Nursing is an evolving discipline in the development of science i.e. theory and research and in professional practice. We have a rich history of thought from Florence Nightingale to the recent nurse researchers, theorists and clinicians. Moreover, nursing professional practice includes integration of knowledge from the broad conceptualizations of models to the level of practice theory. The nursing theoretical frameworks serve in powerful ways as guides for articulating, reporting, recording nursing thought and action. Nurses must know what they are doing, why they are doing, what may be the range of outcomes of nursing, and indicators for measuring nursing impact (Parker, 2001). The aim of this paper is to study, compare and contrast two nursing models given by two nursing theorists who have made major contributions in the field of nursing practice. These models are; Roy adaptation model and Orem’s Self-care model.
Introduction to the theorists, Sister Callista Roy and Dorothea E. Orem
Sister Callista Roy received a bachelor’s degree in nursing in 1963 from Mount Saint Mary’s College as master’s degree in pediatric nursing in 1966, a master’s degree in sociology in 1975 and a doctorate degree in sociology in 1977, all from the University of California, Los Angeles. Roy first proposed her model while studying for her master’s degree, where she was challenged by Dorothy Johnson to develop conceptual models of nursing. Therefore, the development of the adaptation model for nursing has been influenced by Roy’s personal and professional background. She had her experience as a pediatric staff nurse where she mainly noticed the children and their ability to adapt in response to major physical and psychological changes.
Dorothea E. Orem was born in Baltimore, Maryland. She received her diploma in nursing from Providence Hospital School of Nursing in Washington, DC, baccalaureate in nursing from Catholic University in 1939 and master’s degree in 1945 from the same university. She decided to develop her theory after she and her colleagues were given an assignment to produce a nursing curricula for practical nursing for the department of Health, Education and Welfare in Washington, DC. Between 1971 and the 1995 editions, there have been some changes in Orem’s theory, notably in the concept of an individual and the idea of the nursing system. Orem delineates three theories; self-care, self-care deficit, and nursing system.
Focus of Roy’s and Orem’s Model
Roy’s model was initially developed for education; however, it continued to work in research and practice settings. Roy’s model focuses on the concept of adaptation of man. Her concepts of nursing, person, health and environment are all interrelated to this central concept. According to her model, the person receives inputs or stimuli from both the environment and the self. Adaptation occurs when the person responds positively to environmental changes. This adaptive response promotes the integrity of the person which leads to health. Ineffective responses to stimuli lead to disruption of the integrity of the person.
Self-care model was given by Dorothea Elizabeth Orem in 1970. The focus of the model is self-care, self-care agency, self-care demand, self-care deficit, nursing agency and nursing system. Self-care is a requirement of every person, man, woman and child. Self-care is viewed as function and the capability of an individual which means that the things an individual can do and able to do. When self-care is not maintained, illness, disease or death will occur. Self-care requisites result in the regulation of structural and functional integrity and human development. There are three categories of self-care requisites; universal, developmental and health deviation self-care requisites. According to Orem, there are various basic conditioning factors (age, gender, developmental state, health state and health care system, sociocultural orientation, and family system, patterns of living, environment and available resources) that can influence the categories of self-care requisites. The essence of Orem’s model is entirely the nurse-patient relationship.
Metaparadigm of both the Models
Roy described the person in terms of system and adaptation, a biopsychosocial being in constant interaction with a changing environment. She defines person as a recipient of nursing care, as a living complex, adaptive system with internal processes (the cognator and regulator) acting to maintain adaptation in the four adaptive modes: physiological (biologic), self-concept (psychological), role function and interdependence (social). The cognator controls processes related to perception, learning, judgment, and emotion i.e. psychological adjustments. The regulator functions primarily through the use of the autonomic nervous system in making physiologic adjustments.
On the other hand, Orem expressed that the individual person is the primary focus in the model. People are basically rational beings who assess situations, reflect and understand them. Based on this person as agent or having agency that chooses to perform specific actions and goal directed. Moreover, in comparison to Roy’s model, she also indicated that empowering person helps to cope with the causes and effects which ultimately progress to the positive adaptation of an individual.
Roy’s goal of nursing is to help individual adapt to changes in his psychological needs, self-concept, role function and interdependent relations during health and illness. Nursing fills a unique role as a facilitator of adaptation by assessing behavior in each of these four adaptive modes and intervening by managing the influencing stimuli (George, 1995).
Similarly, Orem defines nursing as a human service and facilitates that nursing special concern is a person’s physiological needs for the provision and management of self-care action on a continuous basis in order to sustain life and health. However, the goal of nursing in both the theories is to overcome the patient’s limitation whether it is psychological or physiological needs.
According to Roy and Andrews (1999) health is a state and process of being and becoming an integrated and whole person. Likewise Orem (1985) sees health as an ideal when living things are structurally and functionally whole. Health can be viewed as a human adaptive system within a changing environment. Lack of integration represents lack of health. Adaptation is a process of promoting this integration i.e. maintaining physiological, psychological and social integrity. Similarly, according to Horsburgh (1999), Orem views health state as the basic conditioning factor also comprises on physiological, psychological and social imbalances most likely to influence adult self-care abilities and behaviors.
According to Roy (1999), environment is all the conditions, circumstances that influences surrounding and affect the development and behavior of persons or groups. Environment is the input into the person as an adaptive system involving both internal and external factors. Any environmental change demands increasing energy to adapt to the situation. Factors in the environment that affect the person are categorized as focal, contextual and residual stimuli. Focal stimulus mostly confronts the person that precipitates the behavior. Contextual stimuli are all other stimuli present that contribute to the behavior caused or precipitated by the focal stimuli. Residual stimuli are factors that may be affecting behavior but whose affects are not validated.
Orem acknowledges self-care requisites to have their origins in human beings and the environmental factors, elements, conditions, etc. Environmental factors influences health care abilities of a person and are shaped within a person’s sociocultural context. Furthermore, she proposed the similar concept of Roy’s theory that man and environment interact as self-care system. If the system of man and environment gets change, the adaptation of self-care system will be affected.
Compare & Contrast of both the Models with Literature Support
Identification of the underlying assumptions is necessary to internal and external evaluation of the theory which deals with logic, consistency and congruence with the practical world (Barnum, 1998). The concept of person, health, nursing and environment are well defined however there are some similarities and differences among the two models. Firstly, Roy’s model focuses mainly on psychological aspects of a person. She discusses about the adaptation of a man and stresses on ways of adaptation and coping mechanisms whereas Orem’s model focuses greatly on physiological and sociological aspects of a person and lacks psychological aspects. She talks about individualism, autonomy, self-directed and self-reliance. Moustafa (1999) also noted that Orem’s theory is generally accorded to the physiological and sociological wellbeing of the person, undermining the importance of mental health. For e.g., a person who is a paranoid schizophrenic will not admit that he needs help regarding his self-care demands and without acceptance of the self-care deficit, it will be difficult to care for the person using Orem’s theory concepts.
Secondly, according to Roy (1999) environment is internal and external stimuli and the person receives inputs from the external and internal environments. In her earlier writing (1981) that environment is different from internal stimuli and now she viewed internal stimuli is a part of environment. However, the question arises if internal stimuli are a part of environment than how it is different from the person’s adaptation level? Moreover, Roy’s model of nursing management specify that the manipulation of the stimuli is different from the manipulation of people however the question still remains the same can internal stimuli be manipulated without manipulating the person? It seems that the relationships of adaptation to person, health and nursing are clear however the person-environment interaction is less clear. In contrast, Orem simply proposed that the change in person-environment system will ultimately change the entire self-care system. Both the models highlight similar factors but the objective of both the theorists differ as in case of Orem, it is self-care whereas Roy as adaptation. Nevertheless, both the models can be interrelated as for e.g., in order to perform self-care successfully, a person needs to adapt to the internal and external stimuli or the environment. The person needs to be stress free and comfortable both physically and psychologically. Both adaptation and self-care is a behavior of a person that are influenced by various factors such as culture, personality, socioeconomic status, education, age, gender and available resources etc.
Thirdly, both of these models primarily focus on individualism. None of them takes the viewpoint of family, society, or a community as a whole. However, with certain modification, the models are seen empirically tested on various age groups such as among student’s community, elderly, various disease specific groups etc. Roy sees person as a living complex, adaptive system acting to maintain adaptation in four adaptive models (physiological needs, self-concept, role function and interdependence) whereas according to Orem, person as rational beings who has mastery over their destiny. In other words, the individual as a person is independent to choose and select whatever they want. It is normal for the person who wants to attain optimum levels of self-care. However, this is not true at all the time; a person looking for a secondary gain from the illness may not give importance to his/her wellness. Regarding health, both of them believe that health is a state and a process for becoming an integrated and whole person. However, these models lack the spiritual and existentialist aspects of a person. These models describe nurse as a facilitator. The aim of the nurse in Roy’s model is to help man adapt to changes brought about during the health illness continuum whereas according to Orem’s model, nurse facilitates the self-care abilities of a person which is more towards the physiological needs of a person.
Lastly, Orem’s model is somehow culturally biased. In scientifically advance culture, people believe that sickness is because of natural reason. However, some cultures believe on traditional and folk premises. Therefore, these perceptions are still failing to recognize the variety of health related cultural belief and practices. Orem’s theory does not explain the traditional and folk health believes even she called a scientifically advanced culture (Orem, 1991). On the contrary, Roy’s model talks about the person’s relationship with the world and God on philosophical premises. Persons use human creative abilities of awareness, enlightenment and faith. In my judgment I feel that as an external stimuli or factor, cultural and religious believes can hinder in adaptation process.
Furthermore, both the theories are very complex and have broad concepts for the practical implication. Roy’s model is difficult to categorize the behaviors of the person in the four adaptive modes (George, 1995). In addition, there is an overlapping of concepts definitions. Similarly, Orem’s self-care model is used with numerous configurations; this multitude of terms such as self-care agency, self-care demand, self-care deficit, requisites can be very confusing to the reader. Abdul (2002) also noted that Orem’s work is easy to explain but difficult to differentiate among numerous terminologies and hypothesis. The holistic approach of these models helps prevent putting too much emphasis on aspects of illness and allows for the inclusion of health promotion. In addition, they are easy to apply as a family center model. Both have been found very useful in inpatient and outpatient settings as well as in work settings and in the community. However, it is difficult to apply Roy’s model in intensive care units where situations change rapidly (George, 1995). Moreover, the clinical research generating from these theories have health promotion application also. Nursing, when define in terms of focus ( for knowledge and practice), is a specialized health service necessitated by an adults inability to maintain the amount and quality of self-care i.e. therapeutic in sustaining life and health , even in recovering from disease or injury, or in coping with their effects through adaptation.
Application of models in clinical Practice & Conclusion
Roy’s ad Orem’s model have greatly influenced nursing profession. The integration of both the models is not only applicable in clinical practice but also in nursing education, administration and research. These models guide nurses to use observations and interviewing skills in doing an individualized assessment of each person. It is a useful guide in nursing assessment and formulating nursing diagnosis. Therefore, apparently both the models are valuable in nursing clinical practice. Alligood and Marriner-Tomey (2002) state that conceptual or theoretical models of nurse practice are significant to the field, providing the profession with a guide to patient care and with a general frame of reference that connects the structural environment to the patterns of behavior and relationships within the organization. Nurses have a unique role to promote health in majority of the setting by utilizing these theory in acute healthcare settings, community settings, rehabilitation nursing, palliative care, in learning disability nursing etc. The goal of both the theories is giving assistance adapted to specific human needs and limitations. I suggest that the concept development of different models and analysis will contribute to further identification of functional theories in nursing. Thus, we need to continue our efforts to develop diverse types of theories and consider the advancement of the nursing discipline.