The History of Nursing

The concepts and theories related to the practice of nursing have begun to sharply evolve into a far more complex definition than ever before. Historically, nurses were viewed somewhat simplistically. They were caring and nurturing individuals who aided the physicians. Yet, their medical knowledge and expertise was always subordinate to that of the doctor’s.

In addition, they were perceived as assisting the doctor and not necessarily as a practitioner themselves. This perception of a nurse no longer exists in modern medicine. The practice of nursing has evolved so that both women and men serve in the profession and nursing itself is an extremely broad-based practice with numerous specialties such as psychiatric nursing, surgical nursing, end of life care and other important areas of medicine. In addition, nurses are understood and respected as highly skilled medical professionals who provide an essential core of medical practice and the care of people in need.  

One of the true pioneers in the field has been Dorothea Orem. It was in the 1950’s that Orem first began to formulate her theories on the need to define the parameters of nursing as a field of medical practice. In particular, she promoted the notion of ideas of man, the environment and health in relation to nursing practice itself; that is, as viewed by nurses. She developed her own theoretical foundation known as ‘Self-Care Nursing Deficit Theory’.   Integral to this overall philosophy are three theories that comprise her beliefs about nursing. They are the theory of self-care, the theory of self-care deficit and the theory of nursing system. In Orem’s view, self-care is very much about the ability of an individual to identify their own specific needs and provide the care they need. There is of course a definite relationship between a person’s self-care abilities and their specific self-care demands. Her overall theory describes the ways in which the nursing system can address these demands.  

In Orem’s view every person has the potential to direct their own self-care. This ability or individual power we have is something she terms as self-care agency.   This agency empowers people to learn and perform the actions they need in order to allow for their own survival and overall well-being in life. There are, of course many factors that can and do affect a person’s ability to care for themselves including age, capacity, culture, social conditions and a person’s developmental or emotional state. For example, if a person has a psychiatric condition as well as a physical condition, their ability or self-care agency may be diminished, or they may need assistance from a health-care provider. One of the interesting facets of this philosophy is that self-care agency, in Orem’s view, is also very much connected to their cultural and therefore their culture-specific belief system and values.   Yet, Orem believes that people have the potential to integrate the various aspects of their lives — interpersonal, psychological and social needs in order to provide for themselves. To accomplish this however, people must reflect on themselves and their environment in order to determine these ongoing needs. Thus, she sees people as intelligent, thoughtful, able to be self-empowered and the ability to care for themselves in many instances.  

Orem also identifies people as having the ability to learn to identify not only their own needs but the needs of others as well. People gather together in groups and these groups are often structured. Thus, these relationships may define the parameters of self-care. It is important to note that Orem does not identify this as an innate behavior or ability but rather a learned one.   “The idea central to these nursing-specific views of individuals is that mature human beings have learned and continue to learn to meet some or all components of their own therapeutic self-care demands and the therapeutic self-care demands of their dependents” (2005, p. 142). Of course there are people who are unable or unwilling to learn, depending on external and internal circumstances. According to Orem, when a person is unable to provide for their own self-care needs then they are in what she terms as self-care deficit. That is, they require an external provider to assist them.   From this perspective, people are dynamic partners in their own health care and have the ability to continually learn and adapt to changing health needs and circumstances. It implies that we can and should be an active partner in our own health care and not simply someone who is passive and submits to the care of others. An analysis of Orem’s theory leads Parissopoulos and Kotzabassaki to state the following; “Responsibility and self-care could be linked; self-care is a self-initiated, deliberated and purposeful activity linked to health and well-being” (2004, p. 1). This notion of people as responsible beings is integral to Orem’s theory and her beliefs about the ways in which people interact with nurses.  

Self-care, in Orem’s theory is not only about the ability to learn to take of oneself and one’s dependents, but it is also about self-empowerment, taking responsibility and motivation. “Orem has identified motivation as an instrumental factor in making decisions about care of the self and to ‘operationalise’ these decsions’” (Parissopoulos and Kotzabassaki, 2004, p. 3).

For Orem, the environment is quite simply the domain in which we exist. Yet, this is an interactive relationship and our well-being can very much be affected by the environment. In other words, we have a reciprocal relationship with the environment and this relationship is affected by internal and external factors. Some of the internal factors could be understood as the person’s attributes — physiological, psychological and even spiritual beliefs. External factors would be understood as the socio-cultural, economic, physical and organizational elements of the environment where one lives.  

In terms of health, Orem uses this term to describe the notion that one’s psychological, interpersonal and social aspects of health are all part of a whole. She does not separate these terms and as such, she takes a very holistic view of health and suggests that these aspects of our individual ‘self’ cannot and should not be separated. When one is healthy, there is a sense of harmony with these elements but when they are in disharmony then there is an absence of health. Orem sees an intricate and close relationship between the state of one’s health and the behavior we engage in, in order to maintain our own self-care. Individuals always have the choice not to engage in self-care behavior and as stated earlier, Orem attributes motivation as being a key concept in self-care and one’s ability to maintain that state. “Orem’s concept of health is holistic as a way of understanding the web of influences upon someone’s ‘health and well-being’. A healthy person is able to meet the universal developmental and health-related needs” (Parissopoulos and Kotzabassaki, 2004, p. 3).

Yet, Orem recognizes there are important factors that do influence our ability to maintain self-care. She tends not to use the word ‘healthy’ as that may imply a judgment on one’s ability to maintain their own self-care.   A good example of this is a person who sustains a serious injury. While they require external assistance (possibly surgery and/or a hospital stay), they are not necessarily unhealthy, or unwell. However, they are not in a position to maintain self-care on their own.  

Orem identifies the notion of ‘health’ as one of wholeness as opposed to the notion of ‘healthy’ per se. She also identifies the important notion that what constitutes good health will vary across cultures and different belief systems do see the body in different ways and apply their own techniques of self-care. Thus, the concept of health is not simply a technical or medical one but very much a cultural one. “Similarly, health care is influenced by culture, with its shaped values and beliefs, and society. Nurses are learning to listen to clients’ desires and goals and starting to recognize their patients’ beliefs, practices and worldviews as resources” (Parissopoulos and Kotzabassaki, 2004, p. 3).

One of the most important contributions of Orem’s work is her redefinition of the role of nurses in society. First and foremost, because she sees individuals as capable of guiding their own self-care, she does not promote the notion of submitting to someone else’s care but rather engaging in a partnership, or even a contractual relationship in order to receive the assistance that one requires. In this philosophy, Orem views people as having ‘health-associated limitations’ and having the need for assistance in order to promote their self-care agency. In this notion, nurses provide assistance relative to the person’s needs at the time. This could be education and support (physical and/or psychological), teaching and guiding or directing self-care.   Nurses have the ultimate role of facilitating and increasing a person’s abilities to engage in their own self-care (Parissopoulos and Kotzabassaki).  

In many ways, Orem views nurses as agents of self-empowerment. They are not meant to take over for someone’s ability to provide their own self-care but to facilitate one’s ability to perform this function. Thus, nursing is not so much about caring for people but rather empowering and guiding people to understand how they can best care for themselves. According to Marjorie A. Isenberg (2005), This does not imply that nurses do not provide care, but rather a far different model of care and what that means in a practical sense.  

According to this theory, nurses use their specialized capabilities to create a helping system in situations where persons are deemed to have an existent or potential self-care deficit. Decisions about what type of nursing system is appropriate in a given nursing practice situation rests with the answer to the question, ‘Who can and should perform the self-care operations?’ When the answer is the nurse, a

Wholly compensatory system of helping is appropriate (p. 150).  

As with individuals who have self-care agency, nurses have, what Orem terms as, nursing agency. This is their power to care for others. Orem sees this as a critical power in society. It is indeed a role which is looked upon, in many societies, as not only one of power and responsibility but also one of esteem. Often times when people enter into a hospital in the United States, for example, the first person they will see is the nurse. Very often, they will only see a doctor if the nurse deems it to be necessary, such as a critical situation (a traumatic injury for example, or a heart attack). In an overly burdened medical system, nurses have begun to assume critical roles in the nation’s health care.  

Orem considers a critical aspect of the science of nursing to be the examination of   the power nurses have in society and the ways in which this power is used.   She considers it absolutely essential that nurses be trained in the ability to analyze and assess an individual’s self-care demands and abilities. In other words, every nurse must be able to identify the crucial elements of self-care and whether or not an individual is capable of engaging in all aspects of self-care or not. The areas in which they are not capable (self-care deficits) must be analyzed and nurses must be able to meet these areas of need with appropriate assistance. This implies that nursing is no longer simply about meeting patient demands or queries. It is more about understanding and accepting that each person is cable of meeting their own self-care needs, but some to a greater degree than others. In addition, it is about understanding how people have been socialized in the various aspects of self-care within their own cultural contexts and beliefs. Science therefore is not only a theoretical science, it is also a highly practical one in which the outcomes are to contribute to the person’s overall health and well-being. According to Orem (2005) “nursing is a triad of interrelated action systems; a professional-technical system, the existence of which is dependent on the existence of an interpersonal system, and a societal system that establishes and legitimates the contractual relationship of nurses and persons who require nursing care” (p. 144).  

This theory provides both nurses and individuals with the means to negotiate an empowering rather than power-based relationship. While the notion of nursing agency (in Orem’s theory) is the power that nurses have, Orem’s theory also stipulates that nurses engage in a contractual relationship with their patients. The fact is, Orem redefines the ways in which nurses and their patients can interact with each other. Rather than assuming a role of power, the nurse has the option to assume the role of who empowers. These are two distinctly different roles. In the former, it is more a role of one who is in control. In the latter, it is a role of one who respects the ability of the patient to direct their own self-care and provides the knowledge and guidance in order to assist the person in this process. It is also a radically different role for the patient. This theory perceives people as having the intellectual ability to guide their own self-care and therefore the ability to understand the medical information they need in order to so. It is not a passive role where one simply goes to a medical professional and submits to their authority. It is a role where one is an active partner in a relationship which seeks to honor the whole person and provide the type of information and guidance they may need from time to time in order to direct their own self-care.  

In terms of my own profession as a nurse working with individuals who are in end stage renal disease and end stage liver disease, there may have been, in the past, a sense that at this stage people must submit to the care of others. I also work with person who receive kidney and liver transplants, another decision which has often been left to the medical practitioner to determine for the patient. With this model, I believe there is the potential to work with patients in a different way. In the case of persons awaiting transplants, there are often difficult decisions to be made and there is also very often a long waiting time involved. In addition, there is the reality that someone waiting for an organ may never receive it due to the long lists of people who require organ transplants. Thus, it becomes very important in this field to be able to assess and determine a person’s self-care abilities but we cannot assume that even though the situation may be dire or difficult, that the person no longer has the ability for some self-care.  

In working with patients who are at end stage renal or liver disease, there may be a strong psychological component in their overall self-care abilities. As a nurse, I must   be able to assess and identify any psycho-social overlay that may be impeding my patients and their self-care abilities. However, one cannot assume that because one has reached end of life, the person is no longer able to participate in at least some aspects of self-care.  

From Orem’s perspective, a person’s life is about the connection between themselves and their bodies, their beliefs, the environment in which they live and the people who are around them, end of life nursing must then be about far more than just the physical care. At this stage, nurses have the challenge to understand what dying means to this individual within a multiplicity of contexts. There may be cultural beliefs to adhere to or rituals which they wish to perform. Therefore, the nurse could possibly be seen as an agent to empower these patients to honor their own belief systems which accompany end of life. It is important, as a nurse, to understand any ethnic or cultural beliefs and practices which are important to my patients and adhere to them per the patient’s directions.  

There is also the matter of patient rights and their right to participate in the medical decisions which accompany end of stage renal and liver disease. The nurse once again becomes an agent in this process, empowering the patient to understand all the decisions that need to be made and taking care to guide the patient with this knowledge. It is important as a nurse not to assume one’s psychological state as end of life approaches. While one individual may be depressed and/or angry, another may be accepting and ready. As a nurse, one can never assume control for a patient simply because they have come to end of life. In fact, for many people this may be the ultimate moment of taking control and directing the care they wish to have at end of life.  

Another aspect of nursing with patients who are at end of life, is to understand that from this theoretical perspective, dying may not mean the same thing to everyone. Culturally, death is understood and honored in different ways. In addition to a wide range of burial rites, there are also spiritual and cultural beliefs about what death actually means. It may be, from my patient’s perspective, that death is simply another transition. Therefore, as a nurse, even though I may feel that it is sad to see someone in pain and even what I perceive of as suffering; the patient may have an entirely different perspective. In fact, even pain and suffering are understood differently across cultures. End of life may even be welcomed by some patients who have experienced a long and debilitating condition.  

From Orem’s perspective, a nurse does not have ‘to take control’ when a patient approaches end of life or is waiting for an organ transplant which may, or may not take place. It is not for the nurse to direct the patient’s care which is the way this situation has historically been perceived. Rather, both the nurse and the patient are empowered to work together to guide the patient in their own self-care and their own decision making. This frees both the nurse and the patient from the traditional power relationship which used to take place when nurses would be expected to make certain decisions for patients in specific situations.  

More specifically, the relationship between patient and nurse and the decisions that used to be made by nurses or expected of nurses are completely different in Orem’s theory. Self-care is about meeting the needs of the specific person and also honoring/respecting these needs as they are understood within the person’s specific cultural practices and beliefs. Nursing is transformed from a highly clinical practice to a highly personalized practice, one that respects the person’s beliefs, cultural background, and individual abilities to make decisions on their own behalf. As such, the nurse engages in a contractual relationship with their patients for the purpose of empowering them to make the decisions they need to make in order to guide their own self-care at whatever stage of life they may be.  

References

Isenberg, Marjorie, A. (2005). Nursing Theories and Nursing Practice (M.E.Parker, Ed.). Philadelphia: Davis Co.  

Orem, Dorothea. (2005). Nursing Theories and Nursing Practice (M.E.Parker, Ed.). Philadelphia: Davis Co.  

Parissopoulos, S & S. Kotzabassaki. (2004). Oem’s Self-Care theory, Transactional Analysis and the Management of Elderly Rehabilitation. ICUS Nursing Web Journal, 17, 1-11.