Homework: Nursing theory paper Discussion

Creative Nursing, Volume 23, Issue 1, 2017 ARTICLES AND ESSAYS A Foundational Analysis of Dorothea Orem’s Self-Care Theory and Evaluation of Its Significance for Nursing Practice and Research Ahtisham Younas, MN(c), BSN In-depth understanding of the ontological and epistemological assumptions of nursing theories can be achieved through theory analysis. Several theory analysis criteria have been proposed for examining ontological and epistemological assumptions, but there are limited examples of actual analysis of these assumptions. This article presents an analysis of the ontological and epistemological assumptions of Dorothea Orem’s selfcare theory and evaluates its significance for nursing practice and research. Keywords: Dorothea Orem’s self-care theory; foundational analysis; ontological and epistemological theory analysis; theory evaluation; nursing research and practice N ursing theories claim to offer guidance for nursing practice and to share unique perspectives about different nursing phenomena. Homework: Nursing theory paper Discussion

These perspectives are based on distinct philosophical underpinnings which give theorists’ views about human-universal health processes (Kim & Kollak, 2006) and are primarily composed of ontological and epistemological assumptions (Fawcett, 1993). Ontology and epistemology are Greek words within the realm of philosophy. They share an interdependent relationship because both help in the logical generation of knowledge (Reber, 1995). An ontology is a “philosophical belief system about the nature of social reality” (Hesse-Biber & Leavy, 2010, p. 4). In nursing, it refers to claims about the kind and nature of nursing, health, illness, and the structure of human beings. It seeks to answer what exists in the world (Bruce, Rietze, & Lim, 2014; Rawnsley, 1997; Schuh & Barab, 2008). An epistemology is a belief system of looking at the world and making sense of it. It involves knowledge; exemplifies a certain understanding of what that knowledge entails (Bruce et al., 2014; Crotty, 1998); and examines the “origins, nature, methods, and limits of human knowledge” (Reber, 1995, p. 256). Epistemology provides a philosophical basis for deciding what are the probable kinds of nursing knowledge and how we ensure they are adequate and reasonable (Bruce et al., 2014; Maynard, 1994). “Ontological assumptions are concerned with what constitutes reality, and epistemological assumptions are concerned with how knowledge can be generated, learned, and communicated” (Scotland, 2012, p. 9). In short, ontology concerns itself with what is true, and epistemology comprises different methods © 2017 Springer Publishing Company Ahtisham Younas, MN(c), BSN, has been a junior lecturer at Shifa College of Nursing in Islamabad, Pakistan, where he taught nursing theories and models. Currently, he is a graduate student in the School of Nursing at Memorial University of Newfoundland in St. John’s, Newfoundland, Canada. 13 http://dx.doi.org/10.1891/1078-4535.23.1.13 CN23-1_Final_A3_013-023.indd 13 1/13/17 9:37 AM Ontological assumptions are concerned with what constitutes reality, and epistemological assumptions are concerned with how knowledge can be generated, learned, and communicated. 14 CN23-1_Final_A3_013-023.indd 14 of unraveling that truth. Homework: Nursing theory paper Discussion

The strong linkage of ontology and epistemology in nursing knowledge greatly influences the way nurses investigate different nursing phenomena and practice nursing (Arslanian-Engoren, Hicks, Whall, & Algase, 2005). Understanding the ontological and epistemological assumptions is necessary for the in-depth understanding of nursing theories (Fawcett, 1993). This understanding can be achieved through theory analysis (Meleis, 2012), which refers to a methodical process of objectively examining the content, structure, and functions of a theory (Fawcett, 1993; McEwen & Wills, 2002; Meleis, 2012). Several analysis criteria have been proposed for examining the ontological and epistemological assumptions of nursing theories. Despite these criteria, there are limited examples in the literature of actual analysis of these assumptions. The most recent analysis criteria are those of Chinn and Kramer (1995) and Kim and Kollak (2006). Chinn and Kramer’s criteria include clarity, simplicity, generality, empirical precision, and derivable consequences of a theory. Kim and Kollak offered a multifaceted theory analysis approach entailing different types of analyses such as content analysis for the metaparadigm orientation, coherence among components, theory structure, theory progression, and foundational analysis. The discussion of all these analyses is beyond the scope of this article, which will focus on the foundational analysis of a nursing theory and its relevance for the nursing profession. Foundational analysis is a strategic process which enables a comprehensive understanding of a theory and its distinct concepts. It helps in systematically understanding the philosophical orientations of the concepts in a theory through identification of its ontological and epistemological assumptions (Kim & Kollak, 2006). This article presents a foundational analysis of Orem’s (1959) self-care theory through the examinations of its ontological and epistemological assumptions. It also evaluates the significance of this theory for nursing practice and research using Fawcett’s (2005) theory evaluation criteria. DOROTHEA OREM’S SELF-CARE THEORY Orem’s (1959) theory was selected for this analysis because it includes three interconnected theories, which make it composite and potentially difficult to understand. It is important to delineate its ontological and epistemological assumptions clearly, so that every nursing professional will have a similar understanding of this theory. Many authors have analyzed the self-care theory in terms of its theoretical progression, metaparadigm orientation, and coherence of the theoretical components. These analyses are somewhat related to Chinn and Kramer’s (1995) theory analysis framework. Homework: Nursing theory paper Discussion

For example, Melnyk (1983) presented a descriptive and analytical examination of Orem’s theory in terms of its commonplaces, elements, principles, internal construction, clarity, and generality. This analysis highlighted the relationship and worth of this theory for modern nursing practice and research using Stevens’s (1979) analysis criteria but did not analyze the underlying implied assumptions of the theory. Hanucharurnkul (1989) conducted a comparative analysis of Orem’s self-care theory and King’s (1981) theory of goal attainment, considering their theory development strategies and views of nursing metaparadigm concepts. This analysis covered the scope, usefulness, and the unique contribution of these theories for nursing science but did not analyze the underlying assumptions of the theories. Comley (1994) also presented a comparative analysis of the concepts and assumptions of Orem’s theory and Peplau’s (1952) interpersonal theory with focus on their theoretical origins, meanings related to nursing metaparadigm, logical Younas 1/13/17 9:37 AM adequacy, generalizability, and testability. Comley identified five obvious assumptions of Orem’s theory regarding nature, capacities, and limitations of human beings and their self-care needs but did not examine other implied assumptions. The aforementioned authors mainly illustrated the theoretical development and application of Orem’s theory in nursing practice. Hence, their work partially contributes toward the conceptual and philosophical understanding of this theory because of the incomplete analyses of the theory and its comparative analyses with other theories. Recently, Fawcett and Desanto-Madeya (2013) identified the obvious and implied premises, assumptions, and presuppositions of Orem’s theory but did not sort them as ontological and epistemological in nature. Also, their theoretical analysis is brief and did not include the theoretical foundations of the theory. This indicates the need to delineate the philosophical nature of Orem’s theoretical assumptions. Foundational analysis is a strategic process which enables a comprehensive understanding of a theory and its distinct concepts. Homework: Nursing theory paper Discussion

OVERVIEW OF THE PHILOSOPHICAL BASIS Orem’s (1959) theory of self-care stems from the totality paradigm. According to this paradigm, human beings and the universe form a cause–effect relationship (Parse, 1987). The theories within this paradigm view body, mind, and spirit as separate entities and emphasize their practical modalities on the psychological, physiological, spiritual, and social well-being of human beings (Parse, 1987). Numerous features of the totality paradigm are evident in Orem’s theory: • Human beings are viewed as a summative entity that needs adaptation with their environment to meet life goals. • Human beings are recognized as active agents who are capable of taking deliberate actions to maintain self-care. • Environment is considered as a means to provide basic human needs for survival. • Orem viewed nursing as a form of assistance to meet the required need for self-care of patients (Orem, 2001). Homework: Nursing theory paper Discussion

This concept of nursing is related to the nursing process, which is the primary practice methodology within the totality paradigm (Parse, 1987). Orem’s theory is a grand nursing theory encompassing three interconnected theories: the self-care theory, the self-care deficit theory, and the theory of nursing systems. The theory of self-care describes why and how human beings care for themselves. The theory of self-care deficit clarifies why and how human beings can be helped through nursing. The theory of nursing systems describes relationships between nurses and patients and the importance of these relationships for quality nursing care (Orem, 2001; Tomey & Alligood, 2010). These three theories as a whole present philosophical ideas about self-care, nurses, patients, and their interaction. EXAMINATION OF ASSUMPTIONS UNDERLYING OREM’S THEORY The theory of self-care includes assumptions about human beings, nursing-specific assumptions about human beings, assumptions about nursing, assumptions about self-care and self-care requisites, and assumptions about deliberate action (Fawcett & Desanto-Madeya, 2013; George, 2011; Tomey & Alligood, 2010). Foundational Analysis of Dorothea Orem’s Self-Care Theory CN23-1_Final_A3_013-023.indd 15 15 1/13/17 9:37 AM Orem’s theory encompasses the selfcare theory (describing why and how human beings care for themselves), the self-care deficit theory (clarifying why and how Assumptions About Human Beings Orem (2015) viewed two types of human beings in her theory: those who need nursing care (patients) and those who provide it (nurses). She presented two main assumptions about human beings. First, human beings are unique individuals. Second, they share basic needs for maintaining their living conditions. These living conditions support life processes and the formation, maintenance, and promotion of their structural and functional integrity. These assumptions by Orem are ontological in nature because they give awareness about the nature and characteristics of human beings. The first assumption indicates that both patient and nurse possess their own capacities, abilities, powers, values, and personal dispositions. Orem (2001) proposed three primary differences between human beings and other living things: human beings • Human beings have ability to reflect on themselves and their environment. can be helped • Human beings symbolize their experiences. through nursing), • Human beings use symbolic ideas in thinking and guiding efforts to make things beneficial for themselves and others. and the theory of nursing systems (describing relationships between nurses and patients and The second assumption specifies that human beings have common needs, but they are also self-reliant and responsible for self-care. It implicitly states that health, well-being, and human development are dependent on self-care requisites (Basavanthappa, 2007; Fawcett & Desanto-Madeya, 2013; George, 2011). Homework: Nursing theory paper Discussion

The second assumption will also be discussed later in relation to self-care requisites. the importance of these relationships for quality nursing care). Nursing-Specific Assumptions About Human Beings (Patients) From a nursing perspective, Orem’s ontological assumption about human beings is that they need continuous self-maintenance and self-regulation through selfcare (2001). Orem noted that all human beings are willing to engage in self-care for themselves and their dependent family members. They have the potential and the ability to learn how to meet their self-care needs. The epistemological assumption is that they need continuous and deliberate interaction among themselves and their environments for their self-care and survival. This is epistemological in the sense that Orem offers a strategy for developing self-care abilities. Assumptions About Nursing Orem’s (2001) ontological assumption about nursing is that it is a form of assistance for the people who need it for preventing disease, promoting health, and sustaining life. Nursing is required when a person cannot maintain the type and quality of self-care to sustain life and health and to recover from disease (Roberson & Kelley, 1996). Orem believed that nursing practice has both technological and moral aspects. Nursing is technical because of the various nursing procedures that nurses use in ongoing practice. It is moral because nursing decisions influence the health and well-being of human beings. These assumptions are ontological in nature because Orem examines the structural and functional nature of nursing practice. Orem posits that the simplest way to conceptualize nursing is by considering it a deliberate action (Fawcett & Desanto-Madeya, 2013). This assumption is both ontological and epistemological in nature. It is ontological because Orem asserts 16 CN23-1_Final_A3_013-023.indd 16 Younas 1/13/17 9:37 AM that nursing is a deliberate action. It is epistemological because she suggests a way to understand nursing and makes a connection between nursing and deliberate action. Assumptions About Self-Care Requisites and Self-Care Orem (2001) proposed three main assumptions concerning self-care requisites. First, human beings possess common needs for the consumption of materials necessary to sustain life (universal self-care requisite). Second, human beings require various actions to promote their growth and development throughout different life stages (developmental self-care requisite). Third, deviation from normal structural and functional well-being requires actions to reduce occurrences and also to control the effects of any deprivation (health deviation self-care requisite). Orem’s (2001) ontological assumption about self-care is that it is essential for health, development, and well-being of human beings. Self-care includes deliberate actions to meet an obvious need for care. Her epistemological assumption about self-care is that every person’s knowledge of probable health problems is essential for promoting self-care behaviors. The way an individual engages in self-care varies because of influences from his or her culture and environment (Fawcett & Desanto-Madeya, 2013; George, 2011). According to Orem, nursing is a form of assistance for Assumptions About Deliberate Action According to Orem (2001), deliberate action is an action that intends to bring a particular outcome; deliberate action is crucial for self-care. Her ontological assumption is that deliberate action is not innate; rather, it is learned through communication and human interaction. Homework: Nursing theory paper Discussion

 Her epistemological assumption is that human beings should have incoming sensory knowledge and a realistic awareness of the situation to perform deliberate action. They should reflect on the meaning of existent conditions relative to their self-care abilities. This epistemological assumption about deliberate action can be dichotomized into two perspectives: deliberate action and patients, and deliberate action and nursing. Deliberate Action and Patients. To perform deliberate actions, patients should be aware of their conditions and situations and the difficulties associated with them.

They should have the capacities to manage these difficulties in the best possible ways (Orem, 2001). Deliberate Action and Nursing. Nursing practice is a deliberate action which is performed by members of a social group to benefit others in specified ways (Orem, 2001). In this assumption, members of a social group could be nurses, families, or other health care providers. people who need it for preventing disease, promoting health, and sustaining life; nursing is required when a person cannot maintain the type and quality of self-care to sustain life and health and to recover from disease. EVALUATION OF OREM’S SELF-CARE THEORY The significance of Orem’s theory for nursing practice and research was evaluated using Fawcett’s (2005) theory evaluation criteria that are broader than many previous sets of criteria. Fawcett’s (2005) criteria include the significance, internal consistency, parsimony, testability, empirical adequacy, and pragmatic adequacy of a theory. Foundational Analysis of Dorothea Orem’s Self-Care Theory CN23-1_Final_A3_013-023.indd 17 17 1/13/17 9:37 AM Significance The criterion of significance questions the context of a theory; its explanation about person, nursing, health, and environment (metaparadigm); and the clarity of the philosophical claims (Fawcett, 2005).

Orem (2001) clearly explained the origins of her theory in different editions of her book and acknowledged the works of other researchers in the development of self-care theory (Fawcett & DesantoMadeya, 2013). Orem also explicated the philosophical claims of self-care theory, which have already been outlined, and thoroughly defined the concepts of her theory, including the two metaparadigm concepts of human and nursing (2005). However, she did not explicitly define environment, health, or illness. Her definitions of health and illness are implied in the concept of self-care; the definition of environment is not explicit (Fawcett & Desanto-Madeya, 2013). These missing definitions lessen the significance of the theory. Orem’s theory assumes that human beings have common needs, but they are also self-reliant and responsible for self-care; they need continuous and deliberate Internal Consistency The criterion of internal consistency includes the content, context, semantic clarity, and semantic consistency of a theory. Semantic clarity refers to the presence of explicit definitions of the major concepts of the theory, whereas semantic consistency refers to the use of consistent concepts and terms within the theory (Fawcett, 2005). Based on the content and context, the self-care theory meets the criterion of internal consistency. It also meets the criterion of semantic consistency because its ontological and epistemological assumptions, concepts, and the linkage among three interconnected theories are clear and consistent. There are logical linkages between the content, structure, and concepts of the subtheories (Hagran & Fakharany, 2015). Homework: Nursing theory paper Discussion

However, it has less semantic clarity because of the missing definitions of the concepts of the metaparadigm. interaction among Parsimony themselves Parsimony refers to the presentation of a theory in the best possible way; this criterion is met if a theory explicates the concepts in a clear and concise manner (Fawcett, 2005). The self-care theory meets this criterion because its major concepts are explained in depth. Although it is a complex theory to understand, the use of pictorial representations helps in better understanding the linkages among the concepts (Cassum, 2014; Rajani, 2013). and their environments for the … Homework: Nursing theory paper Discussion