The purpose of this project is to develop a resource guide for nurses in the hospital

setting to identify the patient's needs at discharge.

Dorothea E. Orem's (1991) self-care deficit nursing theory is utilized as the theoretical framework for the development of this project. A brief overview of the theory is presented as well as a discussion regarding how the theory was utilized to guide the development of the project. In addition, Orem's (1991) theoretical definitions for nursing’s four metaparadigm concepts (nursing, health, person, and environment) as well as the Project Author’s operational definitions for nursing’s four metaparadigm concepts will be presented.

Self-Care Deficit Nursing Theory

Dorothea E. Orem's impact on nursing reflects on her work towards developing and establishing her self-care deficit nursing theory (SCDNT). Her theory development began with the reflection question: "What condition exists in a person when that person or a family member or the attending physician or a nurse makes the judgment that the person should be under nursing care?" (Orem, 1991, p. 61). In the fourth edition of her book, Nursing: Concepts of Practice, Orem explained that the journey towards her theory development began with the need to define nursing, identify when a nurse is needed, and the support a nurse can provide a patient.

The self-care deficit nursing theory is divided into three theories: the theory of selfcare; the theory of self-care deficit; and the theory of nursing system (Orem, 1991). In order to understand the theory, it is important to first have an understanding of its major concepts: selfcare, self-care agency, self-care demands, nursing agency, self-care deficit, and conditioning factors (Orem et al., 2003) . Self-care is defined as the person's general act of providing necessary everyday needs for themselves in order to maintain human function and well-being. Self-care agency is the person's learned competence to practice self-care. Self-care demands refer to the actual actions that are necessary for the person's body to maintain health, e.g., feeding oneself independently. Without these actions, the person's health will deteriorate. Nursing agency refers to the nurse's ability to assess and provide a care plan that matches the needs of the patient. Selfcare deficit is the lack of the person's self-care agency to provide for the self-care demands. Conditioning factors refer to elements that can affect a person's ability to practice self-care, such as age, gender, developmental state, sociocultural influences, lifestyle habits, and health status.

The Theory of Self-Care

The theory of self-care centralizes on the idea of a person who is able to provide requirements that are essential for the maintenance of life and function. Orem called these requirements "universal self-care requisites" and they refer to a person's basic needs, including sufficient intake of air, water, and nutrients , elimination of body waste , providing the body the balance between activity and rest , privacy and social interaction/human relationships , and prevention of illness (which also includes seeking medical assistance when ill) (Orem, 1991, p. 126). As an alternative to self-care, Orem (1991) identifies that there are individuals who are not able to provide their own self-care as part of their baseline function, e.g., children or seniors. Therefore, Orem referred to this as dependent care, where someone who is capable will be the person to provide self-care actions to the individual who is dependent.

Orem (1991) provided assumptions and propositions within the theory of self-care.

According to Orem (1991), the theory of self-care assumes that all individuals have the possibility to learn how to develop and provide self-care as well as dependent care. This results in the assumption that one can learn to see recurring patterns of needs, allowing one to form a self-care and dependent care routine towards the repeating self-care or dependent care demands. The theory also assumes that self-care requisites are met with the influence of one's culture and social influences. Therefore, it assumes that the action of self-care and dependent care depends on the person's preference in how they respond given a certain event.

The theory of self-care, as per Orem (1991), provides the proposition that regularly practiced acts of self-care will be applied effectively and successfully. It also proposes that the act of self-care is in response to the best of the person's knowledge of how the self-care needs can be met. Self-care also involves the use of materials needed to complete the act of self-care. It also proposes that externally projected self-care is observable (e.g., the ability to mobilize independently), while those that are internally projected can only be observed through collecting information from the person (e.g., the person's motivation to practice mobility to gain progress). Another proposal under this theory explains that self-care that is routinely done over time forms a self-care system where the person will be able to identify and predict how their actions will result in their self-care. It also allows the person to learn to adjust and adapt to change, e.g., learning and taking new medications as prescribed.

The Theory of Self-Care Deficit

The theory of self-care deficit explains how nursing is needed by the person who is unable to provide self-care (Orem et al., 2003). Orem (1991) explains that the person's inability to provide self-care could be due to issues related to their health or brought forth by interventions for their health care. Examples of this include weakness from treatment such as chemotherapy that disables a person's level of energy and requires them to take medications that counteract the side effects of treatment. Another example is that of surgery. Depending on the type of surgery, multiple organ systems can be affected as well as the person's mobility. Nursing is essential for these patients in order to accommodate the inability of the person to provide specific self-care practices.

Assumptions that are identified by Orem (1991) within the theory of self-care deficit are divided into people who have the capability to provide self-care and those who are relying on dependent care. For those who can have the ability to provide self-care, this theory assumes that a person should be able to manage their self-care in a stable environment but also be able to identify their limits in certain situations. It also assumes that a person's participation in self-care depends on their values and outlook toward their health and life, cultural beliefs, and influences from their social circle. For those who are dependent on their care, it is assumed that the health care system and available community resources will provide assistance for the person, such as nursing care, if needed. It also assumes that if a person is a part of a facility, for instance, a longterm care home, this becomes the patient's main means of acquiring the care that they need. The propositions provided by Orem's (1991) theory of self-care deficit include the idea that those who are able to participate in self-care or dependent care are under the influence of the conditioning factors mentioned above. The theory also proposes that nursing is necessary when the self-care ability of the person is not able to meet the self-care demands. It also adds that nursing is necessary when there is anticipation that the patient will not be able to practice selfcare immediately e.g., post-surgical care.

The Theory of Nursing System

The theory of nursing system establishes nursing agency and the structure of nursing the patient needs and is divided into three types : wholly compensatory, partially compensatory and supportive educative system (Orem et al., 2003). Wholly compensatory defines the inability for self-care agency to meet self-care demands. The patient is unable to practice self-care that meets their body's needs therefore this is when nursing is needed as a temporary substitute to assist the patient with their self-care needs until they are able to attend to them themselves. Partially compensatory is identified when the patient is able to practice some self-care activities, is not fully dependent on the nurse and the nurse's role changes to an assistive role. Supportive educative system requires the more minimal amount of nursing assistance as the nurse takes on a more supportive role where they are there to supervise or guide the patient to further strengthen their self-care agency.

The assumptions provided by Orem (1991) toward the theory of nursing system describes the role of the nurse as part of patient care that is time-limited as long as the patient needs assistance in self-care activities until they are able to practice them independently. The theory also includes in its assumption that nursing is a profession that acts within its scope of practice under a governing body that provides a focus to the profession.

Propositions suggested by Orem (1991) to reflect the theory of nursing system include the relationship between the nurse and the patient, who has specific self-care requisites but cannot meet the demands. Nurses in turn, attend to the patient by identifying the patient's selfcare requisites that need assisting and formulating a care plan to support the patient into practicing independent self-care. Through assessment, the nurse is able to know the patient's capabilities regarding the patient's self-care agency therefore will increase or decrease the amount of support given to the patient. Lastly, the theory proposes that the nurse and patient work collaboratively in order for the patient to improve towards meeting their own self-care demand through practice of self-care as independently as possible.

Graduate Student Project and Orem's Theory

With the advancement of science and medical interventions, comes prolonged life for the general population. With that said, humans are living longer, resulting in patient populations reaching ages in their 100s, as seen by this writer at the bedside. From this writer's nursing experience, while the healthcare system provides great care for illness and treats the cause of disease, it has not solved the emerging issues regarding the coping mechanisms of elderly patients as they continue to live their lives at home. The goal of medicine is to treat illness, yet patients come into the hospital system with the admitting diagnosis of "failure to cope." This brings back the question for the project: How can nurses provide further support for elderly patients when their main concerns revolve around the home as a place of fear for their return? This issue fits well with Orem's self-care deficit nursing theory because the patient's inability to cope at home translates to their inability to practice self-care. The elderly person becomes someone who identifies with dependent care and becomes admitted to the hospital due to "failure to cope."

Self-Care Deficit Nursing Theory and Nursing's Metaparadigm

Orem did not directly relate her theory to the metaparadigm concepts of person, environment, health, and nursing, but she clearly communicated in her writings how each contributed to her theory's meaning. According to Orem's (1991) self-care deficit nursing theory, understanding the person is to understand that they initially refer to an individual who is able to provide basic human needs for themselves (self-care agents) through learned experiences, enabling them to practice self-care. The person can also refer to someone who is of dependent status where they are unable to practice self-care as they are incapable of doing so and therefore rely on family or their caregiver to provide their self-care actions for them. The person is also identified as someone who is unable to practice self-care due to medical or health care intervention reasons (Orem, 1991). The person becomes a patient who needs assistance, training, and guidance to be able to practice self-care again with the help of nursing. For the purpose of the project, the person is operationally defined as the patient who is receiving care due to their inability to cope and function at home. The person could be in a position where they are unable to practice self-care with or without support and hence is admitted to a hospital to seek assistance. The main issue for these patients could simply be a lack of energy or being too weak to mobilize and participate in self-care activities. The patients may or may not have underlying medical issues that are causing a lack of participation in their activities of daily living.

Although the person refers to the individual, Orem (1991) makes it a point to emphasize that the person is not isolated by the self. Orem (1991) explains that humans should be seen as functioning "biologically, symbolically, and socially" as someone who comes from a place with their own responsibility and role towards others (p. 181). This introduces nursing's metaparadigm concept of the environment. Orem (1991) explains that a person is consistently linked to their environment. Individuals exist within their environment, which Orem explains as features that are physiochemical, biologic, socioeconomic-cultural , and community in nature (Orem, 1991). Physiochemical features of the environment refer to the air, pollutants, weather, and the status of the earth's stability. Biologic features involve animals, including the person's pets, infectious organisms, and other people or animals that can be agents of bacteria or diseases. Socioeconomic-cultural features refer to the person's family, their role and relationship with their family, cultural values, dynamics, as well as beliefs that could affect their decision making. Community refers to a person's access to health care services, resources for cultural and healthcare needs, as well as accessibility. Overall, it is important to have an understanding that their type of environment affects how patients perceive their care and the decisions they make regarding their care plan. E nvironment is operationally defined, for the purposes of the project, as a location that begins at the hospital and ends at their home. Cultural beliefs, social support, financial status, educational level, and accessibility of health care resources and availability from the area they live in are also vital information that is important to understand as the person is transitioned to their environment. Home can be defined as their place of residence, whether it is in an apartment, house, long term care home or retirement home where they may or may not live alone.

Orem (1991) sees health as an element that can affect a person's ability to practice selfcare. This is because Orem (1991) views health as synonymous with "wholeness" and a change in this structure would be an "absence" toward one's health (p. 179). Orem (1991) also explains that health is not the responsibility of one individual. Health is a societal responsibility, because the mental, interpersonal, and physical aspects of health are all linked to the person. When one becomes ill, it is not always possible to focus only on healing and treatment. The person's environment becomes a factor that plays into the patient's ability to attend to their health. If they are the sole breadwinner of their family or they are the primary caregiver of their sick relative, it becomes difficult for them to focus on their health due to the circumstances of their responsibilities. Therefore, this places a demand on the societal responsibilities toward a person's health and involves necessary assistance that can be provided in order for the individual to focus and become an independent self-care agent once more. Health is operationally defined as the person's subjective view of themselves when faced with illness or a deficit in their ability to function. It is important to understand how the person defines health and what is most important to them, as well as their goals. Health should be discussed with the person's caregiver as well (if possible) in order to properly communicate goals for home and the reality of the elderly patient's own capability to provide self-care. This writer agrees with Orem's definition of health as a societal responsibility where assistance towards one's wellness journey also depends on the responsibilities and services that are available to provide assistance for them. It will be difficult for a patient to return home if there are no available resources to help them be managed at home. Hence, it is the nurse's role to have an understanding of not only the patient's current state but also their social history.

Orem (1991) sees the metaparadigm of nursing as synonymous with her concept of nursing agency, where nursing is necessary as a complement to a patient's inability to practice self-care. The presence of nursing allows the person to appropriately rely on the nurse as someone who can provide a care plan that adjusts to the patient's improvement or decline and provide assistance throughout their health care journey. Nursing should have an understanding of the person as someone who comes with certain cultural values and beliefs that can affect their outlook on health and wellness. Orem (1991) explains that nurses and their patients should work together and form a good working relationship where they have an understanding of the goals that meet the needs of the patient while keeping in mind what is most important to them in their environment. Nursing is operationally defined in the project as those in the nursing profession that approach patient care with a holistic perspective. The patient is not to be seen as an individual who is simply admitted for limitations in their physical function. The role of nursing proves effective when they have a better understanding of the patient and how the patient perceives their care. If the patient is unable to make their own decisions due to impairment in their cognition, it is part of the nurse's role to communicate with the patient's caregiver (someone who is providing dependent care) to understand the patient's capabilities, wishes, and concerns.

It is also important for the nurse to present information to the health care team regarding the patient's situation at home and consult with the proper allied health professions to further assist in the patient's potential need for health care support once they return home.

A review of nursing and health related literature was conducted to explore discharge planning using th