing, the
SCDNT is expressed in the following three
theories:
1. Theory of nursing systems
2. Theory of self-care deficit
3. Theory of self-care
The three constituent theories, taken together in
relationship, constitute the SCDNT. The theory
of nursing systems is the unifying theory and
includes all the essential elements. It subsumes the
theory of self-care deficit and the theory of self-
care. The theory of self-care deficit develops the
reason why a person may benefit from nursing.
The theory of self-care, foundational to the
others, expresses the purpose, method, and
outcome of taking care of self.

Theory of Nursing Systems

The theory of nursing systems proposes that
nursing is human action; nursing systems are
action systems formed (designed and produced)
by nurses through the exercise of their nursing
agency for persons with health-derived or health-
associated limitations in self-care or dependent
care. Nursing agency includes concepts of deliberate
action, including intentionality, and the operations
of diagnosis, prescription, and regulation. Figure
14–1 shows the basic nursing sys- tems categorized
according to the relationship between patient and
nurse actions. Nursing systems may be produced
for individuals, for persons who constitute a
dependent-care unit, for groups whose members
have therapeutic self-care demands with similar
com- ponents or who have similar limitations for
engagement in self-care or dependent care, and for
families or other multi-person units.

Theory of Self-Care Deficit

The central idea of the theory of self-care deficit
associated with the subjectivity of mature his or her self-care requisites” (Taylor &
and maturing persons to health-related or Renpenning, 2011, p. 24). For persons who are
health care– related action limitations. These socially dependent and unable to meet their
limitations render them completely or therapeutic self-care demand, assistance from
partially unable to know existent and other persons is necessary. In many ways self-care
emerging requisites for regulatory care for
themselves or their dependents. They also
limit the ability to engage in the continuing
performance of care measures to control or in
some way manage factors that are regulatory
of their own or their dependent’s
functioning and development.
Self-care deficit is a term that expresses the
rela- tionship between the action capabilities of
individuals and their demands for care. Self-
care deficit is an abstract concept that, when
expressed in terms of action limitations,
provides guides for the selection of methods
for helping and understanding patient roles in
self-care.

Theory of Self-Care
Self-care is a human regulatory function
that indi- viduals must, with deliberation,
perform themselves or must have performed
for them to maintain life, health,
development, and well-being. Self-care is an
action system. Elaboration of the concepts of
self- care, self-care demand, and self-care agency
provides the foundation for understanding the
action require- ments and action limitations
of persons who may benefit from nursing. Self-
care, as a human regulatory function, is distinct
from other types of regulation of human
functioning and development, such as neuro-
endocrine regulation. Self-care must be
learned, and it must be performed deliberately
and continuously in time and in conformity
with the regulatory requirements of
individuals. These requirements are associated
with their stages of growth and develop-
ment, states of health, specific features of
health or developmental states, levels of
energy expenditure, and environmental
factors.

Theory of Dependent-Care
The theory of dependent care “explains
how the self-care system is modified when it
is directed to- ward a person who is socially
dependent and needs assistance in meeting
and dependent care are parallel, with the main
operational or become operational in the
dif- ference that when providing dependent-care,
production of nursing systems, systems of care for
the person is meeting the self-care needs of
individuals or for dependent-care units or multi-
another person. For the dependent-care agent,
person units served by nurses” (Orem, 1997, p.
the demands of providing dependent care can
31). The overall theory is logically congruent.
influence or condition the agent’s therapeutic self-
care demand and self-care agency. The need for
dependent-care is expected to grow with the Acceptance by the
increasing age of the population and the number Nursing Community
of persons living with chronic and/or disabling Orem’s SCDNT has achieved a significant level
conditions. of acceptance by the international nursing
community, as evidenced by the magnitude of
Logical Form published material and presentations at the
International Orem Society World Congresses
Orem’s insight led to her initial formalization and
(2008, 2011, and 2012). In research using the
subsequent expression of a general concept of
SCDNT or components, Biggs (2008) found more
nurs- ing. This generalization then made possible
than 800 references. Berbiglia identified se-
induc- tive and deductive thinking about
lected practice settings and SCDNT conceptual
nursing. The form of the theory is shown in the
foci from a review of more than 3 decades of
many models that Orem and others have
use of the SCDNT in practice and research and
developed, such as those shown in Figure 14–1
publicized selected international SCDNT practice
and Figure 14–2. Orem described the models and
models for the twenty-first century (in press).
their importance to the development and
The SCDNT was introduced as the basic
understanding of the reality of the entities. These
structure for nursing management in German
models are “. . . directed toward knowing the
hospital DRG (diagnosis-related group)
structure of the processes that are
implementation. The move- ment toward SCDNT-
based nursing management in

Self-care
Con
dit
Conditioning factors

io
Self-care Self-care ni
agency demands n
g

Deficit

Nursing
Conditioning factors

agency

FIGURE 14-2 A conceptual framework for nursing. R, Relationship; ,, deficit relationship,

current or projected. (From Orem, D. E. [2001]. Nursing: Concepts of practice [6th ed., p. 491]. St.
Louis: Mosby.)
Germany is credited to Bekel. Although it is nursing systems. Important work has been done on
difficult to fully assess the international the nature of person and interpersonal features of
application of the SCDNT, it is clear that, over nursing. Orem
time, Germany and Thailand have been
landmark examples of the more recent
utilization of the SCDNT (Bekel, 2002;
Harnucharunkul, 2012). The Luxembourg Ministry
of Social Security and Health co-sponsorship of
the 12th IOS World Congress marked the
recognition of the SCDNT as one of the
frameworks for health care for Luxembourg.
The following U.S. schools are among those
with SCDNT curriculum frameworks (Berbiglia,
2011, 2012):
• Illinois Wesleyan University
• University of Tennessee at Chattanooga
• College of Saint Benedict
• Anderson College
• University of Toledo
• Alcorn State University
• Southern University Baton Rouge
The influence of Orem’s SCDNT has continued
at the international level through the translation
of Nursing Concepts of Practice into several
languages (Spanish in 1993, German in 2002,
and Japanese in 2005) and the proliferation of
SCDNT-based practice, education, and research
worldwide.

Further Development
From the time of publication of the first edition
of Nursing: Concepts of Practice in 1971, Orem
was engaged in continual development of her
conceptual- izations. She worked by herself and
with colleagues. The sixth and final edition was
completed and pub- lished in 2001. Her work
with a group of scholars, known as the Orem
Study Group, further developed the various
conceptualizations and structured nurs- ing
knowledge using elements of the theory. This
work led to the expression of a Theory of
Dependent Care (Taylor, Renpenning, Geden, et
al., 2001) and the foundational Science of Self-
Care (Denyes, Orem, & Bekel, 2001).
Nursing: Concepts of Practice (Orem, 2001) is orga-
nized with two foci: nursing as a unique field of
knowledge and nursing as practical science. The
text includes an expansion, from earlier editions,
of con- tent on nursing science and the theory of
identified many areas for further development Simplicity
in her descriptions of the stages of theory Orem’s theory is expressed in a limited number
development. She also described the of terms. These terms are defined and used
development of the Science of Self-Care, consistently
which could include concepts such as elab-
oration of operational functions of self-care
agency with the elements of sensation and
perception, appraisal, and motivation, and
determining the relevance of foun- dational
capabilities and dispositions to discreet acts.
There is a need to focus on the person in the
situation and on capabilities for action and self-
management. This content has been expanded
in the description of the foundational nursing
Science of Self-Care (Denyes, Orem, & Bekel,
2001).
The IOS was established in 1993. The
purpose of the IOS is to advance nursing
science and scholar- ship through the use of
Orem’s nursing conceptual- izations in nursing
education, practice, and research. The IOS
publishes Self-Care, Dependent-Care &
Nursing, an open access online journal found
on the IOS website (http://www.orem-
society.com/). Since its inception, the IOS has
sponsored international conferences and
maintains a record of the content of these
conferences.

Clarity Critique
The terms Orem used are defined precisely.
The lan- guage of the theory is consistent with
the twenty-first century language used in
action theory and philoso- phy. The
terminology of the theory is congruent
throughout. The term self-care has multiple
meanings across disciplines; Orem defined the
term and elabo- rated the substantive
structure of the concept in a way that is
unique while also congruent with other inter-
pretations. Reference has been made to the
difficulty of Orem’s language; however, the
limitation generally resides in the reader’s lack of
familiarity with practical science and with the
field of action science. Once a basic
familiarity with the terminology of the
SCDNT is achieved, further reading and
studying of Orem’s work fosters a
comprehensive understanding of her view of
nursing as a field of knowledge and as a field
of practice.
in the expression of the theory. Orem’s general persons. Self-care system, dependent-care system,and
theory, the SCDNT, comprises the following four nursing
constituent theories: self-care, dependent-care, self-
care deficit,and nursing systems. The SCDNT is a
synthesis of knowl- edge about eight entities,
which include self-care (and dependent care), self-
care agency (and dependent-care agency),
therapeutic self-care demand, self-care deficit,
nursing agency, and nursing system. Development of
the theory using these entities is parsimonious.
The relationship between and among these entities
can be presented in a simple diagram. The
substantive structure of the theory is seen in the
development of these entities. The depth of
development of the con- cepts gives the theory the
complexity necessary to describe and understand a
human practice discipline.

Generality
Orem (1995) commented on the generality, or
univer- sality, of the theory as follows:
The self-care deficit theory of nursing is not an
explanation of the individuality of a particular
concrete nursing practice situation, but rather
the expression of a singular combination of
conceptualized properties or features common
to all instances of nursing. As a general
theory, it serves nurses engaged in nursing
practice, in development and validation of
nursing knowl- edge, and in teaching and
learning nursing (pp. 166–167).
A review of the research and other literature
attests to the generality of the theory.

Accessibility
As a general theory, the SCDNT provides a
descrip- tive explanation of why persons require
nursing and what processes are needed for the
production of required nursing care. The
concepts of the theory are abstractions of the
entities that represent the proper object of nurses
in concrete nursing practice situa- tions. Self-
care, dependent care, and nursing care all are
forms of deliberate action engaged in to achieve
a particular purpose. The concepts of thera- peutic
self-care demand, self-care agency, dependent- care
agency, and nursing agency refer to properties of
persons. Self-care deficitand dependent-care deficit
refer to relationships between properties of
system are systems of care that are designed theory of nursing systems provides a unique
and implemented to achieve desired focus for nursing. The significance of Orem’s work
outcomes. Basic conditioning factors refer to extends far beyond the development of the
factors that condition or influence the SCDNT. In her works, she provided expression of
variables of persons. These factors may be the form of nursing science as practical science,
internal to the person, such as along with a structure for ongoing development
developmental level, or external, such as of nursing
available resources. In nurs- ing practice
situations, the data collected by nurses can be
categorized readily according to the concepts
of the SCDNT.
For research purposes, both quantitative and
quali- tative research methods are appropriate
for the devel- opment of knowledge related to
the SCDNT. Specific research methods to be
used in any investigation are selected on the
basis of the questions being asked. Examples
of various approaches can be found in this
publication’s companion text summary of
recent SCDNT-based research (Berbiglia, in
press). Although the concepts of the SCDNT
refer to real entities, they are complex in
nature. Operationalization of these concepts
requires a comprehensive understanding of
Orem’s work. Instruments to measure some of
these concepts have been developed.
The current emphasis in the SCDNT is on
building a body of knowledge-related nursing
practice, rather than engaging in theory-testing
research. Instrument development has an
important role in building nurs- ing
knowledge as well as other types of
scholarly work. A great deal of work is
needed with regard to the structuring of
existent knowledge around the practice
sciences and the foundational nursing sci-
ences identified by Orem. Therefore,
comprehensive descriptive studies of various
populations in terms of their self-care
requisites and self-care practices are needed.
The structuring of existent knowledge and the
findings from descriptive studies will provide a
solid base for the development of
instruments to measure the concepts of the
SCDNT.

Importance
The SCDNT differentiates the focus of nursing
from other disciplines. Although other
disciplines find the theory of self-care helpful
and contribute to its devel- opment, the
knowledge in the stages of theory development.
a body of knowledge. The efforts of nurse scholars
Orem presented a visionary view of contemporary
and nurse researchers to build on this foundation
nursing practice, education, and knowledge
will result in a body of knowledge that serves
development ex- pressed through the general
nurses in their provision of care to persons
theory.
requiring nursing.

Summary CASE STUDY

The critical question—What is the condition that Theory of Dependent-Care
in- dicates that a person needs nursing care?—was This case study documents an ongoing interaction
the starting point for the development of the between a wife and her husband who live in a spa-
SCDNT. Orem noted that it was the inability of cious home in a gated community.
persons to maintain on a continuous basis their When Dan (now 80) and Jane (now 65) began
own care or the care of dependents. From this dating over 15 years ago, both were emotionally
observation, she began the process of formalizing charged to begin their lives anew. Well-
educated and financially secure, they had a lot
knowledge about what persons need to do or
in common. Dan was a protestant minister, and
have done for themselves to maintain health and Jane’s deceased husband had been a protestant
well-being. When a person needs assistance, what minister. Both had lost their spouses. Jane’s first
are the appropriate nursing assistive actions? The husband had suffered a catastrophic cerebral
theory of self-care describes what a person aneurysm 2 years earlier. Oddly enough, Dan
requires and what actions need to be taken to had conducted the funeral service for Jane’s
meet those requirements. The theory of husband. Dan’s wife had died of terminal
dependent- care is complex. It parallels Orem’s cancer a little over a year earlier. Dan’s first
theory of self-care. The theory of self-care deficits wife had been a school counselor; Jane was a
school teacher. Both had children in college.
describes the limita- tions involved in meeting They shared a love for travel. Dan was retired
requirements for ongoing care and the effects they but con- tinued part-time employment, and
have on the health and well- being of the person Jane planned to continue teaching in order to
or dependent. The theory of nurs- ing systems qualify for retire- ment. Both were in great
provides the structure for examining the actions health and had more than adequate health
and antecedent knowledge required to assist the benefits. Within the year they were married.
person. These theories also are descriptive of Summer vacations were spent snorkeling in
situations involving families and communities. Hawaii, mountain climbing in na- tional parks,
and boating with family. Their lives were full
Orem’s work related to nursing as a practical and productive. After 7 years, Dan expe-
sci- ence and the identification of three practice rienced major health problems: a quadruple
sciences and three foundational nursing sciences cardiac bypass surgery, followed by surgery for
provides direction for the development of nursing pancreatic cancer. Jane’s plans to continue
science. This work offers a structure for the working were dropped so she could assist Dan
organization of existing nursing knowledge, as well to recover and then continue to travel with him
as for the generation of new knowledge. and enjoy their remaining time together. Dan
In an interview with Jacqueline Fawcett (2001), did recover— only to begin to exhibit the early
Orem identified factors essential for the development signs and symp- toms of Alzheimer’s disease.
One of the early signs appeared the previous
of nursing science. They included the following: Christmas as they were hanging outdoor lights.
(1) a model of practice science, (2) a valid, reliable, To Jane’s dismay, she noted that Dan could not
general theory of nursing, (3) models of the follow the sequential direc- tions she gave him.
operations of nursing practice, (4) development As time passed, other signs appeared, such as
of the conceptual structure of the general theory, some memory loss and confusion,
and (5) integration of the conceptual elements of
the theory with the prac- tice operations (p. 36).
Orem’s work related to the SCDNT and the form
of nursing science as a practical science provides a
foundation for the development of
frequent repeating of favorite phrases, sudden out- chair first, and then, while she showers, he sits on
bursts of anger, and decreased social involvement. the nearby toilet seat drying himself. Her girl friends
Assessments resulted in the diagnosis of early suggested that this was material for an entertaining
Alzheimer’s disease. Aricept was begun, and Jane home video! While Jane is cautious in her care for
began to prepare herself to face this new stage of Dan, she often drives a short distance to her
their married life. She read Alzheimer’s literature neighborhood tennis court for brief games with
avidly and organized their home for physical and friends or spends time tending the lovely gardens
psychological safety. A kitchen blackboard displayed she and Dan planted. During these times, she locks
phone numbers and the daily schedule. Car keys the house doors and leaves Dan seated in front of
were appropriately stowed. It was noted that she the television with a glass of juice. She watches the
began to savor her time with Dan. Just sitting time and returns home midway through the hour to
together with him on the sofa brought gentle check on Dan. On one occa- sion when she forgot to
expressions to her face. It was apparent that she lock the door while she was gardening, Dan made
was building a store of memories. They contin- ued his way to the street, lost his balance, reclined face-
to attend church services and functions but stopped first in the flower bed, and was discovered by a
their regular swims at their exercise facil- ity when neighbor. Jane has given up evenings out and
Dan left the dressing room naked one day. Within increased her favorite pastime of reading. Her days
the year, Jane’s retired sister and brother-in-law are filled with assist- ing Dan in all of his activities of
relocated to a home a short walk from Jane’s. Their daily living. And, often, her nights’ sleep is
intent was to be on call to assist Jane in caring for interrupted by Dan’s wandering throughout their
Dan. Dan and Jane’s children did not live nearby so home. At times, when the phone rings, Dan answers
could only assist occasion- ally. As Dan’s symptoms and tells callers Jane is not there. Jane, only in the
intensified, a neighbor friend, Helen, began to next room, informs him “Dan, I am Jane.” Friends
relieve Jane for a few hours each week. At this time, are saddened by Dan’s decline and concerned with
Jane is still the primary dependent-care agent. She the burdens and limitations Jane has assumed due
prides herself in mas- tering a dual shower; she to Dan’s dependency.
showers Dan in his shower

CRITICAL THINKING ACTIVITIES

Case Study Analysis 2. Now, using the Basic Dependent-Care
We will use two conceptual models to analyze this System model (Figure 14–4), assess Dan
case. The Dependency Cycle (see Figure 14–3) and Jane. Identify the basic conditioning
presents the way dependency occurs. The outer factors (BCFs) for each. Ask “What is the
arrows show how an independent person can effect of Dan’s BCFs on his self-care agency
become dependent, progress to interdependency, (SCA)?” Is he able
and even become inde- to meet his therapeutic self-care demands
pendent again. (TSCDs)? Continue on to diagnose Dan’s self-
Figure 14–4 displays the Basic Dependent-Care care deficit (SCD) and resulting dependent-
System in which Dan and Jane are interacting. care deficit (DCD). Next, assess Jane’s self-care
1. Let’s examine this case through the system (SCS).
Dependency Cycle model (see Figure 14–3). 3. Design a nursing system that addresses Jane’s
The outer arrows show a progression through SCS while she increases her role as
varying stages of dependency. The inner circle dependent- care agent (DCA).
represents who can be involved in the
dependency cycle. Indicate where Jane and
Dan are in this cycle.
 Dependent

Infant

Feeble Elderly

Interdependent Family Family Interdependent

Adult

Independent
FIGURE 14-3 Dependency cycle. (From Taylor, S. G., Renpenning, K. E., Geden, E. A., Neuman,
B. M., & Hart, M. A. (2001). The theory of dependent-care: A corollary to Orem’s theory of self-care.
Nursing Science Quarterly, 14(1), 39–47.)

SCA
TSCD

B
C SCDF DCD B
S
DC C
C

F SCA
Actions F
S

TSCD DCA

Responsible Person
Dependent Dependent Care Agent(s)

NOTE: BCF = basic conditioning factors; SCA = self-care agency; TSCD = therapeutic self-care
demand; SCDF = self-care deficit; DCD = dependent-care demand; DCA = dependent-care agency;
SCS = self-care system.
FIGURE 14-4 Basic dependent-care system. (From Taylor, S. G., Renpenning, K. E., Geden, E. A., Neuman,
A.M., & Hart, M. A. (2001). The theory of dependent-care: A corollary to Orem’s theory of self-care.
Nursing Science Quarterly, 14(1), 39–47.)

POINTS FOR FURTHER STUDY

n Fawcett, J. (1988). The nurse theorists. Portraits n Fawcett, J. (1992). Excellence in Action:
of excellence: Dorothea Orem (Video/DVD). Dorothea Orem (Video/DVD).
Athens, (OH): Fitne, Inc. Athens, (OH): FITNE, Inc.
n The companion text for Nursing Theorists and n The Johns Hopkins Archives house the
Their Work includes Berbiglia, V. A. (in press).
Dorothea Orem Collection at:
Orem’s self-care deficit nursing theory in
http://www.medicalarchives. jhmi.edu.
practice. In M. R. Alligood (Ed.). Nursing theory:
n The official online IOS journal, Self-Care,
Utilization & application (5th ed., Ch. 12). St.
Dependent- Care & Nursing, is archived on the
Louis: Mosby Elsevier.
IOS website.
n The International Orem Society (IOS) website at:

http://scdnt.com/.