Self-Care Theory in Hursinq Selected Papers of Dorothea Orem docx

Self-Care
Theory
in
Hursinq
Selected Papers
of
Dorothea
Orem
Katherine
McLaughlin Renpenning, MSN, holds
a
Bachelors
of
Science
from
the
University
of
Saskatchewan
and a
Masters
from
the
University
of
British Columbia.
She is
president
and
chief

nursing
consultant
of MCL
Educational Services, Inc.,
and
McLaughlin Associates.
She has
held
a
variety
of
positions
in
nursing
education
and
nursing
service
and
consulted
extensively
in
relation
to
self-care deficit nursing theory
in
research, prac-
tice,
and
education.

Ms.
Renpenning
was
coauthor
of
Nursing
Administra-
tion
in the
21st
Century:
A
Self-Care
Theory
Approach,
published
by
Sage
Publishing,
and has
worked with Dorothea
Orem
since 1983.
Susan
Gebhardt Taylor, PhD,
RN,
FAAN,
is
Professor Emerita, Sinclair
School

of
Nursing, University
of
Missouri-Columbia.
Her
Bachelor degree
is
from
Alverno College, Milwaukee,
Wisconsin,
and her
graduate degrees
are
from
The
Catholic University
of
America, Washington,
DC. She is the
recipient
of
awards, including Alumnae
of the
year
from
Alverno College,
Missouri Tribute
to
Nurses Nurse Educator,
Kemper

Fellow
for
Teaching
Excellence,
and MU
Alumni Association Faculty Award.
Dr.
Taylor
has
worked with Dorothea Orem since 1976, collaborating
on
writing, consulta-
tions,
and
presenting work related
to
self-care
deficit
nursing theory.
in
Nursing
Selected Papers
of
Dorothea
Orem
Katherine
Mclaughlin
Renpenning,
MSN
Susan

G.
Taylor,
RN,
PHD,
FAAN
Editors
Springer Publishing Company
Self- caaaree ttheeory
Copyright
©
2003
by
Springer Publishing Company, Inc.
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rights
reserved
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recording,
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Springer
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Springer Publishing Company, Inc.
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York,
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Acquisitions
Editor:
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Production
Editor:
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Yoo
Cover
design
by

Joanne
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03
04 05 06
07/5
4321
Library
of
Congress
Cataloging-in-Publication
Data
Self-care theory
in
nursing
/
Katherine
McLaughlin
Renpenning, Susan
G.
Taylor,
editors.
p. cm.
Includes bibliographical references
and
index.
ISBN
0-8261-1725-2
1.
Nursing—Philosophy.
2.

Self-care,
Health—Study
and
teaching.
3.
Patient
education—Study
and
teaching.
4.
Nurse
and
patient.
5.
Nursing—Study
and
teaching.
I.
Renpenning,
Kathie
McLaughlin.
II.
Taylor, Susan
G.
RT84.5
.S456
2003
610.73'01—dc21
2002036655
Printed

in the
United States
of
America
by
Maple-Vail Book Manufacturing Group.
To
Dorothea Orem
for
the
wisdom
and
foresight
she
manifests
in the
papers
and for
working with
us
through
the
years
to
enhance
the
scholarliness
of
nursing
This page intentionally left blank

Contents
Contributors
xi
A
Note from Dorothea
Orem
xiii
Foreword
by
Sarah
E.
Allison
and
Cora
S.
Balmat
xv
Introduction
xix
PART
I:
OREM'S
WRITINGS
1.
Essential Requirements
for the
Practice
of
Nursing:
3

An
Analysis
(1956)
2.
The Art of
Nursing
in
Hospital Nursing Service:
6
An
Analysis
(1956)
3.
Nursing Education,
1966-1967
(1966)
18
4.
Inservice
Education
and
Nursing Practice
(1968)
25
5.
Clinical Evaluation
(1968)
37
6.
Levels

of
Nursing Education
and
Practice
(1968)
46
7.
The
Nursing Process With
a
Focus
on
Data
Collection
56
(1969)
8.
Design
of
Systems
of
Nursing
Assistance
and
Plans
for the 61
Individual
(1969)
9.
Design, Production,

and
Control Operations Required
for 69
the
Delivery
of
Nursing
on an
Agency-Wide
Basis
(1969)
10.
Nursing
and
Nursing Education:
The
Problem
of
Relations
72
(circa
late
1960s)
vu
viii
Contents
11.
Processes
in the
Development

of a
Conceptual Framework
80
for
Teaching Nursing
and for the
Practice
of
Nursing
(1973)
12.
Some Premises
and
Rules
for Use in
Curriculum Design
93
and
Development
in
Nursing
(1974)
13.
Validity
in
Theory:
A
Therapeutic Self-Care Demand
for 98
Nursing Practice

(1976)
14.
Nursing Theories
and
Their Function
as
Conceptual
108
Models
for
Nursing Practice
and
Curriculum Development
(1978)
15.
Scholarly Endeavors: Eight Sets
of
Work Operations
for
117
Advancing
One's
Scholarship (revised 1979)
16. The
Structure
of
Antecedent Nursing Knowledge
(1979)
121
17.

Nursing:
A
Dilemma
for
Higher Education
(1982)
142
18. A
System
of
Concepts About Nursing:
152
A
Personal History
(1984)
19.
Self-Care Model
of
Standards
for
College Health Nursing
162
(1986)
20.
Some Remarks Relevant
to
Nursing Practice
(1986)
168
21.

Nurses
and
Nursing Knowledge
(1987)
178
22.
Development
and
Dissemination
of a
General Theory
of 189
Nursing:
The
Past, Present,
and
Future
(1987)
23.
Changes
in
Professional Nursing Practice Associated With
200
Nurses'
Use of
Orem's
General Theory
of
Nursing
(1987)

24.
Self-Care
and
Health Promotion: Understanding
Self-Care
212
(1987)
25.
Motivating
Self-Care—The
Reality:
223
Persons
as
Self-Care Agents
(1987)
26.
The
Profession
and
Nursing Science
(1988)
237
27.
Theory Development
in
Nursing
(1988)
248
28. The

Development
of the
Self-Care
Deficit
Theory
of 254
Nursing: Events
and
Circumstances
(1988)
29. A
Perspective
on
Theory-Based Nursing
(1988)
267
30.
Multiple Roles
of
Nurses (probably 1988)
271
31.
Nursing Systems
(1989)
280
Contents
ix
32.
Perception
of

Theory Application Around
the
World
289
(1990)
33.
Some Considerations
in the Use of One
General Theory
of 293
Nursing
to
Formalize
the
Provision
of
Nursing
at
Crawford
Long Hospital
(1992)
34.
Work
to Be
Done
(1993)
299
35. The
World
of the

Nurse
(1996)
301
36.
Self-Care Deficit Nursing Theory Development Group
316
(1997)
37. The
Formalization
of
General
and
Subsidiary Self-Care
318
Requisites
and
Components
of
Associated Therapeutic
Self-Care
Demand
for a
Particular Health State
(1998)
38.
Nursing Practice Models (undated)
325
PART
II:
INTERNATIONAL

PERSPECTIVES
ON
OREM'S WORK
39. The
Contribution
of
Self-Care
Deficit
Theory
331
to
Nursing
in
Mexico
Esther
C.
Gallegos
40.
Self-Care
Deficit
Nursing Theory
in
Germany
333
Gerd
Bekel
41.
An
Integrative Review
and

Meta-Analysis
of
Self-Care
339
Research
in
Thailand:
1988-1999
Somchit
Hanucharurnkul,
Jariya
Wittaya-sooporn,
Yuwadee
Luecha,
and
Wantana
Maneesriwongul
References

355
Index
361
This page intentionally left blank
Contributors
Dorothea
Orem,
MSNEd,
FAAN
Savannah,
GA

Other
Contributors
Gerd
Bekel,
Soz
Wiss
RN FIG
Cloppenburg,
Germany
Esther
C.
Gallegos,
PhD
Universidad
Autonoma
De
Nuevo
Leon
Monterrey,
N.L.
Mexico
Somchit
Hanucharurnkul,
PhD,
RN
Ramathibodi
Hospital
Bangkok,
Thailand
Yuwadee

Luecha, EdD,
RN
Ramathibodi
Hospital
Bangkok,
Thailand
Wantana
Maneesriwongul,
DScN,
RN
Ramathibodi
Hospital
Bangkok,
Thailand
Jariya
Wittaya-sooporn,
DNS,
RN
Ramathibodi
Hospital
Bangkok,
Thailand
XI
FIGURE
P.I
Nursing's
placement
in the
world
of

humankind
and in
human
affairs.
Nursing
Development
Conference
Group
(1979),
Concept
Formalization
in
Nursing
(2nd
ed.),
p. 22.
Applied
Science*
Nurse Scholars
Researchers
Developera
Theorists
Nursing
Frame
1
Nursing's
Pwowrwnt
in
the
World

Frame
2
Nursing's
Pl&comont
m
Human
Affairs
Other
Applied
Nursing
Science
Instructional
Systems
In
Operation
Structured
Nursing Knowledge
Practical Nursing
Science
Nursing
Systems
in
Operation
Seeking!
Consuming
Nursing
Practicing
Nursing
Consumers
of

Nursing
Practitioners
of
Nursing
Practical Sciences
Human
Cooperation
Organization
of
Environment
Deliberate
Action
Human
Groups
Human
Beings
Man
Culture
Community
Knowledge
Art
Work
Professions
and
Service
Occupations
Teaching
Health
Care
Students

ol
Nursing
Teachers
of
Nursing
Society
Fields
of
Knowledge
and
Human
Endeavor
Institutionalized
Human
Services
Theoretical
and
Practical
Knowledge
Health
Care
Health
Care
Education
Practice
Disciplines
Other
Scholarly Endeavor
Research
&

Development
Theorizing
Teaching
Nursing
Studying
Nursing
A
Note From Dorothea Orem
he
writings selected
for
publication
by the
editors represent three
areas
of
professional responsibility that have been
of
interest
and
concern
to me
during
my
years
in
nursing.
The
papers
reveal some

results
of my
search
for
understanding
of the
nursing sciences, nursing
education,
and
nursing practice, including formalized
and
expressed
in-
sights
about their nature, structure, content,
and
relations.
The
papers
are
historical
in the
sense that they
reflect
time-specific conditions, events,
and
issues
in
nursing about which nurses
had

questions
and
sought answers.
My
work
confirmed
for me
that
the
three above-named areas
of
responsi-
bility
of the
nursing profession, while distinct
from
one
another
but
also
related, must
be
investigated
and
developed separately. Investigation
in
one
area,
often
proceeding

in the
same time
frame
with investigation
in
another
area,
led to
verified
insights about
the
nature
of
each
and the
relationships between them.
For
example,
the
identification
and
formaliza-
tion
of the
proper
object
of
nursing
in
society

and the
subsequent modeling
of
the
self-care
deficit
theory
of
nursing (nursing science area)
led to
conceptualizations
and the
formalizations
of the end
product
of
nursing
practice,
namely systems
of
nursing care,
to the
expression
of the
human
results
to be
sought through nursing,
and to the
form,

structure,
and
content
areas
of
nursing practice (nursing practice area).
In
1973, while preparing
a
paper
on the
processes
of
developing concep-
tual
frameworks
for
nursing practice
and
nursing education,
I
experienced
a
need
for an
answer
to the
question: Where does nursing
fit in the
world

of
humankind
and
human
affairs?
Figure
P.I
is an
illustration
of the
outcome
of my
deliberations. Accepting that nursing, like
all
areas
of
human
endeavor,
has its
origins
and
existence
in the
tendencies, interests,
and
capabilities
of
individual
men and
women working alone

or in
groups,
I
located nursing within
a
broad
frame
of
human
affairs
that
I
named
xin
T
xiv
A
Note
from
Dorothea
Orem
"fields
of
knowledge
and
human endeavor."
I
identified
three
subframes

that would subsume nursing, namely, professions
and
service occupations,
practice disciplines,
and
institutionalized human services. Nursing practice
and
nursing education
are
located
in the
subframe
of
institutionalized
human
services
and
nursing science
in the
subframe
of
practice disciplines.
Nursing
practice
is
located within
the
broader category
of
health services.

In my
subsequent work
I
found
the
results
of
this exercise
of
formally
locating nursing
in the
world
of
human
affairs
a
continuing guide
in
boundary setting.
The fit of
nursing
in the
world
in
which
we
live
is an
essential understanding

for all
nurses
who
seek
to
fulfill
their professional
responsibilities
for
nursing.
I did not do
in-depth work
to
formally
develop
the
subframe
"professions
and
service
occupations."
However,
it was
neces-
sary
for me to be
knowing about
and use
knowledge
from

this area
to
make
some developments
in the
area
of
nursing education, including
its
relations
to the
nursing practice area.
The
writings
in
this book
are for the
most part general
in
their orienta-
tion. They
are
pieces
of a
larger picture. Together with
Nursing:
Concepts
of Practice and Concept Normalization in Nursing: Process and Product, they
have
afforde

d
some direction
to
practitioners
of
nursing, educators
and
teachers
of
nursing,
and
nursing researchers
who
work
at the
operational
level
to
ensure that nursing
and
nursing education,
as
they
are
provided
in
their communities,
are in
accord with
the

needs
and
concerns
of
per-
sons
served.
I
thank
the
editors
for
their interest
in my
work
and for the
efforts
they
have
expended
in
developing
this
publication. Susan Taylor
and
Kathie
Renpenning
have made
major
contributions

to the
continuing
effort
to
bring nursing
true
status
as a
profession
in our
society.
Dorothea
Orem
Foreword
his
publication
of the
collected papers
of
Dorothea
E.
Orem
is a
significant
and
valuable contribution
to the
nursing literature. These
writings give insight into
the

development
and
range
of
thinking
about
nursing over
the
years. Orem's conceptualizations have provided
a
mental
model essential
to the
development
of
nursing
as a
discipline
of
knowledge—a
practical science with applied sciences
and the
foundational
nursing sciences.
As
Mary
B.
Collins,
an
experienced clinical nurse, once

said,
"It
gives
me the
words
to
express what
1
know
to be
nursing."
Through
six
editions
of her
book, Nursing:
Concepts
of
Practice,
and
two
editions
of
Concept
Formalization
in
Nursing:
Process
and
Product

by
the
Nursing Development Conference Group,
of
which Orem
was the
leader,
key
contributor,
and
editor, Orem
has
provided
the
theoretical
structure upon which
to
develop
and
expand
nursing
knowledge.
She has
clarified
nursing's particular contribution
to
health care
and
given direction
for

its
future
development.
Dorothea
Orem
has a
unique ability
to
listen
to a
group
of
nurses
expressing their concerns
and
ideas about nursing
and to
analyze
and
conceptualize
the
essence
of
meaning
in
what
is
being said. Through
this process
she

frequently formulates
an
abstract model
to
illustrate
the
relationships among
the
concepts.
Dorothea
Orem
has
always been gracious
and
considerate about others'
ideas
and
exemplifies
a
scholarly approach
to
whatever subject
is
under
consideration.
She
always functions
as an
integral part
of the

group, never
dominating,
but
sharing with
others
in a
collaborative working
relationship.
She
quietly encourages input
from
nurses, facilitating
in
developing their
ideas,
helping
them gain
insights
and
stimulating them
to
take
a
similar
scholarly
approach
to
nursing.
Notable about Orem
is not

only
her
depth
of
thought
but
also
her
continuing growth over
the
years
in
developing
her
conceptualizations,
as
xv
T
xvi
Foreword
evidenced
in
this collection
of
papers
and the six
editions
of her
book.
In

the
most recent edition
of
Nursing:
Concepts
of
Practice,
Orem
not
only
added
to the
structure
of her
nursing theories
but
laid
the
groundwork
for
areas needing
further
development
in the
practical science
of and the
foundational
sciences
of
nursing.

For
more than thirty years, Orem's concepts, based
on the
self-care
deficit
theory
of
nursing, have given direction
to
many nurses, inspiring
them
to
seek better ways
to
develop
and
express
the
knowledge base
of
nursing.
She has
been
a
consultant
to
many groups
of
nurses
in

education,
practice,
and
nursing administration, both nationally
and
internationally.
She
also
has
made
a
significant contribution
in
developing
a
theory
of
nursing administration. From
the
late
1960s
to the
present, numerous
regional
and
international conferences
and
institutes based
on her
concep-

tualizations have taken place.
In
honor
of her
contributions
to
nursing,
Orem
has
received recognition
from
many sources, including Sigma Theta
Tau,
the
National League
for
Nursing,
the
Distinguished Alumni
Award
from
The
Catholic University
of
America,
and
three honorary doctorates.
The
International Orem Society
for

Nursing Science
and
Nursing Schol-
arship
was
established
in
1990
for the
purpose
of
advancing
nursing
science
and
nursing scholarship through
the use of
Dorothea
E.
Orem's conceptual-
izations
in
nursing education, practice,
and
research.
The
Society seeks
to
establish
a

worldwide network
for
interaction among nursing
scholars
and
sponsors
conferences
and
promotes scholarly activities designed
to
encourage
the
advancement
of
nursing science.
Much
research
has
been done based
on the
self-care
deficit
nursing
theory, beyond serving
as the
basis
for
master's
theses
and

doctoral
disserta-
tions.
A few
examples
of its use
are:
the
early development
by
Horn
and
Swain
(1977)
at the
University
of
Michigan
on
Criterion
Measures
of
Nursing
Care',
the W. K.
Kellogg Foundation grant
to
Alcorn
State University
for

development
of
family-centered
adolescent health promotion centers
in
rural Mississippi;
the
establishment
of the
Center
for
Experimentation
and
Development
in
Nursing
at The
Johns Hopkins Hospital during
the
late
1960s
and
early
1970s,
whose projects
for
developing nursing practice
were
based
on

Orem's concepts;
and a
grant
for a
post-doctoral program
at
Wayne State University
for
scholars
to
work with
the
theory. Moreover,
the
self-care
deficit
nursing theory
has
been used
to
develop nursing prac-
tice
in
many service agencies, such
as
hospitals, home health care,
and
community
health agencies.
It is the

basis
for
nursing practice
and
educa-
tion
in
Thailand
and is
being used
in
other countries around
the
world.
Foreword
xvii
In
education,
it has
been
the
basis
of
nursing courses
and
curricula
in
baccalaureate
and
community college nursing programs.

Orem
served
as a
consultant
for
many
of
these agencies, helping them
to
develop creative
and
innovative approaches
to
achieve
desired
outcomes.
Some
of
this work
has
been published.
Her
model
has
provided impetus
for
the
development
of
exemplary programs

in
nursing practice,
in the
teaching
of
nursing
and
nursing curricula,
as
well
as in
nursing research.
As
two
members
of the
former
Nursing Development Conference Group
who
early
on had the
benefit
and
privilege
of
working with Orem
and
applying
her
ideas

in
both practice
and
education,
we
have
found
her
mental model
for
nursing
to be
insightful, logical,
and
representative
of
the
reality
of
nursing. Working with Orem's conceptualizations
has
been
both exciting
and
challenging
in our
professional lives. Orem
has
provided
the

structure
for the
ongoing
and
future
development
of
nursing
as a
practical
science
and as a
practice discipline.
Sarah
E.
Allison,
RN,
MSN,
EdD
Cora
S.
Balmat,
RN,
MSN,
PhD
Members
of the
Nursing Development Conference Group
REFERENCE
Horn,

B. J., &
Sevain,
M. A.
(1977).
Development
of
Criterion
Measures
of
Nursing
Care: Volumes
I and 11.
Prepared
for
National Center
for
Health
Services
Research.
Hyattsville,
MD.
This page intentionally left blank
Introduction
HOW
THIS
BOOK
CAME
ABOUT
We,
the

editors
of
this book, both have
a
long association with Dorothea
Orem—Susan
Taylor
since
1976
and
Kathie Renpenning
since
1983. Col-
laboration
between
the two of us
began
in
1983
at the
instigation
of
Orem
and
continues
to
this
day
through theory development activities, writing
and

publishing,
and
giving presentations
in
North America, South
America,
Asia,
and
Europe.
As we
have worked with Orem
and
learned
of her
theoretical
and
conceptual work,
we
also
got to
know
her
personally
and
were
privileged
to
have access
to her
working papers

and
presentations.
There
is
great value
in
these
materials
and we
wanted
to
share
them with
the
nursing community.
The
papers
that
are
included
in
this
book
are
representative
of
Orem's
thinking throughout
the
years. Most

of the
papers were developed
for
presentation.
In
a few
instances notes that Orem
had
made
in
preparation
for
presentations, writings,
or
classes
are
included.
The
materials
are
pre-
sented
in
chronological order
to
illuminate
the
development
of
Orem's

ideas about nursing theory, education,
and
practice over time.
At the end
of
the
book there
are
papers
by
nurses
in
other countries which highlight
the
status
of
Orem's theory internationally.
Papers
that
had
been typed were scanned into
the
computer
and
edited
for
accuracy. Handwritten papers were edited
for
readability, abbreviations
converted

into words, transcribed
by a
professional typist,
and
edited
by
one of us.
Some
format
changes were made
for
readability
and
publication
style
such
as the
format
of
references,
lists,
and
publications.
The
original
papers were
not
written
in a
particular style. However, whenever possible

APA
was
used
in
editing.
xvc
xx
Introduction
As
with
any
historical document, these papers need
to be
read with
consideration
of the
historic
and
cultural context
in
which they were
written
or
presented.
For
example,
it
should
be
noted that

in the
early
years,
the use of man or the
pronoun
he was
acceptable when referring
to
the
individual. Because
of
where
Orem
was
working,
the
early focus
is on
hospital nursing, while
in
later years many settings were represented.
THE
ROOTS
OF
DEVELOPMENT
OF
SELF-CARE
DEFICIT
NURSING
THEORY

In
1945,
after
working
as a
nurse
in the
operating room, emergency room,
private duty, pediatrics,
and
adult
medical/surgical
nursing
and
teaching
at
The
Catholic
University
of
America
(CUA),
Orem accepted
a
position
as
Director
of
Nursing Service
and

Director
of
Nursing Education
at
Provi-
dence Hospital
in
Detroit.
In a
personal communication
(11/20/97)
she
recounted
an
experience
she had
when
she was
director
of the
school.
We had a good program, good students. We were having a curriculum committee
meeting,
and a
question
was
asked;
it was a
substantive question.
I had no

glimmer
of an
answer
to it. I
knew there
was
something missing.
I was
director
of
the
school.
We had a
good
faculty.
It was a
question that raised questions
in
my
mind. What's
the
answer?
I
don't know.
1
knew that
I
should, but,
if you
don't

have
a
conceptualization
of
nursing there
are
certain things that
you
can't
answer.
You're
oriented
to
doing this
and
doing
that
and
doing
the
other.
The
lack
of a
substantive, structured body
of
nursing knowledge surfaced
again when
she was
working

in
Indiana.
She
went
to
Indiana
in
1949, with
the
Indiana State Board
of
Health, Hospital Division,
to
help
in
upgrading
of
nursing services
in
general hospitals.
She
worked closely with
Ann
Poorman
Donovan, conducting studies
of
organizational structure
of
nursing services
and

variations
in
types
of
patients
and
length
of
stay.
She
described
this
period.
Some
of the
things
we
came
up
with included
the
demands placed
on
nurses
by
length
of
stay
of
patients,

by the
scheduling
of
admission
and
discharges,
by
how
activities were planned throughout
the day in
nursing units

nurses
had
difficulty
representing their needs
to
hospital administrators. They didn't know
how to
talk about nursing, they
didn't
know
how to
represent what they needed.
The
same would
be
true
in
communicating with boards

of
trustees
and
with
physicians.
But one of the
things
I
found
in
talking with physicians
was
that
if
Introduction

xxi
you
talk nursing, they understood. They weren't anti-nursing, they
just
needed
somebody
to
represent things properly
to
them,
(personal communication,
117
20/97)
Orem reports that

it was at the end of
writing
a
report
on the
study
of
administrative positions that
she
felt
the
need
to
write
a
chapter
on
hospital
nursing services
and
then
a
chapter
on the art of
nursing that included
her
first
definition
of
nursing.

I
actually
had to
construct
it. I
think
one of the
important things
was
that
I had
some conceptualization
of how a
science develops because
of my
background
in
biology,
including
the
sequence
of
courses
through
bachelor's
and
master's
programs
in
biology.

At
least,
I had
some understanding
of
scientific knowledge.
I
knew that
it
didn't exist
in
nursing,
but to
develop nursing science, that
wasn't
in my
mind.
I was
concerned with expressing what nursing
is.
(personal
communication,
11/20/97)
The
first
two
chapters
reflect
the
results

of her
thinking
at
this time.
Although
the
study
from
which these chapters
are
extracted
was
done
in
the
1950s they
are
included here
for the
definition
of
nursing with
the
first
specification
of
self-care
limitations
of
persons

as the
object
of
nursing
and the
clear statements
of the
inherent distinctions between nursing
and
medicine. During this time
in
nursing there
was
beginning
to be a
focus
on
planning nursing care. Orem became aware that
the
"point
of
departure
for
planning
care
had to be the
patient's,
not the
nurses', tasks."
The

emphasis
on
planning nursing care
led
Orem
to
ask, "What
is the
basis
for
planning? What
are you
planning?
To me,
there wasn't anything"
(personal communication,
11/20/97).
Following
her
work
in
Indiana, Orem returned
to
Washington, D.C.,
and
took
a
position with
the
Office

of
Education, Vocational Section
of
the
Technical Division, where there
was an
ongoing project
to
upgrade
practical
nurse training.
It was at
this time that
the
more
formal
work
of
structuring began including authoring
Guides
for
Developing Curricula
for
the
Education
of
Practical Nurses
(Orem, 1959).
In
my

thinking that started
at
that time,
I
came
to the
conclusion that
the
question
that
had to be
answered
was
"Why
do
people
need
nursing?"
I
didn't
go
back
to the
work
I had
done
in
Indiana.
I
didn't look

at
nursing references
but I
asked myself
the
question.
I can
still remember
the
situation
in
which
I
had
the
insight
to
answer
the
question "Why
do
people need nursing?"
The
knowledge
was
within
me. I was
able
to use
that knowledge

in
answering
the
xxii
Introduction
question.
I
remember
sitting,
how I was
sitting
at the
desk when
I did ask and
answer
that
question.
It is a
specific
memory. From
that
time
onward,
the
knowledge
I had
about nursing began
to
structure
itself.

It
wasn't
anything
I did
deliberately,
but the
pieces started
to
come
together,
(personal
communication,
11/20/97)
NURSING
THEORY
AND
NURSING EDUCATION
Orem
returned
to the CUA
School
of
Nursing
in
1959
to
teach graduate
students
and
direct them

in
their research. During
the
next twenty years
the
development
of
self-care
deficit
nursing theory, theory-based curriculum
building,
and the
design
of
nursing practice
from
a
nursing theory perspec-
tive
occurred
synergistically
as can be
seen particularly
in
chapters 3-16.
These chapters
reflect
Orem's interaction with educators
and
practitioners.

In
addition
to
being active
in
curriculum development
at CUA
Orem
was
active
as a
curriculum consultant
for
schools
of
nursing developing nursing
theory based curricula.
The
interactions with
faculty
at CUA and
three
other
schools
(Morris Harvey College, Charleston, West Virginia,
the
newly
developing nursing program
at the
University

of
Southern Mississippi,
Hattiesburg, Mississippi,
and the
Georgetown University School
of
Nursing,
Washington, D.C.) were particularly
meaningful
in the
development
of
self-care
deficit
nursing theory. Publications
and
papers describing this
work contain much information
of
interest
to
nursing educators
and
histori-
ans. These materials
are
outside
the
scope
of

this book,
as
they were
developed
by
people working with Orem
and not
Orem herself.
In
1974,
the
accrediting body
of the
National League
for
Nursing (NLN) revised
the
standards
for
accreditation
to
include
the
requirement that nursing
curricula have
a
theoretical
basis
(NLN, 1972). This
was a

stimulus
for
continuing theory development.
There
are
identifiable themes
in the
chapters
on
education.
In the
early
ones,
Orem
is
dealing with
the
then current issue
of
levels
of
nursing
education programs
and the
need
for
maintaining standards that would
be
helpful
to

both
the
profession
and
society.
This
was a
period when
there
was a
nursing personnel shortage
and
increasing complexity
in
prac-
tice.
This
led to the
development
of the
nursing technician programs
in
the
junior
and
community colleges
as
well
as an
increase

in the
number
of
baccalaureate programs
for
nurses
in
colleges
and
universities,
and
master's
clinical specialization.
The
ideas expressed
in
these
papers
remain
meaningful
in the
contemporary health care milieu,
as
ways
of
dealing
Introduction
xxiii
with
the

current issues
of
nursing shortages
and the
essential
and
legitimate
roles
of
professional nursing
are
debated.
The
later papers
reflect
the
influence
of
theory development
on
Orem's
understanding
of
curriculum
development
and the
need
for
theoretical understanding
of the

object
of
nursing.
She
spoke
and
wrote
to the
need
for
knowing
the
object
of
nursing
and
using structured knowledge
to
build curricula.
She
maintained
her
belief
that
the
intellectual work
of
nursing
is
most appropriately

the
work
of
the
professionally educated nurse.
NURSING
THEORY
AND
NURSING PRACTICE
Coincidentally
with
the
curriculum work,
the
Nursing Development Con-
ference
Group
(NDCG),
which grew
out of the CUA
Nursing Models
Committee,
was
formalized
in
1968. This group
was
made
up of
eleven

nurses
from
a
variety
of
backgrounds
in
education
and
practice
who
were
concerned about
the
lack
of an
organizing framework
for
nursing.
This
group
set
about working with Orem
and the
embryonic
self-care
deficit
nursing theory
to
continue

the
work
of
formulating
the
theory.
One of the
"laboratories"
for
analyzing nursing
and
designing
of
nursing practice
was
The
Center
for
Experimentation
and
Development
of
Nursing
at The
Johns
Hopkins
Hospital. Orem
was an
active
consultant

to
this
center
and
person-
nel
from
the
center were members
of the
NDCG.
The
results
of the
delibera-
tions
of
Orem
and the
NDCG
were published
in two
editions
of
Concept
Formalization:
Process
and
Product
(NDCG,

1973
and
1979).
The
scholarly
activity
and
productivity
of
this group under
the
leadership
of
Orem
is
illustrated
in
chapter
16.
With
the
publication
of the
first
edition
of
Nursing:
Concepts
of
Practice

(Orem
1971) information about
self-care
deficit
nursing theory became
widely disseminated
and
Orem came
to be
much
in
demand
as a
speaker
and
consultant
in
relation
to the
theory itself
and in
relation
to
nursing
practice
and
education issues.
In
chapters
17-31

the
development
of the
theory
can be
seen
and the
specific
contribution
of the
theory
to
advancing
nursing education
and
nursing practice
can be
appreciated.
Orem
frequently
refers
to
self-care deficit nursing theory
as a
theory
of
nursing practice.
The
theory emerged
in

part
as
Orem sought answers
to
the
question "Why does
a
person need
a
nurse?" Answering
the
question
has
resulted
in the
lifelong
work
of
theorizing about nursing
and
making
"explicit
the
elements
and
relationships that give
form
and
meaning
to

xxiv
Introduction
nursing
as a
field
of
practice
and a
field
of
knowledge" (Orem,
2001,
p.
489).
In
the
first
chapter
in
this book Orem lays
out the
essential requirements
for
the
practice
of
nursing. Although
this
was
written

in
1955
it
still
has
meaning
today. This early work
has
been
influential
in
Orem's thinking
as
self-care
deficit
nursing theory
has
evolved.
Orem's
facility
for
listening
to
nurses;
observing
and
analyzing practice
situations; breaking down
and
analyzing systems, individual acts,

and
sequences
of
actions;
and
categorizing
and
structuring
the
disparate pieces
of
information,
as
well
as her
ability
to
bring
out the
scholar
in
practicing
nurses resulted
in the
Nursing Development Conference Group's contribut-
ing to
laying
out the
substantive structure
of the

variables
of
concern
to
nursing
(NDCG, 1973,
1979).
This
also resulted
in
making explicit
and
sharing insights about
the
relationships among those variables. This
was
a
significant milestone
in the
development
of
nursing
as a
practice disci-
pline.
The
theories
and
knowledge bases
of

other disciplines would remain
important
to
nursing
but the
issues
and
questions
of
concern
to
nurses
and
their answers could
now be
framed
and
explored
from
the
perspective
of
nursing rather than
from
that
of
another discipline.
Development
of
nursing

as a
discipline
is
dependent
in
part
on
structur-
ing the
knowledge base
of
nursing practice
so
that nurses
can
share with
each
other what they have learned through their many
and
varied experi-
ences.
This requires
a
language that enables
nurses
to
describe
experiences
and to
articulate what they have learned

from
those experiences. Without
this specific language nurses rely
on the
language
of
other disciplines
which incompletely
describe
nursing's
focus
of
concern.
In
chapters
7, 8,
and 9 the
value
of
identifying
the
variables
of
concern
to
nursing
and the
provision
of a
nursing language

to the
processes
of
nursing
are
illustrated.
As
a
point
of
interest,
these
workshops
occurred
prior
to the
publication
of Nursing: Concepts of Practice and Concept Formalization: Process and
Product.
In
these chapters
the
utility
of
self-care
deficit
nursing theory
in
guiding
and

making specific data collection, designing,
and
planning sys-
tems
of
nursing assistance
is
presented.
Early
in her
career Orem recognized
the
interrelationships among orga-
nizational structure, nursing practice,
and the
development
of
nursing
knowledge.
She
frequently writes
and
speaks
about
the
need
for
nurses
and
persons responsible

for
delivery
of
health care
and
nursing services
to
recognize
and
address
the
articulation
of
nursing systems with other
organizational systems,
and the
need
for
nurses
to
recognize
their
responsi-
bility
and to
have
a
strong voice
in the
development

of
health care delivery