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Theories and models have taken a significant place in the discipline of nursing during the past fifty years. The purpose behind formulating these theories was to provide a theoretical basis for provision of care and recognition of

Effective communication is a prerequisite skill in nursing. Miller and Nicholson defined communication as a way of exchanging information from a source to a receiver, which often stimulates a behavioural response. This is a way in which ideas and feelings are shared in an attempt to establish a successful nurse-client relationship. Department of Health (2006) enforced changes in the way nurses communicate in order to improve care for adults for the purpose of minimising illness, promoting patient autonomy, supporting equalities and providing effective long-term care. Healthcare providers will be able to achieve these goals by having a deeper understanding of self-awareness.

Patients are sensitive to the ‘affect’ and the body language of the nurses. ‘Affect’ is the word used to describe the way a person communicates, taking into account the intonation, pace of delivery, pauses in between sentences and other paralinguistic behaviours (Lindberg, Hunter and Kruszewski 1983 p.280). An example of a scenario in which awareness is displayed was in my placement. Post-surgery patients were required to be transferred from the theatre back to the ward. However, it was essential that the patient was seated upright first to regain balance as they were on the trolley during the operation. They were then informed to notify the staff when they were ready to walk for transfer, thus they were more in control of the situation. Despite having said that they can manage, it was essential to judge individual patient’s responses with their ‘affect’ and body language. Egan (1977) stated that the recipients are more likely to accept the non-verbal displays exhibited as the truth rather than what was said.

When conversing with a patient face-to-face, Egan (2009) put forward the acronym ‘SOLER’ as a basic guide to demonstrate attentiveness and respect. This is particularly vital when dealing with patients of a different cultural background as they appear more sensitive with the bodily expressions. This acronym provides information of the appropriate posturing, to indicate participation, and the behaviours to display that they are willing to engage in the conversation including open posture, maintaining eye contact and being ‘relaxed’. In this context, Egan (2009) emphasised on the avoidance of ‘distracting facial expressions’ and being comfortable with expressing ideas and thoughts. In my ward, it was essential to approach the tasks with confidence, so that the patients will feel safe and secure at the hands of the nurses. This also meant that masking emotions to the patients became a necessity due to the fact that appearing nervous can result in uneasiness. For example, in an account from a post-general anaesthetic patient, the client felt agitated and stressed as she could not leave the ward as her discharge documents remain uncompleted. The reason was that her blood pressure reading showed a higher reading compared to when she first came for admission. Thus, by explaining to her the circumstances in a calm manner, it became apparent that her behaviour turned somewhat calmer and less anxious. Smith (1759) acknowledged that most people tend to display ‘motor mimicry’ when conversing with someone; ‘receivers’ are likely to mimic emotions or actions performed or displayed by the ‘senders’ and vice versa (Arnold and Boggs 2006).

Moreover, it is important to constantly be self-aware and to discover new truths about oneself. Jourard (1971) stated that a lack of personal awareness can lead to a feeling of vulnerability when approached by patients expressing feelings, due to the fear of not knowing how to respond in an appropriate way. By having self-awareness, the sources of limitations that have the tendency to cause anxiety can be identified, so forward planning can be prepared in order to reduce or eliminate the impact this may have on performing activities and approaches to patients. Certain individuals utilise different techniques to minimise anxiety such as deep-breathing exercises or thinking of the positive outcome that comes once the source of fear or anxiety is overcame. Meanwhile, others prefer being critiqued, since it allows areas within practise needing improvements to be highlighted and alternatives to be considered.

It is crucial to engage in self-evaluation in between practices in order to see the progress of one’s personal growth. Distinguishing what empowers and what hinders one’s desires to achieve is fundamental in the journey of self-awareness (Burnard 1988). This emphasises the significance of reflective practise in healthcare. Oelofsen (2012) and Boros (2009) defined this as the capacity to be cognitive about the ‘events, situations and actions’ that occur during practice with the intentions of engaging in a process of self-growth. Boud, Keogh and Walker (1985) suggested that it becomes beneficial for students to keep a diary for the purpose of reflecting. He proposed several guidelines when recording information, such as being ‘honest’, ‘spontaneous’ and express their thoughts and opinions by the use of ‘diagrams or shorthand’ if found useful.

Dewey (1933) advocated approaches to effective learning in a process called “reflective thinking”. He proposed that this technique will allow students to recognise their weaknesses, so that they can attempt to develop a way in which they can handle their services in a better way. This, at the same time, improves their problem-solving as they are constantly thinking of alternative ways to improve. Therefore, the purpose of “reflective thinking” is to “transform a situation in which there is obscurity, doubt, conflict and disturbance of some sort into a situation that is clear, coherent, settled and harmonious” (Dewey 1933). Several nurses do not engage as much in this process, as a result, many do not perform in their duties the most effective way. Oelofsen (2012) advised setting up meetings and appointing an independent ‘facilitator’ for the purpose of sharing experiences, discussing different point of views amongst one another. This brings about the opportunity to gain criticisms and advices for the purpose of improving service to patients and service-users.

In my experience, admitting patients in the ward for their operation was challenging. The admission pack provided guidance with the questions that needed to be asked, however the questions were brief, thus it was necessary to give examples. This also meant that judging the mental capacity of the patient was necessary when asking the questions, as it would appear offensive if questions were asked in an intimidating manner. Reflecting in between admissions was important, so that it is possible to recognise how else to approach the questions, hence sounding in a way that would lower patients’ dignity could be avoided. Keeping a diary whilst on the placement meant it became possible to record various activities skills gained each day. In addition, it would also be simpler to keep track of the progress, review and reflect upon the feelings, emotions, and the overall experience that have arisen whilst dealing with people in the hospital. If improvements were plausible, this learning can be turned into action, which is the inception for another reflective cycle (Royal College of Nursing 1995; Oelofsen 2012).

Being in control of one’s own emotions has been a challenge for most nurses. Bond (1986) commented on the perception of ‘getting emotional’ in healthcare settings, stating that it is deemed unprofessional when expressed inappropriately. Due to the social and cultural bias, many nurses are encouraged to manage their emotions to avoid being labelled as a ‘failure’. Several nurses become vulnerable to crying especially after situations of death especially in wards where death is uncommon. However, it is about grief of the patient’s family and not personally the nurse’s, thus crying in the presence of the family can appear disrespectful and may sometimes offend the deceased patient’s family. Nurses can provide improved care and services once they become more aware of when and how to express themselves (Bond 1986; Burnard 1992). Furthermore, Boud, Keogh and Walker (1985) attached importance to keeping abreast with personal ‘feelings and emotions’ whilst on practice, as it has the potential to increase awareness and gain a greater understanding of self.

Self-awareness is a vital skill that nurses of any discipline must practise in order to provide the utmost care and services possible. Putting into practise the constant reflection will require dedication especially with the pressure put on by work. However, the enhanced knowledge of oneself will result not only as a better nurse but a better person as well.

the nursing profession. This paper will mainly focus on the two grand nursing care models, the Dorothy Orem’s self care deficit nursing theory (SCDNT) and Sister Callista Roy’s adaptation model (RAM). Firstly, this paper will explain the main concepts in both the models and compare and contrast the similarities and differences between the two. Furthermore, these models would be analysed as to which model would better apply to the Nursing practice.

Orem’s Self Care Deficit Nursing Theory

Orem’s ideas basically developed from the reflections of her experiences. Orem’s familiarity is not limited to nursing sciences alone, but her work shows evidence of underpinnings from metaphysical and epistemological context as well. The foundations of her theory lie in the philosophical system of realism (Alligood & Tomey, 2010). Orem refers to her theory of self care deficit as a general theory, which includes three theories, the theory of self care, self care deficit and nursing systems model.

Orem’s theory of self care discusses how people take care of themselves, and the theory of self care deficit talks about how people can be helped by nurses or significant others. The theory of nursing systems describes the relationships that should take place and be preserved for nursing to be generated (McEwen & Wills, 2011). In her model she discusses about several concepts which would be briefly discussed to understand her theoretical framework. In her theory she refers to self care requisites which further branch into universal self care requisites (air, food, water, etc. and prevention from hazards, etc.), developmental self care requisites (Developmental aspects), and health deviation self care requisites ( for the ill, injured, pathological conditions, etc.).

A person is placed in the centre of SCDNT. The theory of self care views a person as taking deliberate actions in maintaining and promoting health. This transforms to dependent care agency and self care deficit according to the demands of a person. Nursing care agency comes into action, which helps individuals to meet therapeutic self care demands and plays a professional role towards achievement of nursing goals, thus activating the nursing systems. Nursing system performs a series of actions to meet the therapeutic self care demands or regulates the patients self care agency by guiding, directing, educating, providing physical and psychological support, and provision and maintenance of an environment which fosters development. The SCDNT also describes the basic conditioning factors that affect self care and therapeutic self care demand namely age, gender, developmental state, health state, pattern of living, health care system, family system, socio-cultural, availability of resources and external environmental factors (Alligood & Tomey, 2010).

The theory of nursing system is divided into supportive educative (demands patient’s actions and regulation of self care agency by nurse and patient), partly compensatory (nurses perform some self care functions, assist patients, and patient also performs some self care activities and both are involved in the regulation of self care agency), and wholly compensatory ( nurse performs therapeutic self care, compensates the ability of the patient in self care and protects and supports the patient) (Alligood & Tomey, 2010).

Roy’s Adaptation Model

The adaptation model by Sister Callista Roy was a result of her Master’s degree project to develop a conceptual model on Nursing. Being a paediatric nurse she had observed the quick resilience and adaptation among children in response to physical and psychological changes (Alligood & Tomey, 2010), resulting in the adaptation model. Roy’s model is a derivative of Harry Helson’s adaptation theory of psychophysics which incorporates social and behavioural sciences. Roy’s adaptation model places emphasis on the adaptation of a person. The metaparadigms in this model person, environment, health and nursing are interconnected to the main concept (Alligood & Tomey, 2010).

Major concepts discussed in her model would be presented here to understand her theoretical framework. Roy & Andrews (1999) refer to adaptation levels as integrated, compensatory and compromised. Furthermore, that the adaptation level of an individual changes constantly while encountering focal, contextual and residual stimuli and represent a person’s own adaptive responses. Moreover, there are Adaptation problems which raise concern among the nurses related to positive adaptation among individuals and groups. Coping processes are described as innate coping mechanisms which are genetic and acquired coping mechanisms which are developed through learning and experiences. These are further divided into regulator subsystem (chemical, neural, and endocrine systems) and cognator subsystem (cognitive- emotive channels: perceptual, information processing, learning, judgement and emotion) (Alligood & Tomey, 2010). The responses can be adaptive (helps the person achieve, growth, reproduction, survival, mastery, individual and environmental transformations.) or ineffective (do not attain the goal of adaptation). Integrated life process refers to the adaptation level in which structures and functions of a life process work towards meeting human needs. These processes are categorized as Physiological-physical (oxygenation, nutrition, elimination, activity and rest, and protection and fluid electrolyte balance, senses, neurological function, acid base balance, and endocrine function.), Self concept group identity ( psychological and spiritual needs), role function and interdependence. Role function includes primary (woman, her gender, age, etc.), secondary (role of wife, mother) and tertiary (teacher/ role in society). Interdependence mode includes relationships with significant others and support systems, which means those contributing to interdependence needs (Alligood & Tomey, 2010).

Compare and Contrast Roy’s and Orem’s Model

Orem’s theory and Roy’s model are both considered as grand nursing theories (McEwen & Wills, 2011). These grand theories are conceptual models which identify a focus on nursing inquiry and direct the development of midrange theories which turn out to be useful for nurses as well as other health care professionals. Besides this Orem’s theory is based on human needs as for self care while Roy’s on interactive processes such as adaptation.

Metaparadigms in both theories are defined differently as the core concepts of their models differ. Orem uses self care as the central concept whereas Roy uses adaptation. Both the models have a different core concept, but engender greater patient involvement.

Person: According to RAM, person persistently encounters environmental stimuli, and then a response occurs, leading to adaptation. This response may be effective (adaptive) or ineffective. Moreover, an individual is an adaptive system and this includes a person, groups, organizations, communities and society (McEwen & Wills, 2011). Roy also considered the human as a bio-psycho-social being. On the other hand, Orem defines an individual as a person struggling to have self-care needs met in order to live and mature (Current Nursing, Orem’s Theory of Self-care, Human Being, 2012). Both the models have described a person as an individual and his struggle to achieve optimum health, but the means are different.

Environment: According to Roy, a person constantly interacts with the changing environment and responds to stimuli and this ability determines the adaptation level. (Current Nursing, 2012, Roy’s Adaptation Model). Orem believes that the environment influences the patient. She emphasizes that basic needs such as air, ventilation etc. and prevention of hazards are required for human integrity and functioning (George, 2002).

Both the models Orem and Roy are of the view that environment plays an integral role in human development and survival. Roy presents environment as a stimuli that disrupts the integrity of development and then simultaneously a person achieves adaptation in response to the stimuli. In contrast Orem considers environment as a mean to provide basic human needs for survival.

Nursing: Roy believes that a Nurse’s role is to help the individual’s adaptation effort by controlling the environment which results in achieving the optimal level of functioning and wellness in a person. Roy’s goal of nursing is to achieve adaptation leading to optimum health, well-being, and quality of life and death with dignity, (Roy & Andrews, 1999). On the other hand, Orem believes that deliberate actions are performed by nurses to attain the goal of self care. Apart from prevention and promotion, Orem also focuses on nursing as a supportive educative system which helps individuals to compensate the deficit.

Both the models explain the role of a nurse helping an individual either to adapt to a situation or to cope with the self- care deficit. However contrasting both, Orem focuses more on the support that is needed opposed to Roy whose focus is behaviour change. In addition to that Orem focuses on the physiological needs of the patient whereas Roy views both physiological and psychological adaptation important.

Health: Previously Roy viewed health being on a continuum from extreme poor health to high level of wellness, but later focussed on health being a process where health and illness can co-exist (McEwen & Wills, 2011 ). On the other hand Orem refers to health as “being structurally and functionally whole or sound” (McEwen & Wills, 2011). Orem emphasizes on the physical, psychological, mental and social aspects of health and focuses on all levels of health maintenance including primary, secondary and tertiary prevention (George, 2002). In view of how the two theories define health, Roy states that a person is healthy if he has adapted to his illness in a optimistic manner, while For Orem being healthy means to be holistically sound and functional.

Orem’s model of care includes three steps of nursing process which are assessment, diagnosis and formation of nursing care plan and the third is implementation. On the other hand Roy’s model has six steps to the nursing process, assessment of patient’s behaviour, assessment of patient’s stimuli, diagnosis, setting goals, intervention and evaluation (Masters, 2011). Orem’s nursing process seems simpler to use compared to Roy’s. The six step nursing process might not be that lengthy, but at a glance it looks as it would be time consuming.

Roy has the spiritual aspect embedded in her model and incorporates spirituality as an essential component of the human adaptive system, whereas Orem’s model has missed this essential feature to address in her model. In a study, White, Peters and Schim (2011) propose that integration of the concept of spiritual self care and spirituality in Orem’s SCDNT is a crucial step in theory development. Moreover, understanding is required that how spirituality and spiritually based practices contribute and promote health and well being in illness of an individual.

Both the theories have strong philosophical support. Orem’s model is purely a theoretical system of nursing focussing on moderate realism. She has also shown interest in Parsons model of social action and system theory by von Bertalanfy (McEwen & Wills, 2011). The impetus behind Roy’s model was Johnson’s nursing model. She has incorporated Helson’s adaptation model, Lazarus’s coping model, von Bertalanffy’s system model, system definition by Rapoport’s system definition and Dohrenrend and Selye’s theories of stress and adaptation. So, both the theories have a foundation of strong philosophical underpinnings.

Besides that, several schools of nursing and colleges have designed their curriculum on the base of SCDNT such as the “Georgetown University School of Nursing, The University of Missouri, Columbia, and the University of Florida and many more (McEwen & Wills, 2011). According to Phillips in McEwen & Wills (2011), Roy’s theory is also used at several universities in the US, Canada and even Japan. Moreover, both these theories are being used in several clinical settings and research. Reviewing the literature, it is good to know that both these theories are being used in the fields of nursing practice, education and research. Evaluating the testability of both the theories, both have been used in several researches and studies and have proven to be applicable (McEwen & Wills, 2011)

Application of Roy’s and Orem’s Model in Practice

While analysing a case study using the Roy’s model, of a young woman, 37 year old who had met with an accident, operated on but had scars on her face. The nurse assesses that the patient had adapted well, except for the self concept. It was evident as she avoided social gathering, wore heavy makeup, dark glasses and a big hat. Here, the focus of care would be to either change the stimuli or strengthen the adaptive processes. Strengthening the adaptive process would be difficult because here the scars on her face wouldn’t disappear, but she would have to live with them. She could opt for plastic surgery but it depends on whether she would be able to bear the expenses. On the other hand if Orem’s model is used to analyze the same situation, the nurse would provide complete care in the wholly compensatory system (in the hospital) and try to make the woman independent, gradually she would perform care activities partially helping the patient and then finally, the patient would become independent caring for herself. In this situation, it justifies that Orem’s model is comparatively fits better than Roy’s model.

In a study when Roy’s model was used on battered women, it was challenging for the study group to assist the women to redefine their intimate relation with their partners in different societies. So, further research is needed to explicate the adaptation concept and the responses from such cases (Woods & Isenberg, 2001).

If we analyze, Orem focuses on finding the self-care deficit of the patient and providing the necessary care to promote his or her well-being. Whereas, Roy is concerned with the different stimuli that forces adaptation in order to achieve optimum health. According to Denyes, Orem and SozWiss (2001) self care is recognized as a practical attempt as it focuses on human functioning and growth by deliberate action in existing or changing environment. Moreover, it has been appreciated as a practice model due to the depth of knowledge and skills required by care providers. Orem’s theory is derived from the clinical base which provides a comprehensive base for nursing practice. Through literature review, it has been found that Orem’s model has been used in several clinical situations, community setting, education and research and it has been applicable to all such scenarios.

Orem’s model is good in terms of applicability, but recommendations suggest that a component of spirituality needs to be added to the model. Spirituality has an essential role in the process of illness to wellness and so it needs incorporation in Orem’s model. Individuals use it as support systems throughout their periods of illness and difficulties, specially pertaining to our eastern culture. Even, White, Peters and Schim (2011) propose the addition of the aspect of spirituality in Orem’s theory, which means it has equal importance in the western culture as well.

Orem’s model is more practical, relatively simple and generalizable to apply to a variety of patients in different conditions. It seems complex as there are three theories incorporated, but once learnt and understood it can be easily applied to different clinical situations, community settings, education and research. Practically, when working in the Emergency Room, I took care of the patients and intervened accordingly. When today I evaluate those interventions, I unintentionally or subconsciously used Orem’s model of self-care and that justifies how simple and practical her model is. Roy’s is more difficult to apply due to a variety of concepts and sub concepts involved and their interaction among themselves is too complex. The level of complexity might make it broad in scope and generalizability, but the compound relations among its sub concepts make its applicability more complicated.

It is important for nurses to assess the different theories and its applicability in different clinical situations. The statements and arguments mentioned above justify that Orem’s theory is suitable to nursing practice and is applicable to all situations where illness, disorder or disability is involved. Orem’s theory and its comprehensiveness give an opportunity to apply it to almost all clinical scenarios.