Utility of the self-care theory to assist the bearer of Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome

Abstracts

OBJETIVO: Analisar dentro da Teoria geral de Orem, a utilidade da Teoria de Autocuidado para pacientes com Vírus da Imunodeficiência Humana/ Síndrome da Imunodeficiência Adquirida (HIV/AIDS), segundo o modelo de análise de teorias MÉTODOS: Estudo de revisão bibliográfica realizado nas Bases de Dados LILACS, MEDLINE e BDENF com as palavras-chave: autocuidado, Orem e HIV/AIDS. Adotou-se o modelo de análise da teoria de Meleis focando o componente utilidade. Foi identificado um estudo que utilizou a Teoria de Orem com pacientes portadores de HIV/AIDS. RESULTADOS: A teoria demonstrou ser útil para orientar a sistematização da assistência de enfermagem ao portador de HIV/AIDS; construir instrumentos de avaliação e orientação; medir a qualidade da assistência; testar modelos; classificar o paciente e ajudar como apoio-educação. CONCLUSÃO: O modelo de Meleis possibilitou compreender a utilidade da Teoria de Orem para a prática, pesquisa, educação e administração.

Síndrome de imunodeficiência adquirida; Autocuidado; Teoria de Enfermagem

REVISION ARTICLES

Léa Maria Moura Barroso^I; Daniele Mary Silva de Brito^II; Marli Teresinha Gimeniz GalvãoIII; Marcos Venícius de Oliveira Lopes^IV

^IPh.D. in Nursing. Professor, Undergraduate Nursing Program at Universidade de Fortaleza - UNIFOR - Fortaleza (CE), Brazil

^IIDoctoral Student in Nursing, Graduate Nursing Program at Universidade Federal do Ceará - UFC - Fortaleza (CE), Brazil; FUNCAP Grantee

^IIIPh.D. in Tropical Illnesses. Professor, Graduate Nursing Program at Universidade Federal do Ceará - UFC - Fortaleza (CE), Brazil

^IVPh.D. in Nursing. Graduate Nursing Program at Universidade Federal do Ceará - UFC - Fortaleza (CE), Brazil

Corresponding Author

ABSTRACT

OBJECTIVE: To analyze, within Orem's general theory, the utility of the Self-care Theory to assist patients who carries the Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS), according to the standard model to analyze theories.

METHODS: Literature review conducted in the databases LILACS, BDENF and MEDLINE with the keywords: self-care, Orem and HIV/AIDS. It was utilized the Meleis's analysis model of theories, focusing on the component of usefulness. It was identified a study that used Orem's Theory on patients who carries the HIV/AIDS.

RESULTS: The theory proved useful to: guide the systematization of nursing care on patients with HIV/AIDS; build assessment and guidance tools; measure the quality of care; verify models; classify patients; and, as an aid to support education.

CONCLUSION: The Meleis model allowed to understand the usefulness of Orem's theory into practice, research, education and administration.

Keywords: Acquired immunodeficiency syndrome; Self care; Nursing Theory

RESUMEN

OBJETIVO: Analizar dentro de la Teoría general de Orem, la utilidad de la Teoría del Auto-cuidado para pacientes con Virus de la Inmunodeficiencia Humana/Síndrome de la Inmunodeficiencia Adquirida (HIV/SIDA), según el modelo de análisis de teorías.

MÉTODOS: Se trata de un estudio de revisión bibliográfica realizado en las Bases de Datos LILACS, MEDLINE y BDENF con las palabras clave: auto-cuidado, Orem y HIV/SIDA. Se adoptó el modelo de análisis de la teoría de Meleis enfocando el componente utilidad. Fue identificado un estudio que utilizó la Teoría de Orem con pacientes portadores de HIV/SIDA.

RESULTADOS: La teoría demostró ser útil para: orientar la sistematización de la asistencia de enfermería al portador de HIV/SIDA; construir instrumentos de evaluación y orientación; medir la calidad de la asistencia; comprobar modelos; clasificar el paciente; y, ayudar como apoyo para la educación.

CONCLUSIÓN: El modelo de Meleis posibilitó comprender la utilidad de la Teoría de Orem para la práctica, investigación, educación y administración.

Descriptores: Síndrome de inmunodeficiencia adquirida; Autocuidado; Teoría de Enfermería

INTRODUCTION

Different studies present reflections on the applicability of nursing models and theories, permitting the validation and construction of new actions forms in nursing care, identifying limits and relations between professionals and individuals in need of care.

Nursing theories expose trends in view on the health-disease process and the therapeutic care experience; they are articulated and communicative conceptualizations of reality, invented or discovered (central phenomenon and relationships) in nursing with a view to describing, explaining, forecasting or prescribing nursing care⁽¹⁾.

Models are considered conceptual reference frameworks, constructed representations on some aspect in the environment, using abstractions as fundamental blocks. The model permits constructing a more solid base for a more informed practice⁽²⁾.

In nursing, publications on models and theories have increased, among which the most mentioned are: Imogene King's Theory of Goal Attainment, Leininger's Cultural Care Theory, Callista Roy's Adaptation Model, Paterson and Zderad's Humanistic Theory and Orem's Self-Care Deficit Theory⁽³⁾.

In the search for support to improve nursing care, different theories and models are suggested. Thus, nurses are responsible for developing theories to support their practice and focus on fundamental nursing concepts.

With a view to care delivery to Human Immunodeficiency Virus / Acquired Immunodeficiency Syndrome (HIV/AIDS) patients, models and theories have been put in practice to explain care-related phenomena, guide solutions that respond to the involved people's needs and interests and equip nurses to help patients take care of themselves, as AIDS is a chronic illness that depends on the patient's personal care to gain a better quality of life and prolong survival.

Self-care is considered individuals' performance or practice of activities for their own benefit, to maintain health, life and wellbeing. When patients apprehend orientations and these are followed, structural integrity and human functioning are maintained, situations that contribute to the development and recovery of health⁽⁴⁾.

Nursing models and theories applied for nursing care delivery to HIV/AIDS patients include Orem's Self-Care Theory. This application is justified because AIDS is a disease characterized by immunodeficiency that affects body functioning, with consequent health deviations, depending on patients themselves as active self-care agents to maintain their health.

Various factors are related to these deviations, such as: acquisition of opportunistic infections; difficulties to maintain sufficient food intake, sleep balance and eliminations; nausea and/or altered palate due to collateral medication effects. Patients also present weight loss, fatigue and decreased muscle mass. Besides physical problems, psychological alterations occur, such as non-acceptance of self-image and low self-esteem. Lifestyle changes occur related to self-prejudice, frequent returns to the health service and unwanted effects of treatment⁽⁵⁾.

The self-care model comprises three interrelated theories: Self-Care Theory, Self-Care Deficit Theory and Nursing Systems Theory⁽⁴⁾.

The Self-Care Theory presents three categories of self-care requisites or demands: Universal - care associated with life processes and maintaining the integrity of human structure and functioning; Developmental - related to human development processes and events occurred during the different stages of the lifecycle; Health deviation - occurs in disease or injury conditions⁽⁴⁾.

The Self-Care Deficit Theory is the core of the general nursing theory⁽⁴⁾. According to this theory, nursing is required when the individual, in a dependent condition, either as a parent or responsible, is incapable or limited to provide self-care. In that case, (s)he needs help. Orem identified five help methods⁽⁴⁾: acting or doing for the other; guiding the other; supporting the other (physical or psychologically); providing an environment that promotes personal development to become capable of satisfying future or current action demands and teaching the other.

The Nursing Systems Theory focuses on interventions outlines by nurses, which should be based on patients' self-care needs to perform personal activities. To comply with the requisites, Orem identified three nursing classification systems: total compensatory, partial compensatory and educative-supportive⁽⁴⁾.

Her theoretical model⁽⁴⁾ also includes a nursing process proposal with the following phases: nursing diagnosis; planning; execution of actions and system control.

The relevance of this study is to get to know the contribution of applying Orem's Theory and its implications for care, theory and research in nursing activities involving HIV/AIDS patients. The choice of this theory is justified, considering that personal care is indispensable for HIV-positive patients' daily reality, in order to guarantee their development for the benefit of life, health and well-being.

In literature, research on the applicability of nursing models and theories is increasing, permitting validation and construction of new forms to interpret this science⁽⁶⁾. These situations enhance the qualitative improvement of care. In Brazil, no theoretical references are found that analyze the use of Orem's Theory in nursing practice involving HIV-positive patients. Therefore, this study was accomplished to analyze, in the framework of Orem's general theory, the utility of the Self-Care theory for HIV/AIDS patients, according to the theory analysis model⁽¹⁾.

METHODS

This study analyzes the utility of Orem's Theory and was accomplished through the use of a theory analysis model⁽¹⁾.

The model covers description, analysis, criticism, theory test and support test. According to the model, structural and functional components can be used for the description, while the analysis is defined as an identification process of parts and components, and criticism is an investigation or estimation of a situation. The theoretical test refers to an assessment of the theory's utility. The support test, on the other hand, verifies validation alternatives, in line with the nature of the subject area⁽¹⁾.

As for the aspects Meleis⁽¹⁾ proposes in her model, in this study, criticism of theory was used, aimed at establishing a relation between structure and function, comprising eight components (clarity, consistence, simplicity and complexity, tautology and theology, diagram, contagion circle, utility and external components). To analyze Orem's Self-Care Theory, among the abovementioned components of criticism, the analysis of the theory's utility was chosen.

To analyze the theories according to Meleis' model⁽¹⁾, studies on the theme are selected to follow the analytic steps the author proposes.

In June 2006, a survey was carried out in LILACS, MEDLINE and BDENF. Using the key words self-care, Orem and HIV/AIDS, four scientific articles were identified that used Orem's Self-Care Theory among HIV/AIDS patients. As their results were summarized, three were excluded. The fourth articles had been extracted from a thesis, which was identified and selected for the study as it presented the abovementioned theory as the theoretical framework and included sufficient contents for the intended analysis.

The article selected for the critical analysis of Orem's Self-Care Theory in HIV/AIDS patients is entitled "The practice of the eye self-exam by HIV/AIDS patients"⁽⁷⁾ and tested a model to teach eye self-exam to patients, based on universal, developmental and health deviation self-care requisites, in the framework of the Self-Care Theory⁽⁴⁾. The selected study was a convergent-care research, carried out in Fortaleza-Ceará in 2002, involving 13 patients who participated in an educative proposal. The patients were followed in an educative workshop, nursing consultation, participant observation and application of an instrument to determine the engagement profile in the eye self-exam practice⁽⁷⁾.

In that research, 26 nursing diagnoses were identified, in which the main eye complaints were: low visual acuity, blurry vision, hyperemia, eye pain, tearing, itching, feeling of a strange body, loss of visual field and dry eyes. Besides the specific eye health diagnoses for the HIV/AIDS patients, the patients' universal, development and health deviation requisites were also identified⁽⁷⁾.

According to the engagement profile, it was confirmed that patients need moderate to great help to respond to universal, development and health deviation self-care demands. The results were sufficient to detect patients' competence to practice the eye self-exam, as well as to justify that, using Orem's model, nursing care systemization is possible for self-care by HIV/AIDS patients⁽⁷⁾.

The utility of the theory analyses its potential use in practice, research, education and administration. Therefore, the analysis of the selected empirical study "The practice of the eye self-exam by HIV/AIDS patients"⁽⁷⁾ was guided by the following analytic questions⁽¹⁾: In practice: Does the theory offer sufficient guidance and organization to reach practice? Is the theory updated? Is it relevant for nursing practice? Does the theory fit in in terms of the nursing process?; In research: Has the theory been used to test propositions or interpret discoveries? Can the discoveries be generalized? Is their any confirmatory evidence?; In education: Does it have the potential to guide the nursing curriculum and theory development?; In management: Does it help the patient classification system? Does it offer help by determining quality control criteria?

After identifying the analytic questions to analyze the nursing theory in the empirical study under discussion, the dissertation was read exhaustively to identify its potential utility for practice, research and education. Each utility was analyzed based on the guiding questions proposed by Meleis⁽¹⁾.

The information extracted from the analysis was organized in four categories, which the researcher elaborate to facilitate data discussion, called as follows: Utility of Orem's Theory for nursing practice involving HIV/AIDS patients; Utility of Orem's Theory for nursing research involving HIV/AIDS patients; Utility of Orem's Theory for nursing education involving HIV/AIDS patients and Utility of Orem's Theory for nursing management involving HIV/AIDS patients.

RESULTS

The selected analytic questions to analyze the theory's utility⁽⁴⁾ for nursing practice, research, education and management involving HIV/AIDS patients are analyzed next, in each analytic category.

Utility of Orem's Theory for nursing practice involving HIV/AIDS patients

In the study under analysis, the usage potential of the theory in practice was related to the elaboration of nursing care systemization for self-care among HIV/AIDS patients, using the nursing process⁽⁴⁾; to the patient's possible accomplishment of the eye self-exam; to the identification of HIV patients' self-care attitudes and deficits through the universal, developmental and health deviation requisites. Besides, the theory collaborated as a method to help patients.

Based on these results, it can be affirmed that, in that research, Orem's Theory provided sufficient guidance and organization for practice, served as a guide to systemize care delivery to HIV/AIDS patients and to elaborate assessment instruments for these patients' eye self-exam.

Utility of Orem's Theory for nursing research involving HIV/AIDS patients

The analyzed study offered important information to guide nursing research, as it demonstrated that the use of Orem's Theory permitted testing an eye self-exam teaching model in HIV/AIDS patients, which can be included in the nursing curriculum. The study's discoveries were analyzed through Orem's Theory; generalizations are difficult, though, due to the small number of participants and restricted statistics, making analysis impossible. Qualitative results, however, provide sufficient information to detect HIV/AIDS patients' competence for eye self-exam practice.

The tested propositions were related to discovering the proportion of patients in different HIV stages, due to the lack of early diagnosis and treatment, had irreversible eye alterations and identifying the incidence of eye problems. As confirmed, infected patients need (moderate to great) help for universal, development and health deviation requisites.

Utility of Orem's Theory for nursing education involving HIV/AIDS patients

According to the analysis, Orem's Theory showed utility for nursing education as, in the study under analysis, the systemization of nursing care delivery to HIV/AIDS patients was described based on Orem's model. Moreover, the obtained results were sufficient for nurses to perceive a gap in learning. As a result, an orientation manual on the eye self-exam was elaborated, testing a model on HIV/AIDS patients for use in the nursing curriculum, based on the educative-supportive nursing system and the help method⁽⁴⁾.

Utility of Orem's Theory for nursing management involving HIV/AIDS patients

The analysis of the study involving HIV/AIDS patients that used Orem's Theory revealed that its discoveries could also be applied to guide nursing management in care services to HIV/AIDS patients. HIV patients' engagement profile in self-care for the eye self-exam was identified as a measure of the achievement or not of self-care actions.

This measure classifies patients in terms of their engagement in self-care and favors a more targeted nursing practice. Besides, the instrument permits measuring nursing care quality related to self-care when used as a form of assessment after the nursing interventions.

DISCUSSION

As observed, through the use of Orem's nursing process, nurses can organize their practice involving HIV/AIDS patients, identifying self-care deficits and corresponding diagnoses^(5,7).

In the empirical research selected for the critical analysis, 19 nursing diagnoses were identified, ten of which regarded universal self-care requisites, five developmental and four health deviation requisites.

These diagnoses favored nursing care systemization (NCS) for these patients⁽⁷⁾.

Besides permitting NCS, the use of Orem's Theory in the assessed research permitted the creation of instruments for nurses to direct their practice. In the research, two instruments were elaborated: Survey of therapeutic demands for the eye self-exam and Engagement profile in the education proposal for the eye self-exam⁽⁷⁾.

The theory's current relevance can be confirmed, as Orem's self-care concept was published for the first time in 1965⁽⁵⁾ and is applied today in different nursing studies. These include the following: involving hypertensive patients⁽⁸⁾, pregnant women⁽⁹⁾, adolescents⁽¹⁰⁾, even those with HIV/AIDS^(11-12), achieving significant results for nursing care.

A study that used Orem's conceptual model as a theoretical framework to support the trajectory of the nursing process for an HIV-positive patient demonstrated approximation between theory and practice, as the nursing process can be put in practice in all phases⁽¹¹⁾.

Supporting these data, when using Orem's theoretical model, some researchers considered it was fundamental to help and promote self-care in a woman with HIV/AIDS, as it offered the nurse support to help the patient perform her own care⁽⁴⁾.

Moreover, different studies^(5,11-12) demonstrate the relevance of Orem's theory for practice and also evidence its utility to elaborate NCS and self-care instruments for nursing activities involving HIV/AIDS patients.

In view of the above, Orem's Theory is considered adequate for the nursing process. Its phases permit the identification of HIV/AIDS patients' attitudes and self-care deficits, besides interventions. The study selected⁽⁷⁾ in this research followed the process phases. Self-care demands were identified and 19 diagnoses were elaborated with their respective targets, goals, nursing system and interventions (help methods)⁽⁴⁾.

For nursing research involving HIV patients, Orem's Theory showed to be fundamental, as researchers, teachers and research institutions use it and obtain significant results.

A case study carried out at a teaching hospital in Metropolitan São Paulo in November 2003, using Nursing Care Systemization, demonstrated that Orem's Self-Care Theory could be considered a valid instrument, which helped to promote more objective communication between researchers and the research subject, adapting nursing care planning to a stroke victim with HIV⁽¹³⁾.

For care planning, targets and goals prioritize supportive-educative actions with a view to HIV/AIDS patients' engagement in self-care, as observed in other studies that used the theory^(5,14).

A research that aimed to apply Orem's Self-Care Theory in nursing care to an ostomized patient used home care, based on the supportive-educative system and permitted health promotion and perception of the patient's importance in care, concluding that Orem's Theory makes it possible to deliver care and therapeutic communication that is adequate to the patient's situation⁽¹⁵⁾.

All of these findings confirm the importance of Orem's Theory to guide the nursing curriculum. Therefore, these instruments, elaborated in the research under analysis, can be included in undergraduate nursing subjects. The results can also contribute to the development of other theories directed at the same clientele.

Putting in practice NCS for HIV/AIDS patients can support institutions interested in putting in practice the self-care diagnosis for patients with infection, with a view to improving health service management. Nurses have been developing NCS as an important instrument to guide nursing care, teaching, research and management. Different health services have put in practice NCS based on Orem's Theory to improve care^(5,14).

CONCLUSIONS

The application of Meleis' critical theory analysis model permitted discovering the utility of Orem's Self-Care Theory for practice, research, education and management practice involving HIV/AIDS patients.

The potential use of the theory in practice was related to the elaboration of nursing care systemization for self-care by HIV/AIDS patients, using the nursing process proposed by Orem and creating instruments to assess these patients.

As for the utility for research, the study showed that Orem's Self-Care Theory could be used to test models for HIV/AIDS patients. Moreover, it permitted discoveries and confirmations and opened up opportunities for other researchers.

Utility for education is proved by the support-education the theory can offer. In addition, help methods have been developed, besides an orientation manual for HIV/AIDS patients.

Orem's Theory proved to be useful for nursing management to HIV/AIDS patients. The latter were classified in terms of engagement in self-care and instruments were created to measure nursing care quality for this patient group. The implementation of Nursing Care Systemization for HIV/AIDS patients is another fundamental resource for nurses to manage care services directed at these patients.

As a suggestion, other studies are needed, analyzing a larger sample of dissertations or articles. Care services for HIV-positive patients and nursing programs should include Orem's Self-Care Theory in their activities to support practice, research, theory and management.

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Utility of the self-care theory to assist the bearer of Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome

Utilidad de la teoría del autocuidado en la asistencia al portador del Virus de la Inmunodeficiencia Humana/Síndrome de la Inmunodeficiencia Adquirida

Publication Dates

• Publication in this collection
  27 Sept 2010
• Date of issue
  2010

History

• Accepted
  11 Apr 2010
• Received
  22 July 2009