Rev. Enferm. UFSM - REUFSM
Santa Maria, RS, v. 11, e28, p. 1-20, 2021
DOI: 10.5902/2179769254723
ISSN 2179-7692
Submission: 09/05/2020 Acceptance: 03/05/2021 Publication: 03/26/2021
Original Article
Professional practice in the hospital context: nurses' view on the contributions of Dorothea Orem's conceptions
Prática profissional no contexto hospitalar: visão de enfermeiros sobre contribuições das concepções de Dorothea Orem
La práctica profesional en el contexto hospitalario: la visión de las enfermeras sobre las contribuciones de las concepciones de Dorothea Orem
Olga Maria Pimenta Lopes RibeiroI
Letícia de Lima TrindadeII
João Miguel Almeida Ventura da SilvaIII
Ana da Conceição Alves FariaIV
I Adjunct Professor, PhD in Nursing Science, Nursing School of Porto. Porto, Portugal. Email: olgaribeiro@esenf.pt, Orcid: https://orcid.org/0000-0001-9982-9537.
II Adjunct Professor, PhD in Nursing, Santa Catarina State University and Community University of the Chapecó Region. Chapecó, Santa Catarina, Brazil. Email: letrindade@hotmail.com, Orcid: https://orcid.org/0000-0002-7119-0230
III Nurse, Master in Nursing Science, University Hospital Center of São João. Porto, Portugal. Email: joao.miguel.silva@chsj.min-saude.pt, Orcid: https://orcid.org/0000-0002-8794-528X
IV Nurse, Master in Rehabilitation Nursing, Northern Regional Health Administration, Ave/Famalicão Health Center Group. Vila Nova de Famalicão, Portugal. Email: acafaria@arsnorte.min-saude.pt, Orcid: https://orcid.org/0000-0002-5838-0080
Abstract: Objective: to analyze the concordance of nurses about the contributions of Dorothea Orem's conceptions to professional practice in the hospital context. Method: a quantitative cross-sectional study conducted in 36 Portuguese hospitals, with the participation of 3451 nurses. Data was collected using a questionnaire between July 2015 and March 2016. For analysis, descriptive and analytical statistics were used. Results: it was confirmed that 75 to 85% of the participants considered that Orem's conceptions regarding the four meta-paradigmatic concepts are in concordance or totally in concordance with their practice. The Region of the country, the service, and the condition in which the profession is practiced were the variables that influenced the concordance with the conceptions. Conclusion: the conformity observed in the results regarding the concordance of the nurses with the meta-paradigmatic concepts reinforces the contribution of Orem's framework to support the practice and to guarantee the scientificity of the profession.
Descriptors: Nursing; Nursing Theory; Models, Nursing; Professional Practice; Hospitals
Resumo: Objetivo: analisar a concordância dos enfermeiros sobre as contribuições das concepções de Dorothea Orem para a prática profissional no contexto hospitalar. Método: estudo quantitativo, transversal, realizado em 36 hospitais portugueses, com participação de 3451 enfermeiros. A coleta de dados decorreu entre julho de 2015 e março de 2016, por meio de questionário. Para análise, usou-se estatística descritiva e analítica. Resultados: confirmou-se que 75 a 85% dos participantes, consideraram que as concepções de Orem com relação aos quatro conceitos metaparadigmáticos, estão de acordo ou totalmente de acordo com a sua prática. A Região do país, o serviço e a condição em que se exerce a profissão foram as variáveis que influenciaram a concordância com as concepções. Conclusão: a conformidade observada nos resultados quanto à concordância dos enfermeiros com os conceitos metaparadigmáticos, reforça o contributo do referencial de Orem para a sustentação da prática e para a garantia da cientificidade da profissão.
Descritores: Enfermagem; Teoria de Enfermagem; Modelos de Enfermagem; Prática Profissional; Hospitais
Resumen: Objetivo: analizar el acuerdo de enfermeros sobre las contribuciones de las concepciones de Dorothea Orem para la práctica profesional en el contexto hospitalario. Método: estudio cuantitativo, transversal, realizado en 36 hospitales portugueses, con la participación de 3451 enfermeros. La recolección de datos se llevó a cabo entre julio de 2015 y marzo de 2016, mediante un cuestionario. Para el análisis se utilizó estadística descriptiva y analítica. Resultados: se constató que 75 a 85% de los participantes consideraron que las concepciones de Orem sobre los cuatro conceptos metaparadigmáticos, están de acuerdo o totalmente de acuerdo con su práctica. La región del país, el servicio y la condición en la que se ejerce la profesión fueron las variables que influyeron en el acuerdo con las concepciones. Conclusión: la conformidad observada en los resultados sobre la concordancia de los enfermeros con los conceptos metaparadigmáticos, refuerza el aporte del marco de Orem para sostener la práctica y garantizar la cientificidad de la profesión.
Descriptores: Enfermería; Teoría de Enfermería; Modelos de Enfermería; Práctica Profesional; Hospitales
Introduction
In Nursing, after a time when scientific principles were fundamentally derived from other sciences, the effort of nurses to recognize and make public their own knowledge has been notorious.1-2 In addition, over the last few years, it has become a consensus among several authors that sustaining nursing practice only in the biomedical model, without incorporating knowledge of its own, essentially through nursing theories, neither expands nor sediments the specific performance of nurses.3-4
Given the complexity of professional practice, nursing theories are capable of producing consistent descriptions and explanations of phenomena, being absolutely determinant in the predictions and prescriptions of nurses.1,3 Although recently some authors have pointed out the potential of the theories, the value that has been attributed to them, and their incorporation into clinical practice, is often lower than expected.1-2
In the certainty that theory and practice should go hand in hand, nursing theories can be instrumental in creating bridges between "practical" and academic nurses, contributing to the annulment of the idea that knowledge is only produced by PhD nurses and consumed by "practical" nurses.3 Although it is recognized that not all theories fit the various contextual realities, it is up to nurses to identify those that best fit the demands of professional care, considering their potential to support the professional practice.2-3
In addition, in order to be implemented with quality, nursing care must be anchored in nursing theories,5-6 which, from different perspectives, explain the phenomena inherent to nursing practice.1 By basing their actions on the theories of the profession, nurses give meaning to their care practice, with potential differentiation in the construction of reasoning and clinical judgment, as well as reveal themselves more subsidized to define nursing interventions and achieve better results.1
Given the essence of Nursing, Dorothea Orem's theoretical framework focusing on self-care has been one of the most frequently incorporated into clinical practice. From the theorist's perspective, self-care refers to the performance or practice of activities that people perform to maintain life, health and well-being.7-8
In addition, its framework integrates three theories: Self-Care Theory (which presents why and how people take care of themselves), Self-Care Deficit Theory (which presents and explains why people can be helped by nursing professionals) and Nursing Systems Theory (which presents and explains how nurses and/or people respond to self-care needs).7,9-10 The Systems Theory of Nursing is the most external and engaging and contains the Self-Care Deficit Theory. In turn, the Theory of Self-Care is a component of the Theory of Self-Care Deficit.7
Tal como aconteceu em relação ao referencial teórico de Orem, à medida que foram sendo desenvolvidas, as diversas teorias de enfermagem alicerçaram a construção de uma base de conhecimento sólida, organizando o mundo fenomenal da Enfermagem em torno daqueles que ficaram amplamente reconhecidos como conceitos metaparadigmáticos: enfermagem, pessoa, saúde e ambiente.3,11
From this perspective, it is important to consider that in order to select the theory that best corresponds to the demands of individualized and intentional care, it is essential that there is congruence between the metaparadigmatic concepts and the nurses' performance in the different clinical contexts.12 Thus, when reflecting on the relevance of a particular theory to support professional practice, it becomes important to inquire about the nurses' concordance on its central concepts, with special emphasis on nursing, the person, health, and the environment.
Based on these assumptions, within the scope of a broader research conducted in Portugal, in the national context, and entitled "Contexts of hospital practice and nurses' conceptions",13 in addition to others, it was established as an objective to identify the degree of concordance of nurses on meta-paradigmatic concepts, in the light of 13 theoretical nursing concepts, and their application in professional practice. The lack of studies on the subject and, consequently, the lack of knowledge about the theoretical frameworks with which Portuguese nurses most identified, constituted the main challenges for this research. Empirically it was known that in Portugal, Dorothea Orem's theoretical framework is one of the most adequate for the professional practice of nurses, however, no previous research had made this fact evident.
Thus, following the above, this research aims to answer the following question: What is the concordance of nurses about the contributions of Dorothea Orem's conceptions of nursing, person, health and environment to professional practice in the hospital context?
In view of the above, this article aimed to analyze the concordance of nurses about the contributions of Dorothea Orem's conceptions to professional practice in the hospital context.
Method
Quantitative, cross-sectional study conducted in 36 hospitals in mainland Portugal. The sampling technique used was non-probability by convenience. Based on an accessible population of 10.013 nurses, for a confidence interval of 95% and a significance level of 5%, a sample of 3.451 nurses was obtained. Inclusion criteria were defined as: exercising professional activity in a hospital context for at least six months, in the departments of medicine, surgery and intensive care and emergency services. Nurses who were on leave during the data collection period were excluded, regardless of the reason.
As data collection instrument, we used a self-completed questionnaire, organized into two parts: the first one with the participants' sociodemographic and professional characterization, and the second one related to the conceptions of nursing, person, health, and environment. Although in the scope of the research conducted in Portugal, in the national context,13 in this second part of the instrument the conceptions of 13 nursing theorists were clearly expressed in relation to meta-paradigmatic concepts, meeting the objective of this study, we will focus on Dorothea Orem's conceptions.
When filling out the questionnaire, the participants were asked to respond according to their concordance with Orem's conceptions of nursing, person, health, and environment. On a Likert-type scale, the answers could vary between 1 "totally disagrees with my practice", 2 "disagrees with my practice", 3 "no opinion", 4 "agrees with my practice", and 5 "totally agrees with my practice".
It should be noted that the questionnaire was designed and validated by the researchers themselves in a pilot study, prior to this study, with the participation of nurses from other hospitals. In the first phase of the design of this instrument, content validation was performed by experts who studied nursing theoretical frameworks and, subsequently, for construct validation and internal consistency, exploratory factor analysis and Cronbach's alpha coefficient were used.
After confirming the validity and reliability of the instrument, data collection, carried out by one of the researchers, occurred between July 2015 and March 2016, after approval by the Ethics Committees and Boards of Directors of the 36 hospitals where the study was conducted. In each service of the included areas, the questionnaires corresponding to the number of nurses working in the sectors were delivered and, subsequently, collected on site, upon prior scheduling and availability of the professionals. In addition to the written information, which was attached to the questionnaire, at that moment, the research was also presented in person to the nurses. After the clarification about the objectives, the nurses were free to fill out the questionnaire or not, placing it later in a closed envelope.
The Statistical Package for the Social Sciences (SPSS), version 22.0, was used for data processing. When analyzing the results, a significance level of 0.05 and a confidence level of 0.95 were considered.
To understand the distribution of the variables, considering their nature, the Wilcoxon-Mann-Whitney test and the Kruskal-Wallis test were used. To confirm the existence of differences in the location of the distributions, the chi-square distribution was used. Given that the degree to which participants agreed with the conceptions is an ordinal qualitative variable, to identify the characterization variables that affected the degree of concordance, cumulative logistic regression models for ordinal responses were used.
Using these models, we first identified the explanatory variables that influenced the degree of concordance with the conceptions of nursing, person, health and environment. Subsequently, to select the explanatory variables to be retained in the model, a backward selection was performed based on Wald's test, eliminating the variables whose estimated parameter was not statistically significant. The characterization variables included in this analysis were the Region of the country, the service, gender, academic degree, the condition in which the profession is practiced and the length of professional experience.
It should be noted that this research, which is part of a national research, was conducted in accordance with the required ethical standards, having been previously approved by an Ethics Committee of a Hospital in the Northern Region of Portugal, on May 13, 2015, under number 98-15. All the nurses who participated in the study signed the informed consent, and the confidentiality and anonymity of the information collected was ensured.
Results
Regarding sociodemographic and professional characteristics, the 3451 participants were mostly female (n=2661), with a mean age of 36.4 years and standard deviation of 8.3. Regarding marital status, 2109 were married or cohabiting, 1168 were single, 163 were divorced and 11 were widowed.
Regarding their professional status, 2633 were general care nurses, 686 were specialist nurses and 132 were nurse managers. In terms of areas of specialization, 306 were specialists in rehabilitation nursing, 259 in medical-surgical nursing, 55 in community nursing, 37 in mental health and psychiatric nursing, 17 in child health and pediatric nursing, and, finally, 12 in maternal health and obstetrics nursing.
With regard to academic degree, 3037 had a bachelor's degree, 369 had a master's degree, 38 had a bachelor's degree, and seven had a doctoral degree. Regarding the distribution of nurses according to the Regional Health Administrations (RHA) that integrate the hospitals where the study was carried out, the North prevailed with 1492 participants, Lisbon and Tagus Valley with 829, the Center with 771, the Alentejo with 213 and the Algarve with 146.
Considering that the hospital institutions are distributed in continental Portugal by five Regions, which correspond to the already mentioned Regional Health Administrations, the results concerning the conceptions of nursing, person, health and environment will be presented according to these territories.
Concordance with Dorothea Orem's conceptions of nursing, person, health, and environment
Concerning Dorothea Orem's conception of nursing, although the option "in accordance with my practice" was the most frequent answer, 32.6% of the participants from the Central Region and 29.8% from the Northern Region stated that this conception is "totally in accordance with their practice" (Table 1).
Table 1 - Concordance of nurses with Dorothea Orem's conception of nursing, in the five regions of the country. Porto, Portugal, 2017
|
Country Region |
Concordance with Dorothea Orem's conception of nursing |
|||||
|
1* |
2† |
3‡ |
4§ |
5|| |
Total |
|
|
n(%) |
n(%) |
n(%) |
n(%) |
n(%) |
n(%) |
|
|
North |
20(1.3) |
102(6.8) |
169(11.3) |
757(50.7) |
444(29.8) |
1492(100) |
|
Center |
3(0.4) |
14(1.8) |
119(15.4) |
384(49.8) |
251(32.6) |
771(100) |
|
Lisbon and Vale do Tejo |
7(0.8) |
52(6.3) |
138(16.6) |
467(56.3) |
165(19.9) |
829(100) |
|
Alentejo |
1(0.5) |
7(3.3) |
38(17.8) |
116(54.5) |
51(23.9) |
213(100) |
|
Algarve |
0(0.0) |
0(0.0) |
21(14.4) |
98(67.1) |
27(18.5) |
146(100) |
Key: 1* - Totally disagree with my practice; 2† - Disagree with my practice; 3‡ - No opinion; 4§ - Agree with my practice; 5|| - Totally agree with my practice
Source: own elaboration, survey data, 2017.13
After descriptive analysis, using the Kruskal-Wallis test, significant associations between Regions and nursing design were confirmed, with a test statistic of 37.2 and p < 0.001. Consequently, it became necessary to perform multiple comparisons between all pairs of Regions. In this sense, using the Wilcoxon-Mann-Whitney test for independent samples, with Bonferroni correction and a corrected significance level of 0.5%, we found that Orem's conception of nursing is more in line with the practice of nurses in the Northern and Central Regions than in Lisbon and Tagus Valley, being also in line with the practice of participants in all other pairs of Regions.
Regarding Dorothea Orem's conception of person, although the option "in concordance with my practice" was the majority answer, 32.4% of the participants from the Center and 27.9% from the North stated that this conception is "totally in concordance with their practice" (Table 2).
Table 2 - Concordance of nurses with Dorothea Orem's conception of the person, in the five regions of the country. Porto, Portugal, 2017
|
Country region |
Concordance with Dorothea Orem's conception of nursing |
|||||
|
1* |
2† |
3‡ |
4§ |
5|| |
Total |
|
|
n(%) |
n(%) |
n(%) |
n(%) |
n(%) |
n(%) |
|
|
North |
5(0.3) |
42(2.8) |
223(14.9) |
805(54.0) |
417(27.9) |
1492(100) |
|
Center |
1(0.1) |
8(1.0) |
114(14.8) |
398(51.6) |
250(32.4) |
771(100) |
|
Lisbon and Vale do Tejo |
0(0.0) |
28(3.4) |
138(16.6) |
489(59.0) |
174(21.0) |
829(100) |
|
Alentejo |
0(0.0) |
5(2.3) |
40(18.8) |
113(53.1) |
55(25.8) |
213(100) |
|
Algarve |
0(0.0) |
1(0.7) |
14(9.6) |
102(69.9) |
29(19.9) |
146(100) |
Key: 1* - Totally disagree with my practice; 2† - Disagree with my practice; 3‡ - No opinion; 4§ - Agree with my practice; 5|| - Totally agree with my practice
Source: own elaboration, survey data, 2017.13
After descriptive analysis, using the Kruskal-Wallis test, significant associations were found between the Regions and the concept of person, with a test statistic of 24.8 and p < 0.001. Since there were differences between the Regions, multiple comparisons were made, between all pairs of Regions, using the Wilcoxon-Mann-Whitney test for independent samples, using the Bonferroni correction, and with a corrected significance level of 0.5%, It was concluded that Orem's concept of person is also more in line with the practice of nurses in the Northern and Central Regions than in Lisbon and Tagus Valley, being equally in line with the practice of participants in all other pairs of Regions.
Regarding Dorothea Orem's conception of health, although the option "in concordance with my practice" was the predominant answer, 29.2% of the participants in the Central Region and 28.3% in the Northern Region stated that this conception is "totally in concordance with their practice" (Table 3).
Table 3 - Concordance of nurses with Dorothea Orem's conception of health, in the five regions of the country. Porto, Portugal, 2017
|
Country region |
Concordance with Dorothea Orem's conception of nursing |
|||||
|
1* |
2† |
3‡ |
4§ |
5|| |
Total |
|
|
n(%) |
n(%) |
n(%) |
n(%) |
n(%) |
n(%) |
|
|
North |
8(0.5) |
65(4.4) |
206(13.8) |
791(53.0) |
422(28.3) |
1492(100) |
|
Center |
1(0.1) |
9(1.2) |
124(16.1) |
412(53.4) |
255(29.2) |
771(100) |
|
Lisbon and Vale do Tejo |
5(0.6) |
30(3.6) |
139(16.8) |
515(62.1) |
140(16.9) |
829(100) |
|
Alentejo |
0(0.0) |
9(4.2) |
45(21.1) |
105(49.3) |
54(25.4) |
213(100) |
|
Algarve |
0(0.0) |
0(0.0) |
24(16.4) |
95(65.1) |
27(18.5) |
146(100) |
Key: 1* - Totally disagree with my practice; 2† - Disagree with my practice; 3‡ - No opinion; 4§ - Agree with my practice; 5|| - Totally agree with my practice
Source: own elaboration, survey data, 2017.13
After descriptive analysis, using the Kruskal-Wallis test, significant associations were confirmed between the Regions and the conception of health, with a test statistic of 32.9 and p < 0.001. Since there were differences between the Regions, using the Wilcoxon-Mann-Whitney test for independent samples, using the Bonferroni correction, and with a 0.5% corrected significance level, multiple comparisons were made, between all pairs of Regions, with the conclusion that the conception of health is also more in concordance with the practice of nurses in the North and Center Regions than in Lisbon and Tagus Valley, being equally in concordance with the practice of participants in all other pairs of Regions.
Regarding Dorothea Orem's conception of environment, although the option "in accordance with my practice" continued to be the most frequent answer, 33.2% of the participants from the Center and 32.9% from Alentejo stated that this conception is "totally in accordance with their practice" (Table 4).
Table 4 - Concordance of nurses with Dorothea Orem's conception of environment, in the five regions of the country. Porto, Portugal, 2017
|
Country Region |
Concordance with Dorothea Orem's conception of nursing |
|||||
|
1* |
2† |
3‡ |
4§ |
5|| |
Total |
|
|
n(%) |
n(%) |
n(%) |
n(%) |
n(%) |
n(%) |
|
|
North |
6(0.4) |
27(1.8) |
136(9.1) |
890(59.7) |
443(29.0) |
1492(100) |
|
Center |
0(0.0) |
7(0.9) |
73(9.5) |
435(56.4) |
256(33.2) |
771(100) |
|
Lisbon and Vale do Tejo |
3(0.4) |
9(1.1) |
63(7.6) |
525(63.3) |
229(27.6) |
829(100) |
|
Alentejo |
1(0.5) |
5(2.3) |
26(12.2) |
111(52.1) |
70(32.9) |
213(100) |
|
Algarve |
0(0.0) |
0(0.0) |
12(8.2) |
99(67.8) |
35(24.0) |
146(100) |
Key: 1* - Totally disagree with my practice; 2† - Disagree with my practice; 3‡ - No opinion; 4§ - Agree with my practice; 5|| - Totally agree with my practice
Source: own elaboration, survey data, 2017.13
After descriptive analysis, the Kruskal-Wallis test confirmed that there were no significant associations between the regions and Dorothea Orem's concept of environment, with a test statistic of 5.1 and p < 0.281. In this sense, the degree of concordance with the conception of environment is the same in all regions.
Sociodemographic and professional characteristics and Dorothea Orem's conceptions
Using the multi-category logistic regression models, it was found that in the conceptions of nursing, person and health, the explanatory variables retained in the respective models, that is, those that affected the degree of concordance with these conceptions were the Region of the country, the service and the condition in which the profession is practiced.
In the case of the conception of nursing, the degree of concordance was higher in nurses working in the Center and lower in those working in Lisbon and Tagus Valley. In an intermediate position was the concordance of the participants from the North, Alentejo or Algarve Regions. Regarding the service, Intensive Care and Emergency Medicine was the clinical setting with the lowest level of concordance. As regards the condition in which the profession is practiced, the degree of concordance was higher among specialist nurses.
In the person conception, the degree of concordance was also higher in nursing professionals working in the Center and lower in those working in Lisbon and Tagus Valley. In an intermediate position was again the concordance of those working in the North, Alentejo or Algarve Regions. Medicine and Medical Specialties was the clinical setting with the highest concordance, followed by Surgery and Surgical Specialties and then Intensive Care and Emergency Medicine, where concordance was lower. Finally, specialist nurses were the ones who showed the highest level of concordance.
In the conception of health, the participants working in Lisbon and Tagus Valley, and in Intensive Medicine and Emergency settings, showed a lower degree of concordance than the nurses from any other Region or service. In addition, specialist nurses were the ones who presented the highest degree of concordance.
Regarding the conception of environment, it was evidenced that besides the Region, the service and the condition in which the profession is practiced, gender also affected the degree of concordance. As for the Region of the country, participants working in the Center showed a higher degree of concordance than nurses working in any other Region. Again, nurses working in Intensive Care and Emergency Medicine showed a lower degree of concordance. On the other hand, specialist nurses continued to show the highest degree of concordance. Finally, the nurses' level of concordance was lower than that of nurses.
Figure 1 summarizes the characterization variables that express the most concordance with Dorothea Orem's conceptions.
Figure 1 - Characterization variables that translate greater concordance of nurses with Dorothea Orem's conceptions for metaparadigmatic concepts
Source: Own elaboration, research data, 2017.13
Discussion
The alignment of theories to professional nursing practice is becoming more and more fundamental to achieve good practices and, consequently, to improve the quality of care.2-3,14-15 To be easily integrated into practice, nursing theories must meet three criteria: they must be applicable to professional practice, they must be useful and compatible with the multi-professional and multidisciplinary context characteristic of the health area, and they must be relevant to the care provided to the client.3 Focusing on one of the central concepts of nursing - self-care - Dorothea Orem's theoretical framework corresponds favorably to all these criteria.
From the perspective of several authors, the relevance of this framework lies in its potential to support clinical practice, giving particular focus to the client, as it considers him/her capable of learning new ways to perform self-care.5,10,14
In all regions of Portugal, when the concordance of nurses regarding metaparadigmatic concepts was analyzed in light of 13 nursing theorists, it was found that the conceptions of Virginia Henderson, Afaf Meleis and Dorothea Orem obtained the highest concordance.12
Following the value attributed by nurses to self-care and maintaining, within the professional practice of Portuguese nurses, the emphasis on the "School of Needs",12 it is noteworthy that in this study a significant percentage of participants (75 to 85%) from all regions of the country, qualified Dorothea Orem's conceptions as in concordance or totally in concordance with their practice.
This reveals that in the contexts of practice, Orem's perspective has guided the action of nurses, who deliberately and systematically assist patients with dependence in the performance of activities inherent to self-care.2,15-16 The influence of training and educational institutions in the definition of the conceptual orientation of nurses may justify the concordance of nurses from the Central Region with Dorothea Orem's conceptions.17
Regarding the theoretical conceptions of nursing, health and environment, concordance was higher in participants working in medical and medical specialties and surgery and surgical specialties, and who practice as specialist nurses. In these services, the emphasis on a practice centered on self-care and on the person's ability to meet needs and acquire independence for self-care, requires systematized and intentional professional help, very focused on this nursing focus,2 which has effectively been achieved in a more evident way by specialist nurses.
Although general care nurses understand the relevance of an action based on specific Nursing knowledge, specialist nurses, as a result of their advanced training, usually demonstrate more confidence in decision making, as well as greater capacity for an integral view of the person and individualization of the respective needs, aspects that are central to the promotion of self-care, reconstruction of autonomy and well-being.18
Also in line with Orem's theoretical framework, namely with the Theory of Nursing Systems, the professional help provided by nurses may be based on a totally compensatory system, a partially compensatory system, or a supportive-education system.9,19 In this context, depending on the person's needs and abilities to perform self-care activities, the nurse's intervention, implemented therapeutically, aims at empowering the person to perform as many activities as possible in the different self-care domains.20
The nurse specialist's concern with effectively progressing towards a system that ensures the person's effective empowerment in self-care justifies the high level of concordance of these professionals with Dorothea Orem's conceptions. In addition, the educational intervention to support patients' self-care skills and the optimization of the environment to promote well-being not only contribute to patient satisfaction, but also ensure the quality of the nursing care provided.9,21 In addition, Orem's theories guide actions that centralize in nursing care the active participation of the caregiver, envisioning attention to the continuity of care of clients in the hospital setting and after discharge.16
Therefore, it is also understandable that the conception of environment focused on external factors that affect self-care abilities is more agreed upon by specialist nurses and those working in medicine and medical specialties and surgery and surgical specialties, which is consistent with a practice focused on identifying and resolving factors that may compromise self-care ability, whether in the cognitive, physical, emotional, psychosocial and/or behavioral domains.8,20
Orem understands the person and the environment as a single unit, believing that all human beings are willing to care for themselves and their dependent family members, having the potential and capacity to learn to meet their self-care needs.8,10 However, when self-care needs exceed self-care capacity, people experience health deviations, requiring help, and it is in this context that nurses assume themselves as therapeutic agents.7,10
For self-care to be fully achieved, Orem alerts to the need for the person's involvement and motivation, fundamental aspects in their accountability,8 which is not possible in intensive care and emergency medicine units, contexts in which the clinical condition of clients makes it impossible to consider their intentionality, their involvement in acute care and rehabilitation, as well as, overall, the focus on self-care. The fact that in medical services and medical specialties, clients with high demands on self-care are often hospitalized, but simultaneously with the potential to rebuild autonomy, justifies the fact that concordance with Dorothea Orem's conception of the person is higher among nurses in these contexts.
In summary, from the contributions of this study, it is certain that several aspects contained in Dorothea Orem's theoretical framework are strongly compatible with the designs of the professional practice of nurses, and especially of specialist nurses in the contexts of medicine and medical specialties and surgery and surgical specialties.
The ease with which Orem's conceptions can be brought closer to the reality of nurses' professional practice, particularly specialist nurses, such as nurses specialized in rehabilitation nursing, once again provides an opportunity to reflect on the potential of this theorist's conceptions to become part of nursing professional practice models in use.12 As some authors argue, Orem's theoretical framework should be continuously used to guide nursing practice and research, further evidencing its application and usefulness.7,14
Although the scarce scientific production on nursing theories, namely on those that most contribute to nurses' practice, hampered the discussion of the results, it is hoped that this research may trigger reflection on this theme and provide another opportunity to clarify doubts as to the relevance of theoretical references in supporting nurses' professional practice. However, other approaches that allow a deeper understanding of the nurses' perception of Dorothea Orem's conceptions and the real circumstances of their contribution to professional practice are still essential, which effectively constituted a limitation of this study.
Conclusion
Given that only the connection between theory and practice can ensure the quality of nursing care, the recognition and appropriation of nursing theories, as well as their potential to support professional practice, is increasingly relevant. In this context, it is urgent that nurses support their professional practice in theoretical frameworks that fit the needs of clients and the essence of Nursing.
In this study, the high level of concordance with Dorothea Orem's conceptions of nursing, person, health and environment reflects the use of the theorist's framework as a conceptual guide for nurses' practice in hospital settings. The fact that specialist nurses and nurses working in medicine and medical specialties or surgery and surgical specialties showed higher concordance with Orem's conceptions reinforces the concern of these professionals, and specifically in these care settings, to focus on the effective empowerment of the person in self-care.
The influence of Dorothea Orem's three theories, as well as their concomitant use in different hospital settings, should also be considered, however, the study did not deepen the debate in this direction, and this is a possible element for potential investigations.
References
1. Santos BP, Sá FM, Pessan JE, Criveralo LR, Bergamo LN, Gimenez VC, et al. The training and praxis of the nurse in the light of nursing theories. Rev Bras Enferm. 2019;72(2):566-570. Doi: 10.1590/0034-7167-2018-0394
2. Silva NRF, Farias DC, Sousa JR, Bezerra FMC, Ferreira LS, Carvalho PMG. Nursing theories applied in the care of oncological patients: contribution to the nurse’s clinical practice. Rev UNINGÁ [Internet]. 2018 [cited 2020 Jul 30];55(2):59-71. Available from: http://revista.uninga.br/index.php/uninga/article/view/1385/1685
3. Brandão MAG, Barros ALBL, Primo CC, Bispo GS, Lopes ROP. Nursing theories in the conceptual expansion of nursing practices. Rev Bras Enferm. 2019;72(2):577-81. Doi: 10.1590/0034-7167-2018-0395
4. Queirós, PJP. O conhecimento em enfermagem e a natureza dos seus saberes. Esc. Anna Nery Rev. Enferm. 2016;20(3):1-2. Doi: 10.5935/1414-8145.20160079
5. Silva ESP, Figueiredo JV, Dutra PA, Maia SRT, Prado RFS, Borrajo APC, et al. Theory of support as orem self care for nursing clinical care women mastectomized. Braz. J. of Develop. 2020;6(6):39740-39750. Doi: 10.34117/bjdv6n6-496
6. Merino MFGL, Silva PLAR, Carvalho MDB, Pelloso SM, Baldissera VDA, Higarashi IH. Nursing theories in professional training and practice: perception of postgraduate nursing students. Rev Rene. 2018;19:e3363. Doi: 10.15253/2175-6783.2018193363
7. Wills EM. Grandes teorias da enfermagem baseadas nas necessidades humanas. In: McEwen M, Wills EM, organizadores. Bases Teóricas de Enfermagem. 4ª ed. Porto Alegre: Artmed; 2016. p. 133-161.
8. Orem DE. Nursing: Concepts of practice. 6ª ed. St. Louis, MO: Mosby; 2001.
9. Hernández YC, Pacheco JAC, Larreynaga MR. La teoría The self-care deficit nursing theory: Dorothea Elizabeth Orem. Gac. méd. espirit [Internet]. 2017 [cited 2020 Jul 29];19(3):1-11. Available from: https://www.medigraphic.com/pdfs/espirituana/gme-2017/gme173i.pdf
10. Santos B, Ramos A, Fonseca C. Training to practice: Importance of Self-Care Theory in Nursing Process for improving care. J Aging Innovation [Internet]. 2017 [cited 2020 Aug 09];6(1):51-54. Available from: http://journalofagingandinnovation.org/wp-content/uploads/6-Autocuidado-forma%C3%A7%C3%A3o.pdf
11. Garcia TR. Professional language and nursing domain. Texto & contexto enferm. 2019;28:e20190102. Doi: 10.1590/1980-265x-tce-2019-0001-0002
12. Ribeiro OMPL, Martins MMFPS, Tronchin DMR, Forte ECN. The perspective of portuguese nurses on nursing metaparadigmatic concepts. Texto & contexto enferm. 2018;27(2):e3970016. Doi: 10.1590/0104-070720180003970016.
13. Ribeiro OMPL. Contextos da prática hospitalar e conceções de enfermagem: Olhares sobre o real da qualidade e o ideal da excelência no exercício profissional dos enfermeiros [tese]. Porto: Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto; 2018.
14. Younas A. A Foundational Analysis of Dorothea Orem’s Self-Care Theory and Evaluation of Its Significance for Nursing Practice and Research. Creat Nurs. 2017;23(1):13-23. Doi: 10.1891/1078-4535.23.1.13
15. Hagran A, Fakharany A. Critique of Orem’s theory. J. Middle East North Afr. sci [Internet]. 2015 [cited 2020 Aug 15];1(5):12–17. Available from: https://pdfs.semanticscholar.org/5761/17009ae992dc2e2ee652cb66c03020d633f2.pdf
16. Demoro CCS, Fontes CMB, Trettene AS, Cianciarullo TI, Lazarini IM. Applicability of Orem: training of caregiver of infant with Robin Sequence Rev Bras Enferm. 2018;71(Suppl 3):1469-1473. Doi: 10.1590/0034-7167-2016-0562
17. Ribeiro OMPL, Martins MMFPS, Tronchin DMR, Silva JMAV. Professional nursing practice grounded in the theoretical framework of the discipline: reality or utopia. Rev Enf Ref. 2018;IV(19):39-48. Doi: 10.12707/RIV18040
18. Silva RMO, Luz MDA, Fernandes JD, Silva LS, Cordeiro ALAO, Mota LSR. Becoming a specialist: portuguese nurses`expectations after completing the specialization program. Rev Enf Ref. 2018;IV(16):147-154. Doi: 10.12707/RIV17076
19. Pires AF, Santos BN, Santos PN, Brasil VR, Luna AA. A importância da teoria do autocuidado de Dorothea E. Orem no cuidado de enfermagem. Rev Rede cuid saúde [Internet]. 2015 [acesso 2020 Ago 21];9(2):1-4. Disponível em: http://publicacoes.unigranrio.edu.br/index.php/rcs/article/view/2533/1292
20. Petronilho F, Machado M. Teorias de Enfermagem e Autocuidado: Contributos para a Construção do Cuidado de Reabilitação. In: Marques-Vieira C, Sousa L, organizadores. Cuidados de Enfermagem de Reabilitação à Pessoa ao Longo da Vida. Loures: Lusodidacta; 2016. p. 3-12.
21. Mohammadpour A, Sharghi NR, Khosravan S, Alami A, Akhond M. The effect of a supportive educational intervention developed based on the Orem’s self-care theory on the self-care ability of patients with myocardial infarction: A randomized controlled trial. J Clin Nurs. 2015; 24(11-12):1686-92. Doi: 10.1111/jocn.12775
Scientific Editor: Tânia Solange Bosi de Souza Magnago
Associate Editor: Rafaela Andolhe
Corresponding author
Olga Maria Pimenta Lopes Ribeiro
Email: olgaribeiro@esenf.pt
Address: Rua Dr. António Bernardino de Almeida
CEP: 4200-072 Porto, Portugal
Authors’s Contributions
1 – Olga Maria Pimenta Lopes Ribeiro
Conception or design of the study/research, analysis and/or interpretation of data, final review with critical and intellectual participation in the manuscript.
2 – Letícia de Lima Trindade
Analysis and/or interpretation of data, final review with critical and intellectual participation in the manuscript.
3 – João Miguel Almeida Ventura da Silva
Analysis and/or interpretation of data, final review with critical and intellectual participation in the manuscript.
4 – Ana da Conceição Alves Faria
Analysis and/or interpretation of data, final review with critical and intellectual participation in the manuscript.
How to cite this article
Ribeiro OMPL, Trindade LL, Silva JMAV, Faria ACA. Professional practice in the hospital setting: nurses' view on contributions from Dorothea Orem's conceptions. Rev. Enferm. UFSM. 2021 [Accessed on: Year Month Day]; vol.11 e28: 1-20. DOI: https: //doi.org/10.5902/2179769254723