The Journal of School Nursing2023, Vol. 39(1) 6–17© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405211050062journals.sagepub.com/home/jsn
Often school-age children are thought of as dependent on their parents and not necessarily involved in behaviors related to their own self-care. It is important to implement and advance self-care performance early in life to promote healthy lifestyles. This review examined the use of Orem’s Self Care Deficit Nursing Theory in relation to children’s self-care behaviors. This integrative review followed the Whittemore and Knafl guidelines. A systematic search was conducted using the nursing data-bases. The sixteen study articles were identified for the review, and five themes were identified. Children can develop skills and actively participate in maintaining health and wellbeing. Self-care programs based on Orem’s theory are well suited to assist individuals including children to improve self-care skills that lead better self-care practices. Nurses guided by Orem’s SCDNT will be well equipped to promote children’s knowledge and self-care skills for maintaining health and preventing negative health outcomes.
Research and evidence-based best practices (Alligood, 2017) guided by nursing theories improve the quality of healthcare and advance nursing science for the 21st century and beyond. Orem’s self-care deficit nursing theory (SCDNT) is a well-known theory with three nested nursing theories: the theory of self-care, theory of self-care deficit, and the theory of nursing systems (Orem, 2001). Orem (2001) defined self-care as performing the needed actions in a timely fashion to protect, maintain, and promote wellbeing. Self-care is performed when individuals learn, adapt, develop skills, and are motivated to take care of themselves in expected and unexpected situations (Orem, 2001). Self-care activities assist in managing health conditions and maintain wellbeing. Based on Orem’s SCDNT, self-care practices include three types of procedures: a) estimative procedures acknowledging the condition, b) transitional procedures imply knowing what to do in specific situations, and c) productive procedures evaluating action(s) performed. The major assumptions of SCDNT posit that (1) individuals are persons-as-agents needing continuous and deliberate actions to stay functional, healthy, and alive; (2) individuals must act deliberately to implement self-care action steps to meet their own needs and others; (3) individuals must be in continuous connection with others and their environment; (4) individuals must learn, advance, and convey their needs to others and justify their actions; and (5) individuals in structured relationships must be responsible and accountable to group members (Orem, 2001).
The expectations of this theory are individuals learn and develop skills to promote their own wellbeing in their daily life and prevent an exacerbation of symptoms and complications related to existing conditions (Orem, 2001). Self-care actions vary based on conditioning factors such as age, sex/gender, developmental level, capabilities, resources, socioecological factors, family, culture, environment, individual health status, and healthcare system (Orem, 2001). School-age children and adults routinely practice self-care as part of their daily living (Urpí-Fernández et al., 2017). Nurses, particularly school nurses, along with other health professionals are ideally positioned to help children learn self-care and achieve better self-care skills.
Nurses deliver care through leading, assisting, educating, adjusting, adapting, and role modeling to enhance individuals’ daily lives. The basic principle is to increase individuals’ awareness and skills to become responsible for their own self-care and for others as necessary (Baumann & Dang, 2012). Self-care deficits are observed when individuals have limited understanding, motivation, and capability (Orem, 2001). Supportive and empowering self-care nursing interventions create opportunities to practice skills and advocate for oneself. Such opportunities have the potential to advance an individuals’ knowledge and skills; thus, contributing to overall quality of life, autonomy, and general wellbeing (Drevenhorn, 2018). The person-as-agent is the individual and most individuals can learn and develop the knowledge and necessary skills for appropriate self-care actions (Orem, 2001). Individual self-care is a multidimensional concept and can vary based on the individual’s basic conditioning factors including age, gender, family, living situation, skill level, character, power mechanisms, health conditions, resources, culture, and environmental issues (Orem, 2001). Holistically, individuals are in continuous interaction with their inner and outer self, shaping self-care behaviors (Pickett et al., 2014). Therefore, self-care is the critical link to empower people whether in illness or health to take responsibility for their own health management and wellness (Barnason et al., 2012). Self-care includes both maintenance and management of behavioral components. Human beings are capable of purposeful action to accomplish their goals, and school age children, as well as adults, must be encouraged at a young age to take responsibility for self-care.
Self-care consists of activities that children and adults implement for the preservation of life, healthy functioning, personal improvement, and staying healthy (Orem, 2001). In addition to promoting a healthy lifestyle, self-care practices preserve wellness, promote quality of life, prevent diseases, and prevent injuries as well as manage existing conditions (Urpí-Fernández et al., 2017). Interchangeable with self-care, self-management is the most used term, for this kind of practice (Grady & Gough, 2014). However, self-management usually implies managing an existing health condition to maintain life, prevent complications, hospitalizations, and unplanned doctor visits. SCDNT emphasizes an individual’s capability to accomplish self-care actions to preserve life, health status, wellbeing, and manage existing conditions (Orem, 2001). Most studies guided by SCDNT are focused on adults with chronic conditions (Matarese et al., 2017). However, SCDNT is a comprehensive theory that applies diverse subjects including healthy or ill children and adults (Orem, 2001). Self-care is a learned behavior with patterned, systematic schedules and activities facilitating children’s learning of important self-care skills (Baumann & Dang, 2012).
Often, school-aged children are thought of as dependent on their parents and not necessarily involved in behaviors related to their own self-care (Isik et al., 2020). Nonetheless, every individual including children based on developmental age, engages in some level of daily self-care such as handwashing, brushing teeth, drinking water, eating, and so on (Riegel et al., 2012). Furthermore, selfcare activities increase week by week when children start attending school. Self-care may not be an instantaneous process and is usually more or less complex in various chronic conditions (Riegel et al., 2012). Involvement in carefully planned self-care interventions will likely increase awareness, capabilities, and encourage children to actively participate in self-care (Isik et al., 2020; Riegel et al., 2012). Nurses are well qualified to assess and evaluate the individual’s self-care deficits and need to plan, implement, and analyze interventions designed to enhance self-care performance.
Assessing self-care actions and self-care determinants in children is important prior to developing nursing interventions. Numerous studies highlight the significance of implementing and advancing self-care performance early in life to promote healthy and active lifestyles (Isik et al., 2020; Urpí-Fernández et al., 2017). The purpose of this literature review is to explore the usefulness of SCDNT to identify and promote self-care behaviors in children ages 4 to 21 years old. This review documents and synthesizes the available evidence from primary research using SCDNT in samples of school-age children.
The Whittemore and Knafl (2005) methodological approach was followed for this integrative literature review. This approach has five stages to direct the review: a) identifying the problem; b) conducting a literature search including diverse research methods; c) evaluating data by focusing on the methodological validity of the available primary studies; d) analyzing the data by comparison and conclusions; and e) synthesizing and presenting the findings in an integrated method.
A systematic search was conducted using the Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline, ProQuest Nursing & Allied Health Database, and PubMed databases. Combinations of the search terms were “Orem theory OR Orem self-care theory OR Orem self-care deficit nursing theory”, AND “children OR adolescents OR youth OR child OR teenager”, AND “self-care OR selfmanagement”. The search was limited to human subjects, published between January 2011 and August 2020 in English, and peer reviewed.
Inclusion criteria were studies about children and youth between 4 and 21 years old. While some studies just included children as the study participants, a few studies included both children and a parent. Parents play a critical role in introducing and solidifying independent self-care behaviors; therefore, studies were acceptable if the samples included only children or both adults and children. Studies were excluded if the study sample assessed the self-care behaviors of parents without children, adults, and elderly adults. A total of 1,208 articles were located; the CINAHL search resulted in 14 studies, Medline located 91 studies, ProQuest resulted in 110 studies, and PubMed retrieved 993 studies.
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used, and a fourstage flow diagram is presented in Figure 1 (Moher et al., 2009). Once the duplicated items (799) were removed, the titles and abstracts were reviewed for appropriateness during the initial screen. Studies that sampled subjects older than 21 years of age were excluded (132). Only original research articles were included for further review, yielding 96 eligible research articles following the exclusion of literature reviews (n = 181) and studies that did not relate to SCDNT on children or self-care behaviors among children (n = 82). Fifteen studies with various designs and methods (n = 15) and one additional study retrieved by hand search study from references and bibliographies were retained for the final review (see Figure 1).
Integrative literature reviews include qualitative, quantitative, and mixed method studies. Quality criteria scores may be used as criteria for inclusion/exclusion (Whittemore & Knafl, 2005). In addition to the inclusion and exclusion criteria, the researchers assessed and evaluated the final studies (N = 15) included for data quality and validity using the matrix table (see Table 1). The selected primary studies were read at least three times and organized into a matrix (see Table 1). The table was developed purposefully to reflect a) purpose, or research question, or hypothesis, b) sampling size and setting, c) study design and data collection methods, d) Johns Hopkins Nursing Evidence-based Practice (JHNEBP) rating, and e) summary. The JHNEBP rating scale was used to assess the included studies’ strength, quality, and level of evidence. Based on JHNEBP rating scale, randomized controlled trials were rated as a Level I, non-randomized experimental studies were appraised as Level II, and non-experimental studies, and qualitative studies rated as Level III (Newhouse et al., 2005). Of the 15 studies included in the final integrative review, two rated as Level I, seven studies were appraised as Level II, and six studies were rated as Level III. The studies with adequate sample size, explicit purpose or research question, a theory or theoretical framework, and clear methods rated as good quality. The studies with a small sample size, without a purpose statement, research question, or precise methods were rated as low quality based on JHNEBP quality of evidence rating scale.
Fifteen primary sources—four qualitative studies, 10 quantitative studies, and one mixed method study—were integrated and analyzed in this review. All studies used Orem’s theory and focused on children’s self-care activities in health and illnesses. We followed the Whittemore and Knafl (2005) methodological approach to classify diverse primary studies for an integrative review. The data sources were distributed into groups for data synthesis. The preliminary group classification was based on variables, health conditions, patterns, and conceptual classification. Results are presented under themes in Table 2. The five themes identified were respective self-care skills, power struggles on self-care performances, self-care deficiencies, nursing interventions for self-care, and active engagement in self-care activities.
A self-care pattern is a substantial routine exercise that is usually based on a person’s abilities, experiences, culture, and needs (Mersal & El-Awady, 2018). Almost every individual can perform basic self-care activities in their daily life including handwashing, eating, teeth brushing, walking, and sleeping. SCDNT highlights that self-care is the active role of individuals in their own healthcare (de Lima et al., 2017; Hemati et al., 2017). Recognizing school age children’s self-care behaviors and their contextual features assists nurses to identify potentially damaging or futile self-care behaviors, leading to the development and implementation of well-planned and age-appropriate selfcare interventions (Kongsuwan et al., 2012; Wong et al., 2015). Self-care skills are mostly acquired by imitation, experience, instinct, and education. Self-care performance involves a significant amount of intentional action to maintain and promote physical and psychological well-being and manage existing conditions (Awad et al., 2019; Mersal & El-Awady, 2018).
Parents carry many responsibilities for maintaining the wellbeing and daily care of their child(ren). These responsibilities should be transferred gradually from parents to children (Ali et al., 2014; Tavares et al., 2017). School-age children, particularly elementary school children, have rarely been involved in self-care interventions to maintain their health (Isik et al., 2020). Parents often struggle to shift some of these responsibilities to their young child(ren), especially if the child has a chronic condition (Tavares et al., 2017). Transferring some responsibilities may be difficult for children as well as the parents. However, theoretically grounded, evidence-based, and well-designed nursing interventions may ease the transition from self-care at the family level to the individual level (Altay & Çavuşoğlu, 2013).
Recognizing children’s basic conditioning factors and supporting them to make self-care decisions is critical, and nurses are well qualified to facilitate parents and children in the transition. A child’s individuality and level of health should guide the process of transferring self-care and can be directed toward children alone or both children and their parents (Salinas et al., 2017). First and foremost, developmentally appropriate interventions should involve children from the beginning and allow them to participate in setting goals for their own health and self-care (da Luz Sampaio Filho et al., 2013; Isik et al., 2020; Jaimovich et al., 2015). Fostering responsibility for maintaining health and preventing complications of existing conditions in school age children is important to the extent of their developmental and cognitive ability. Involving children in the planning phase of interventions has the potential to instill an appreciation for learning self-care skills as well as empower them as they acquire responsibility for self-care (Isik et al., 2020). Orem’s SCDNT prioritizes individual independence as much as possible in determining their own care (Tavares et al., 2017).
SCDNT assists nurses to determine and diagnose self-care deficits related to an individual’s health and particular condition. Self-care deficiencies may be the result of inadequate knowledge about one’s health status and condition (Tavares et al., 2017). The included studies indicated that the children had numerous self-care deficiencies related to lack of knowledge about their health conditions (Altay & Çavuşoğlu, 2013; Awad et al., 2019; Kouba et al., 2013). SCDNT is founded on the principle that every individual needs to learn, copy, and perform self-care skills to function independently in daily life (Awad et al., 2019). This is especially important for children and adolescents living with a chronic illness. Including them in focused health education programs will increase their involvement in their self-care. It is important to note that chronic health conditions can manifest in any life stage and complexities will vary based on age, severity, and other factors (Altay & Çavuşoğlu, 2013; Awad et al., 2019; Tavares et al., 2017). Therefore, self-care is multidimensional and task-oriented self-care activities are most effectively taught once self-care deficits have been identified and individualized (Altay & Çavuşoğlu, 2013; Awad et al., 2019). This is consistent with several studies that revealed inadequate or lack of knowledge and self-care deficits are interrelated and might explain individuals’ self-care incompetency (Ali et al., 2014; Altay & Çavuşoğlu, 2013; Awad et al., 2019; de Lima et al., 2017; de Sousa et al., 2012; Kouba et al., 2013; Tavares et al., 2017).
Nursing diagnoses related to addressing self-care deficits and lack of knowledge about health conditions is likely to lead to well-planned, applicable, and effective interventions (Altay & Çavuşoğlu, 2013; de Sousa et al., 2012; Mersal & El-Awady, 2018; Salinas et al., 2017). Nursing interventions should comprise guiding, supporting, educating, and hands-on practice to enhance self-care knowledge and skills (Altay & Çavuşoğlu, 2013; Isik et al., 2020; Mersal & El-Awady, 2018; Salinas et al., 2017). Self-care deficit diagnoses promote the development of tailored self-care approaches that are more useful and inclusive (Altay & Çavuşoğlu, 2013; de Sousa et al., 2012). Furthermore, intervention sessions should be reinforced by follow-up periods to refresh knowledge and check skills (Altay & Çavuşoğlu, 2013; Hemati et al., 2017; Isik et al., 2020). Nursing interventions designed to increase self-awareness and to promote self-care development encourages children to actively engage in their own self-care practices (Ali et al., 2014; Jaimovich et al., 2015).
School-age years are an ideal time to instill healthy habits and behaviors that have the potential to last a lifetime (Ali et al., 2014; de Sousa et al., 2012; Jaimovich et al., 2015; Kongsuwan et al., 2012; Mersal & El-Awady, 2018; Salinas et al., 2017). Researchers agree that school-age children should be involved as early as possible in self-care activities, since the early years are a most advantageous period to foster good, long-lasting lifestyle habits (Isik et al., 2020; Wong et al., 2015). Therefore, self-care nursing interventions for school age children are critical to acquire healthy self-care behaviors maintain well-being and combat health problems such as obesity, poor nutrition, as well as acute and chronic conditions (Ali et al., 2014; de Sousa et al., 2012; Jaimovich et al., 2015; Kongsuwan et al., 2012; Kouba et al., 2013; Mersal & El-Awady, 2018; Salinas et al., 2017). Interventions for school age children afford opportunities to practice self-monitoring, to actively participate in self-care activities, and to practice goal setting for health management under the guidance of nurses (Isik et al., 2020; Kouba et al., 2013). Self-care or selfmanagement intervention objectives include providing information about health and illness to improve the children’s awareness and knowledge related to their particular health circumstance as well as support related to active engagement and self-monitoring (Mersal & El-Awady, 2018).
The fifteen studies combined represented a total of 2,398 school aged children, ranging from 4 to 21 years of age. Sample sizes ranged from four (de Sousa et al., 2012) to 770 (Jaimovich et al., 2015). Four studies were associated with children living with asthma (Altay & Çavuşoğlu, 2013; Hemati et al., 2017; Isik et al., 2020; Mersal & El-Awady, 2018); two studies were related to children living with diabetes mellitus type 1 (Ali et al., 2014; Awad et al., 2019); two studies were interested in children’s nutritional health (Jaimovich et al., 2015; Salinas et al., 2017); one study was related to violence prevention (Kongsuwan et al., 2012); one study was related to postpartum care in adolescents (de Lima et al., 2017); one study was interested in children living with human immunodeficiency virus (da Luz Sampaio Filho et al., 2013); one study was related to children living with chronic kidney disease (de Sousa et al., 2012); one study focused on school age girls with dysmenorrhea (Wong et al., 2015); one study was associated with children living with sickle cell anemia (Tavares et al., 2017); and one study related to the nutritional health of children living with asthma (Kouba et al., 2013). Most researchers were interested in children’s self-care while living with an illness and few studies focused generally on self-care related to daily routines. All 15 studies used Orem’s SCDNT to assess, examine, or increase self-care abilities in children. Based on the integrative review findings, there is a clear consensus that children, with or without health conditions, should be involved in self-care activities.
Orem’s SCDNT highlights the notion that every person needs to know self-care strategies to maintain health, quality of life, and manage real and potential health conditions (Awad et al., 2019; Hemati et al., 2017; Mersal & El-Awady, 2018). Self-care involves purposeful activity and nurses are usually well positioned to determine children’s needs to increase their quality of life and prevent complications (Ali et al., 2014; de Lima et al., 2017). Parents may worry when transferring self-care responsibilities, especially for a young child or child with a chronic condition (Tavares et al., 2017). Managing health conditions in childhood is not an easy task. Children must be supported in learning, understanding, and gradual involvement with self-care activities to successfully live independently as much as possible according to their developmental level (Ali et al., 2014; Altay & Çavuşoğlu, 2013; Awad et al., 2019; da Luz Sampaio Filho et al., 2013; de Lima et al., 2017; de Sousa et al., 2012; Hemati et al., 2017; Isik et al., 2020; Kouba et al., 2013; Mersal & El-Awady, 2018; Tavares et al., 2017). Children without health conditions should still acquire self-care knowledge and skills to make healthy choices to preserve their health and well-being (Jaimovich et al., 2015; Kongsuwan et al., 2012; Salinas et al., 2017; Wong et al., 2015).
Child health and community/public health nurses, particularly school nurses, have recurrent and continued interactions with children, particularly those with chronic conditions (Awad et al., 2019). SCDNT highlights assisting and guiding the person for self-care as well as providing physical or psychologic support (Orem, 2001). School nurses who have long-term relationships with children are often acutely aware of the children’s physiological, social, and psychological needs (Salinas et al., 2017). Nurses who have long-term relationships with their young patients are better situated to deliver practical, age-appropriate interventions, and follow-up regularly to improve the children’s knowledge and self-care skills to increase autonomy and their quality of life (Awad et al., 2019). Follow-up periods are not definitive and can be monthly, quarterly, or annually based on intervention type, condition, and children’s developmental age (French & Kennedy, 2018). Providing periodic self-care support for children reinforces their desire to engage in self-care responsibilities and become competent in their self-care (Hemati et al., 2017). School nurses can play an essential supportive role by educating, coaching, supervising, and encouraging self-care performance in children (da Luz Sampaio Filho et al., 2013; Mersal & El-Awady, 2018; Tavares et al., 2017). Nurses guided by Orem’s SCDNT will be well equipped to promote children’s knowledge and self-care skills for maintaining health and preventing negative health outcomes (Hemati et al., 2017). Simple direct messages that enhance children’s learning and skills to manage their own health will likely improve self-efficacy and facilitate the transition of self-management from the family level to the individual level.
This integrative literature review demonstrated that Orem’s SCDNT is a valuable and applicable theory to use with school age children to improve their knowledge and skills for maintaining health, improving quality of life, preventing health complications, and recognizing self-care deficits. Most evidence related to using SCDNT is focused on adults with chronic conditions in the studies. However, this review demonstrates that SCDNT is applicable for healthy children, children living with chronic conditions, and for developing interventions for children. Future research studies using SCDNT can be beneficial to help children acquire healthy behaviors related to hygiene, nutrition, and other activities of daily living as well as pandemic guidelines to stay safe and protect others and themselves. Research should be conducted to evaluate age-appropriate self-care intervention sessions regarding important steps to minimize spread of COVID-19 and other potential infectious diseases. Avoiding infectious disease exposure and maintaining health is particularly important and highlights the need to focus on self-care activities. In addition, qualitative studies can add to the understanding of self-care experiences and responsibilities from the children’s perspectives related to participation in self-care activities. Giving voice to children has the potential to add to the science regarding prevention of diseases, comorbidities and complications associated with chronic conditions.
This integrative literature review revealed that there is a limited amount of research on school age children’s self-care knowledge and skills especially in relation to their own health conditions. The included studies assessed subjects’ self-care using various study designs including randomized controlled trial, quasi-experimental design, repeated measures design, cross-sectional, descriptive, correlational design, and descriptive qualitative exploratory approach. The studies were conducted in several countries. Future research studies focused on fostering self-care in children are needed. The heterogeneity of the age of the participants, and only including English language studies was a limitation.
Nursing theories are established to guide nursing practice, health, and research (Urpí-Fernández et al., 2017). Orem’s SCDNT highlights the individual’s self-care potential, and nurses are instrumental in promoting positive self-care actions aimed at health and wellbeing (Orem, 2001). SCDNT is appropriate for individuals of all ages, who are ill or healthy. This theory is a useful guide for nurses to promote better self-care, patient care, and advance communication between nurses and individuals. Orem posited that self-care abilities can be learned and are essential to maintain positive quality of life and promote wellness. In addition, self-care is essential to manage illness and prevent negative outcomes. Recognizing the demands and determinants of self-care allows various approaches to meet each individual’s self-care needs. This is especially important in meeting the self-care needs of children, who should not be regarded as little adults. One assumption of SCDNT is that every individual should care for themselves. When there is a disproportion between self-care requirements and individual abilities, nursing interventions are beneficial (Riegel et al., 2012).
In sum, nursing self-care intervention programs based on SCDNT are well suited to assist individuals including children to improve self-care skills that lead better self-care practices (Ali et al., 2014). Self-care intervention programs for children with or without chronic conditions increases the children’s self-care practices by promoting and maintaining their health status, particularly in areas of nutrition, exercise, personal hygiene, and safety. Well-designed nursing interventions that deliver knowledge, skills, and opportunities for mutual goal setting related to health management and wellbeing can improve the children’s involvement in selfcare activities, self-dependency, and quality of life. The findings of this literature review indicated that children should be active participants in self-care; nursing interventions can increase the children’ awareness and skills, as well as ease the gradual transfer of self-care responsibilities from the family level to the individual.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship and/or publication of this article.
Elif Isik https://orcid.org/0000-0002-9845-2659
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1 Texas Woman’s University, Nelda C. Stark College of Nursing, Texas
2 Professor at Texas Woman’s University, Nelda C. Stark College of Nursing
Corresponding Author:Elif Isik, Assistant Professor at Texas Woman’s University, Nelda C. Stark College of NursingEmail: eisik@twu.edu
