Nursing theories are designed by nurses to define nursing and its essence. Clark states that Nurses who deliver patient care need to apply and evaluate the numerous theories and models proposed as guides to nursing practice (p. 127). The basic idea of these theories is to explain the profession of nursing, its practices and an in depth understanding of its concepts. These theories then provide further direction to nursing practice and education (Jones, 1978). The applicability and generalizability of the theories may not be achieved in certain situations. It is however possible that a part of a theory matches a situation but the other parts of it may not. Regardless of all, nursing theories are valuable and useful in terms of guiding and conceptualizing nursing practice. Dorothy Orem’s Self-Care Deficit Theory and Sister Callista Roy’s Adaptation Model are examples of such valuable theories.
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Fawcett (2005) defined Metaparadigm as “the global concepts that identify the phenomenon of central interest to a discipline, the global propositions that describe the concepts, and the global propositions that state the relations between or among the concepts” (p. 4). The four major nursing metaparadigms are person, nursing, health, and environment which are considered as the core concepts of nursing theories by many nursing theorists. This paper is a compare and contrast of Roy’s Adaptation model with Orem’s theory of self-care in relation to the four metaparadigms listed above and concludes with the applicability of these theories in clinical practice.
Essential concepts of Roy’s Adaptation model
Roy’s Adaptation model came into existence in 1960 and is now used in educational, research and practice settings. Roy’s Adaptation Model (RAM) is one of the most useful conceptual frameworks that guides nursing practice, directs research and influences education (Shosha, kalaldeh,G.A., Mahmoud Al, 2012). Roy’s model is organized around adaptive behaviors and a set of processes by which a person adapts to environmental stimuli. Bertalanffy’s (1968) general system theory and Helson’s 1964 adaptation theory forms the original basis of scientific assumptions underlying the Roy’s model of adaptation. Roy at the 25th anniversary of the model restated the assumptions and redefined adaptation as “process and outcome whereby thinking and feeling persons, as individuals or in groups, use conscious awareness and choice to create human and environmental integration” (Roy and Andrews, 1999 as cited in George, 2002, p.296). In her revised edition, Roy focused on people’s affinity with others, world and God. Roy and Andrews (1999) state Roy’s postulates that humans respond to stimuli, initiating a coping process which has an effect on behavior, leading to either adaptive or ineffective response. Roy describes Stimuli (focal, contextual, and residual) as the input to the adaptive system that forces the need for change. Responses to these stimuli fall among any of the four adaptive modes; psychological, self-concept, role function, and interdependence. The infective response, if produced imposes a threat to adaptation, leading to a negative response. As a consequence of this, Roy views the role of the nurse as promoting patient adaptation. In addition, the philosophical assumptions of Roy’s model are based on humanism and veritivity and cosmic unity. The five assumptions of Roy include person’s mutual relationship with God, inclusion of human as an innate part of the universe, God’s destiny of creation and diversity, use of human creative abilities, person’s accountability for deriving, sustaining and transforming the universe (Perrett, 2007).
Essential concepts of Orem’s Theory of Self-care
According to Clark (1986), Orem’s theory of self-care revolves around the principal of innate ability of the individuals and their right and responsibility to care for themselves. Self-care is regarded as the behavior learned in childhood and continued in adulthood. It consists of activities initiated and performed to maintain life, health and well-being. Orem’s concept of self- care was first published in 1959. Her self-care deficit theory is composed of three interrelated theories. First is the theory of self-care. Second is theory of self-care deficit. Third is theory of nursing systems. These theories comprise of six central and one peripheral concepts. These concepts are discussed as follows.
Orem defined self-care as “performance or practice of activities that individuals initiate and perform on their own behalf to maintain life, health and wellbeing” (George, 2002, p. 127). It is to be noted that effective self-care leads to the integrity of human functioning and development. Self-care agency is defined as the power or ability to perform self-care. The factors known as basic conditioning factors are those that affect the ability of an individual to engage in self-care. These factors include, “age, gender, developmental stage, health state, socio-cultural factors , health care system factors ,family system factors, activities of living, environmental factors and resource adequacy and availability” (George, 2002, p. 127). Therapeutic self care demand is defined as the wholeness of the care measures necessary at specific times or duration of time for meeting an individual’s self- care requisites through appropriate methods and related sets of operations and actions. Self care requisites are the reasons or desire for self care. The categories of which include universal (basic necessities like air water ventilation etc.), development (associated with human growth) and health deviation (in case of illness or disease) (Orem, 2001, p. 522 as cited in George, 2002).
Orem’s basic element of general theory of nursing is self-care deficit as it demarcates the need for nursing. Self care- deficit occurs when and individual is incapable or has limited ability to provide effective self-care. Nursing care is needed either to incorporate the new or complex measures of self- care which require special training or when an individual needs to recover from a disease or injury (Orem, 2001 as cited in George, 2002).The nurses may act in either of these five ways to meet individual’s needs. These include “acting for or doing for, guiding and directing, providing physical or psychological support, providing or maintaining the environment and teaching” (Orem, 2001, p.56 as cited in George, 2002, p. 129). Finally Nursing agency is defined as a complex property or attribute of nurses that enables them to act, to know and to help others meet their therapeutic self-care demands by implementing or developing their own self-care agency (George, 2002). The nursing systems may be wholly compensatory, partly compensatory or supportive educative based on the requirement of patient’s needs.
Compare and contrast of the major concepts of Orem’s theory of self-care and Roy’s model of adaptation with Literature Support
Roy’s Adaptation Model has provided us a conceptual path to study human behavior (George, 2002). According to Roy’s adaptation model, an individual is described as an adaptive system that is able to respond to different internal and external environmental stimuli whether positively or negatively. Moreover, Roy has considered the human person in a “social context” as a bio-psycho-social being (Hanna and Roy, 2001p. 9). Roy has also differentiated Individual coping mechanism (regulator and cognator) and Group coping mechanism (stabilizer and innovator) (George, 2002). On the other hand, Orem defines an individual as a person struggling to have self-care needs met in order to live and mature. She has conceptualized a human being as a total being with universal, developmental and health deviation needs and capable of continuous self-care. (Current Nursing, Orem’s Theory of Self-care, Human Being, 2012). Orem distinguishes humans from other living things in three ways. First, humans have capacity to reflect upon themselves and their environment. Second, humans can symbolize their experience. Third, humans use their ideas in thinking and communicating (George, 2002).
Both the theorists have described human or person in terms of individuality and their struggle towards achieving optimum health. While the individual in Roy’s model fights for survival, the individual in Orem also struggles for survival but this individual may or may not be affected by any stimuli. As a contrast, according to George (2002) where Roy’s focus is not just the individual’s adaptation but includes groups that are interconnected, Orem’s initial focus is the individual’s needs and survival followed by family and group.
Orem believes that the environment directly influences the patient. She has emphasized on individual’s basic needs of air, ventilation etc. and prevention of hazards to maintain human integrity and promote human functioning (George, 2002). Roy believes that the person constantly interacts with the changing environment. According to Roy (2009) the environment consists of stimuli including conditions, circumstances, and influences surrounding an individual, whether focal, contextual, or residual. The person’s ability to interact with the environment and respond to the stimuli determines the adaptation level. This sums up that Roy considers environment as all “conditions, circumstances, and influences surrounding and affecting the development and behavior of persons and groups with particular consideration of mutuality of person and earth resources, including focal, contextual and residual stimuli” (Current Nursing, 2012, Roy’s Adaptation Model, para. 7).
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Both Orem and Roy are of the opinion that environment plays an integral role in human development and survival. Roy presents environment as a stimuli that disrupts the integrity of development but at the same time she appreciates that adaptation is achieved when human gets connected to the environment. In contrast, where Roy considers environment as a source of stimuli and that the human system must maintain integrity in the face of environmental stimuli, Clark (1986) believes that Orem considers environment as the medium for provision of basic human needs for survival.
Roy considers nursing as a key player to help patients to develop coping mechanism and positive outcome from the constant stimuli exposure. According to the Roy’s adaptation model, nursing is the “science and practice that expands adaptive abilities and enhances person and environment transformation with the goal of promoting adaptation for individuals and groups” (Barone, Roy, and Frederickson, 2008, p. 354). Roy’s goal of nursing for the patient is to achieve adaptation leading to optimum health, well-being, and quality of life and death with dignity, (Roy & Andrews, 1999). According to George (2012) Roy’s focus in nursing assessment is behavior of the individual. It includes scientific as well as philosophical perspective for nursing interactions with humans such as wholeness, veritivity and cosmic openness. On the other hand, Orem believes nursing as “actions deliberately selected and performed by nurses to help individuals or groups under their care to maintain or change conditions in themselves or their environments” (Current Nursing, 2012, Dorothea Orem’s Self-care Theory, para. 3). Taylor and Godfrey (1999) states Orem’s idea that the nurse’s actions should be directed towards protecting, preserving, or promoting patient’s integrity as human beings, promoting well-being, and fostering continuing movement toward maturity. Moreover, Orem also states that nursing is required when self-care demands of a patient exceeds the self-care ability. Both complement each other to achieve self-care through health promotion and maintenance and emphasis on prevention of hazards to maintain human integrity and promote human functioning. Apart from prevention and promotion, Orem also focuses on nursing as a supportive educative system (George, 2002) which is directed towards empowering individuals to compensate for the deficit. In addition to this, Orem supports nurses to involve family in patient care who is ultimately responsible for the individual.
In view of the above statements, both the theorists explain the role of a nurse as health care promoter and facilities patient to either adapt to the situation or balance or cope up with the self- care deficit. However, in contrast, according to Orem, nursing care focuses more on the areas and the degree to which support is needed as opposed to Roy whose focus is on behavior change (George 2002). Moreover, Orem’s focus is more towards the physiological needs of the patient whereas Roy caters to the physiological as well as psychological adaptation.
According to Barone, Roy, and Frederickson (2008), Roy defines health as “a state and process of being and becoming integrated and whole that reflects person and environmental mutuality and depends on adaptation” (p. 354).Roy views health as reflection of adaptation on a health illness continuum. On the other hand, Fawcett (2005) presents Orem’s idea of health as a state of soundness or wholeness of developed human structures, bodily and mental functions. Health encompasses inseparable “anatomic, physiological, psychological, interpersonal and social aspects” (Orem 2001 as cited in Fawcett, 2005, p. 239). Both Roy and Orem view health as a state of well-being and absence of disease. Roy encompasses health as “the process of achieving adaptation with the environmental stimuli, so, the person is integrated and a whole” (Shosha, kalaldeh, & Mahmoud Al, 2012, p. 2). Roy also conceptualizes health as simplistic and unrealistic as it excludes the individuals with chronic or terminal illness, who despite of their illness are struggling with their life challenges (Roy, 2009). On the other hand, Orem supports the world health organization definition of health as a “state of physical, mental and social well-being and not merely the absence of disease or infirmity” (Orem, 2001, p. 184 as cited in George, 2002). Orem emphasizes on the integrity of physical, psychological, mental and social aspects of health and takes into account all the levels of health maintenance including primary, secondary and tertiary prevention (George, 2002). However, Orem also believes that “adults have the right to decide about the kinds of health care they will accept and the responsibility to act for themselves in matters of self-care and health” (Orem 1995, p. 338 as cited in Taylor & Godfrey1999, p. 203).
Applicability of Orem’s and Roy’s Models in Clinical Practice
Orem’s theory is derived from the clinical base which provides a comprehensive base for nursing practice. According to George (2002) it can be utilized by professional nurses in the areas of education, clinical practice administration, research and nursing information system and contributes significantly to the development of nursing theories. While on the other hand, Roy’s model is applicable and important for nursing practice, nursing education and development (Shosha, kalaldeh, & Mahmoud Al, 2012). Orem focuses on finding the self-care deficit of the patient and providing the necessary care to promote his or her well-being. Whereas, Roy is concerned with the different stimuli that forces adaptation in order to achieve optimum health. Orem’s theory can be applied in clinical practice by a novice nurse as well as advanced practitioner which is one of the major strength of this model (George, 2002). Moreover, Orem in her theory has clearly defined where nursing is needed; that is when one’s ability to provide self-care to maintain quality of life diminishes. However, George (2002) states that nurse’s role in Roy’s adaptation model is to identify the stimuli and planning interventions to either change or strengthen the adaptive response.
According to Knust & Quarn (1983) “some practitioners have found Orem’s theory to be more clinically applicable when more than one system is used concurrently” (as cited in George, 2002, p. 148).This suggests the applicability of Orem’s theory in acute care setting as opposed to applicability of Roy’s model more into the community setting. This is because; the assessment of role function mode and interdependence mode is time consuming and so cannot be applied in acute care setting. Orem has explicitly defined all the terms in her theory which are comprehendible and easy to understand. In contrast, according to Shosha, kalaldeh, and Mahmoud Al (2012) “Roy’s arrangement of concepts is logical, but the clarity of some terms and concepts is inadequate to reflect nursing disciplines” (p. 3). This lack of clarity decreases the application of Roy’s model in any specialized area of practice (Shosha, kalaldeh, and Mahmoud Al, 2012). The Roy’s model is broad in scope and can be used to build or test nursing theories and is generalizable to all approaches existed in nursing practice. Moreover, according to (George, 2002) Roy allows for incorporation of spiritual aspects of human adaptive system, which is often omitted from nursing assessment. Whereas, according to George (2002) Orem has acknowledged the individual’s capacity for physical movement but does not acknowledge the emotional or spiritual needs of the individual.
It is evident that the application and evaluation of nursing theories enhances nurse’s image, assists in the continuous evaluation of nursing knowledge and promotes the acceptance of nursing profession as science based (Clark, 1980 as cited in Clark, 1986).According to George(2002) Orem’s theory is well suited for all those who need nursing care and those who need adjustments in their development phase, Roy’s model has implications for use across life span ; for families groups etc. but portion of it may be more useful for the nurse at different times. In my judgment on the basis of above mentioned arguments, Orem’s theory of self-care is best suited for clinical practice. Orem’s assessment approach according to Clark (1986) is a multisource perspective in which Client, family, other health-care professionals, and health-care records are utilized, Self-care abilities, self-care deficits, and self-care requisites are identified and used to decide which out of three nursing system is suited for the individual. Moreover, Self-care abilities are determined through several factors like age, sex, developmental stage, health status, socio-cultural orientation, and financial and other resources. Furthermore, Orem’s self-care deficit nursing theory “gives substance to the purpose of action and identifies aspects of the situation that have relevance from a nursing perspective” (Taylor & Godfrey, 1999, p. 203). This comprehensiveness of Orem’s model provides nurses an opportunity to apply it in clinical practice without regard to being a novice or an expert.