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Running header: SELF CARE MODEL AND DIABETES MELLITUS TYPE II

Program Development Paper: Self-Care Model and Diabetes Type II


Salena Barnes, RN
Georgia College and State University
Abstract
Diabetes mellitus (DM) type II is a common chronic illness in the United States that can have a
detrimental impact on an individuals life and the lives of their families ("National Diabetes
Statistics Report, 2014," 2014). Diabetes is a systemic disease that can affect every aspect of an
individuals body and elevated blood glucose levels are diagnostic. Due to the increased
prevalence of the disease and the comorbidities associated with DM type II, the self-care deficits
of the population require treatment programs to address their needs. The purpose of this paper is
to utilize Dorothea Orems Self-Care Deficit Nursing Theory (SCDT) to propose a self-care
management program for individuals who are pre-diabetic or diagnosed with DM type II. The
goal of the self-care management diabetic program is to educate individuals on how to perform
optimal self-care in order to stabilize blood glucose levels, lower risk factors, as well as reduce
and preventing complications("National Diabetes Statistics Report, 2014," 2014; Orem, Taylor,
& Renpenning, 2001).
Keywords: diabetes mellitus, obesity, glucose, Dorothea Orem, hyperglycemia

SELF CARE MODEL AND DIABETES MELLITUS TYPE II

Utilizing the Self-Care Theory to Address Diabetes Type II


The role of nursing has evolved over the past decades, as well as the approach taken in
caring for the patient. However, the fundamental concept remains the same, the nurse aids in
caring for patients when they are unable to care for themselves appropriately. Over the years,
there has been an increase in the prevalence of hypertension, diabetes, and cardiac diseases (Fang
et al., 2014). Chronic illnesses such as these can alter an individuals overall physical and
emotional health. Therefore, it is vital to use nursing interventions to optimize the patients
ability to care for themselves, in addition to maintain optimal health.
Nursing theorist Dorothea E. Orem created the Self-Care Deficit Theory (SCDT) that
explored the concept of self-care, self-care deficit, and nursing interventions as a model to obtain
clarity in understanding, as well as interpreting experiences (Orem et al., 2001). Orems theory
encourages promotion of patients caring for themselves, thus resulting in the patients learning
how to manage their disease and becoming self-sufficient in maintaining an optimal state of
health (Orem et al., 2001). The purpose of this paper is to propose a program aimed at
improving self-care management in patients with diabetes mellitus type II utilizing the SCDT.
According to the National Diabetes Statistic Report for this year released by the Centers
for Disease Control and Prevention, diabetes continues to rise in the United States ("CDC report
on diabetes shows the needle is moving, but not in the right direction," 2014). The report
revealed that over twenty-nine million people in this country have diabetes. Approximately, one
in four individuals with this disease are not aware that he or she has this life changing disease.
Furthermore, an additional eighty-six million individuals have pre-diabetes, of which ninety
percent do not know they have it. Individuals who are pre-diabetic who do not alter modifiable
risk factor such as losing weight and engaging in moderate physical activity are fifteen to thirty

SELF CARE MODEL AND DIABETES MELLITUS TYPE II

percent more likely to develop DM type II within the next five years ("CDC report on diabetes
shows the needle is moving, but not in the right direction," 2014; "National Diabetes Statistics
Report, 2014," 2014).
Currently DM type II accounts for 90-95% of the cases of diabetes in the United States
and is a prevalent chronic disease (Spears & Schub, 2014). DM type II is an endocrine
dysfunction, in which the individual has hyperglycemia (elevated blood glucose) due to an
autoimmune destruction of pancreatic beta cell that produce insulin or from varying levels of
insulin resistance or deficiency (Klandorf & Stark, 2014). Risk factors for the development of
DM type II include a history gestational diabetes, pre-diabetes, older than forty-five years old,
hypertension (blood pressure greater than 140/90), polycystic ovary syndrome, metabolic
syndrome, dyslipidemia, and a sedentary lifestyle. Modifiable risk factors such as eating a
healthy diet and regular physical activity aid in the management of diabetes. Furthermore,
management may include a physician prescribing an oral glucose-lowering medication and if
indicated, insulin. However, another crucial aspect of diabetes management is decreasing the
cardiovascular disease risk factors, for example hypertension, hyperlipidemia and tobacco use
(Peters & Laffel, 2011; Spears & Schub, 2014).
With the rise of DM type II in the United States, the detrimental effect of complications
such as blindness, kidney failure, cardiovascular disease, strokes and lower-limb amputation can
render patients disabled ("National Diabetes Statistics Report, 2014," 2014; "Standards of
Medical Care in Diabetes-2014," 2014). Patient education can serve as a powerful tool in
conjunction with medications to aid patients in managing this chronic disease. Teaching patients
self-care practices help with disease management and aid in optimal health. Orems SCDT is
appropriate for utilization in proposing a program to improving self-care management in patients

SELF CARE MODEL AND DIABETES MELLITUS TYPE II

with DM type II. Moreover, due to the complex nature of diabetes treatment, it is imperative that
patients understand, as well as are compliant with daily self-management("National Diabetes
Statistics Report, 2014," 2014).
Overview of the Program
The objective of this community based self-care management diabetic program is to
reduce complications associated with DM type II by addressing modifiable risk factors,
increasing self-efficacy, and support participation in diabetes self-management behaviors
("Standards of Medical Care in Diabetes-2014," 2014). Candidates for this program are prediabetics and those individuals diagnosed with diabetes type II. The program will incorporate
referrals from the primary care physicians (PCP), but will not supersede the PCPs
recommendations and current medication regimen. This is an adjunct therapy for selfmanagement of diabetes and associated modifiable risk factors. The program will incorporate
therapeutic guidelines from the American Diabetes Association (ADA) and National Institute for
Heath and Care Excellence (NIHCE) to ensure glycemic control and prevent complications.
This will include counseling, education on diet, and exercise, self-glucose monitoring, selfassessment, and oral antidiabetic/insulin treatment. (Zitkus, 2014).
The diabetes self-care (DSC) program will consist of weekly meetings to discuss
modifiable risk factors, answer questions, assess feelings, and encourage optimal selfmanagement. Weekly meetings occur for three months, and then decrease to monthly for one
year. The participants can access meetings online if they are unable to attend the program in
person. The DSC program entails an initial comprehensive medical screening and focuses on
stabilization and reducing the risk for complications associated with DM type II. Participants

SELF CARE MODEL AND DIABETES MELLITUS TYPE II

will be educated on self-care behaviors, modifiable risk factors, and complications of DM type II
which are recommended by the ADA ("Standards of Medical Care in Diabetes-2014," 2014).
Once the referral to the program is complete, solicitation for the patient to participate
occurs. Participants in the program must possess the ability to read and write or have a caregiver
to fill out materials and questionnaires. The participation papers and diabetic assessment
questionnaires are sent to the patient, along with a postage paid envelope for return of the
completed information to the office.
Upon receipt of all participant information, a date will be set for a meet and greet.
During this time, participants will receive a written overview of the program and will be
encouraged to ask any questions related to the program, giving the nursing staff an opportunity to
address any concerns. This program will utilizes current technology to make it convenient for
patients to receive education concerning this disease, especially if they are unable to attend the
face-to-face meetings. Using technology also offers patients who are reluctant to ask questions
in front of others the opportunity to do so, as well as an opportunity to refer back to materials
covered within the program. Participants will have access to live as well as recorded meetings,
educational materials, videos, and the ability to receive correspondence concerning questions.
Moreover, they have the ability to keep written or electronic journals. This will be accessable
anytime and through any type of mobile media.
During the meet and greet, participants will sign and fill out a commitment to change
agreement. After each meeting, updates take place to the change the agreement and can be
submitted electronically or by paper after the face-to-face meeting. Next, the participants will
receive a thorough physical assessment by a healthcare professional to address any preexisting
conditions, which may require medical intervention or referrals. During this initial visit, all

SELF CARE MODEL AND DIABETES MELLITUS TYPE II

baseline data will be obtained, including laboratory results. Participants will also be assessed for
depression due to this being a comorbid condition for individuals who have been diagnosed with
diabetes. Furthermore, depression has been linked to poor glucose control, as well as poor selfmanagement of this disease (Peters & Laffel, 2011). The nurses analyze the questionnaires to
assess the participants current knowledge, level of self-efficacy, obstacles, and common
misconceptions concerning DM type II. The information is compiled to create individualized
management plans for each participant. The results, purpose, and rationale of the A1C are
discussed with the patient and a goal A1C is set for review in three months to evaluate progress
in the program. There will be a multidisciplinary team approach, which will include dieticians,
nurses, nurse practitioners, pharmacists, physician assistants, mental health professionals, and the
referring physician with an expertise in diabetes. Thus, the participant will receive support,
assessment of their lifestyle, and then behavior change approaches ("Standards of Medical Care
in Diabetes-2014," 2014).
The program will address any areas of concern. After the initial phase, the patient will
attend monthly meetings, either face-to-face or online, that will last approximately one hour.
During this times risk factors, diabetic complications, self-care, diet, exercise, foot care, selfmonitoring of blood glucose, and compliance with medical treatment will be discussed. The
patient will receive education through auditory, visual, and kinesthetic learning styles, thus
maximizing the goal of reaching all the participants no matter what their style of learning may
be.
DM type II has modifiable risk factors that can help control blood glucose levels and
decrease the risk of complications from this disease. Majority of the individuals affected by this
disease are obese or overweight, which causes the bodys cells to become less sensitive to insulin

SELF CARE MODEL AND DIABETES MELLITUS TYPE II

(Corvera & Gealekman, 2014). In addition, smoking, increased stress levels, and unhealthy
eating habits further contribute to higher glucose levels. Participants in the program are
encouraged to maintain a healthy diet by monitoring carbohydrate intake, consuming vegetables,
fresh fruits in moderation, whole grains, and lean meats ("Standards of Medical Care in
Diabetes-2014," 2014). Overweight participants are encouraged to lose five to ten percent of
their weight and reduce their intake of fat, sugar, alcohol and sodium (Farrer & Golley, 2014;
Nishida & Martinez Nocito, 2007). Furthermore, participants receive education on smoking
cessation due to research showing a significant increase in risk of this disease among men who
smoked (Rasouli et al., 2013; Sun Jung et al., 2014). Participants are also encouraged to
participate in daily physical exercises and the DSC program offers an exercise instructor in the
morning and afternoon at the facility. However, for those who are unable to attend classes in
person, videos are accessible online in the privacy of their own homes for viewing and
instruction.
The participants will receive material describing signs and symptoms associated with
hyperglycemia and hypoglycemia, including how to address these issues. Nurses will review
proper foot care with all participants and complications associated with non-healing wounds in
all participants. The pathophysiology of DM type II and it complications will be review
extensively for the participants to get a thorough understanding of how diabetes affects the body.
Educational games, resources, and hands on activities will be provided to participants at the faceto-face meetings. Additional online resources will be available for review as well as, access to
the online discussion board. Healthcare professionals are available to answer questions via
email, at the face-to-face meeting, and online. This is to ensure the information presented is with

SELF CARE MODEL AND DIABETES MELLITUS TYPE II

clarity, the participants do not miss important facts, and if they forget something discussed or
may not understand it they have access to various resources.
Feedback on their journals is given weekly, which contain daily records of their diet,
blood glucose levels, foot care, and exercise. Review of the journals will aid in identifying
unhealthy behaviors and the development of new self-care management skills. At the end of the
three months, the participants will have another comprehensive medical evaluation and
laboratory testing. In collaboration with the patient, results are reviewed and concerns
addressed. The participants will continue to keep journals and receive feedback monthly for a
year, whether in person or via online access. During this time, healthcare professionals will
continue to encourage self-care management, present new ideas, and identify challenges faced by
this population.
Overview of the Theory
The Self-Care Model is a theory developed by Dorothea E. Orem that she began
developing in the 1950s after working in various clinical settings (Orem et al., 2001). The grand
theory or broad theoretical framework began with her goal of improving the quality of nursing in
healthcare facilities. Orem also realized that nursing knowledge was necessary for professional
advancement, and she conceptualized her purpose and requirements for nursing (Orem et al.,
2001).
The central notion of Orems theory is that individuals have an intrinsic ability that drives
them to care for themselves (Orem et al., 2001). In essence, individuals make every effort to
take care of themselves and in doing so maintain their health and wellness. However, there are
basic needs or self-care requisites required by everyone, and some needs are unique to each

SELF CARE MODEL AND DIABETES MELLITUS TYPE II

individual. An individual can attain his or her optimal state of health when all the needs are met
(Orem et al., 2001).
However, the degree of ability an individuals has to take care of themselves is described
in Orems concept of three related theories: theory of self-care, theory of self-care deficit, and
theory of nursing systems (Orem et al., 2001). Individuals who are no longer able to
appropriately take care of themselves or meet their needs are at a self-care deficit. Nursing plays
an important role in aiding the individual to meet their self-care needs, as well as inspiring
development of these needs. Nursing promotes the goal of patient self-care, thus, assisting in
restoring the balance and improving their health. Furthermore, self-care are behaviors learned
over time, may vary within a socio-cultural context, and upon an individuals knowledge base of
an illness (Orem et al., 2001).
Orems nursing process consists of three major steps, which the first includes assessing
why the patient requires help, the second is designing a nursing system and individualized plan
of care (Orem et al., 2001). The third major step is management of the nursing systems through
planning, initiating, and governing nursing actions. Orems self-care theory has four concepts:
self-care, self-care agency, self-care requisites, and therapeutic self-care demand. Self-care
consists of activities performed independently by an individual that promote and maintain
personal well-being. The individuals ability to perform self-care activities also referred to as
self-care agency. However, this consists of two agents, the first being the self-care agent (the
person who provides care) and the second being the dependent care agent (a person other than
the individual who provides self-car, such as a family member (Orem et al., 2001).
Orems self-care requisites are fundamentally actions used to provide self-care (Orem et
al., 2001). The three categories of self-care requisites are the following: universal,

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developmental, and health deviation. Universal self-care requisites or needs are common to all
individuals, such as activities of daily living. Furthermore, they also include food, water, air,
elimination, prevention of hazards, promotion of human functioning, activity and rest, as well as
solitude and social interaction. Developmental self-care requisites consist of needs resulting
from maturation or develop when an individual experiences certain events or conditions.
Examples of developmental self-care requisites can include college, marriage, acclimating to a
new job, maintaining good health and preventing, as well as treating illness or disease.
Additionally, health deviation self-care needs result from illness, injury, and disease, as well as
its treatment (Orem et al., 2001).
Orems SCDT is the central focus of this grand theory and results when self-care agency
(the individual or patient) are unable to meet self-care requisites or needs (Orem et al., 2001).
Therefore, nursing is required or needed. In addition, the theory covers how utilization of
nursing care to help individuals improve self-care abilities for survival, well-being, along with
their quality of life. Orem developed five methods in which nursing can assist the patient in
meeting their self-care needs, which are as follows: acting or doing for, guiding, teaching,
supporting, and providing an environment to promote the individuals ability to meet present or
future demands (Orem et al., 2001).
The theory of nursing systems becomes essential when the individuals self-care demand
surpass available self-care agency, thus warranting the need for nursing (Orem et al., 2001).
Moreover, the theory describes nursing responsibilities, roles of the nurse and patient, as well as
the rationale for the nurse-patient relationship. In addition, the various actions required to meet
the patients demands (Orem et al., 2001).

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Orem developed three systems nurses utilize to meet the patients self-care requites or
required self-care needs (Orem et al., 2001). These are wholly compensatory, partially
compensatory, and supportive education. Wholly compensatory is when the individual is unable
to perform self-care activities, which may require the nurse to perform most or all of the care.
Partially compensatory is when the nurse assists with the individuals care, thus self-care
activities being performed by both the nurse and patient. Furthermore, supportive education is
when the individual performs their own self-care; however, a nurse is required for support,
education, and knowledge, decision-making to promote the patient as a self-care agent. In
essence, Orems Self-Care Deficit theory supports health promotion, maintenance, as well as the
premises of holistic health in that both the nurse and patient promote the individuals
responsibility for self-care (Orem et al., 2001).
Use of the Theory to Guide Program Development
The utilization of theoretical thinking and scientific methods is crucial. Dorothea E.
Orems (SCDT) guided the promotion of the self-care management program for type II diabetics.
The theory has three interrelated theories: theory of self-care, the self-care deficit theory and the
theory of nursing system (Orem et al., 2001). The theory concerning self-care being founded on
the fact that every adult has the innate ability to act in order to maintain their health and treat
himself or herself in case of sickness, injury, or disease. DM type II is a chronic disease and the
most prevalent form of diabetes, which has modifiable and non-modifiable risk factors
("National Diabetes Statistics Report, 2014," 2014).
The capacity for self-care management of DM type II may vary according to the
individuals knowledge, education, age, life experiences, economy, culture, and current health
status ("Standards of Medical Care in Diabetes-2014," 2014). These various factors may affect

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an individuals self-care management of this chronic disease. The initial screening will provide
feedback on these various factors, which will give insight to current self-care deficits. Self-care
management of DM type II is key to positive outcomes and prevention of associated
complications. Therefore, the participants will require mental and practical skills, as well as
education and motivation to be able to organize and perform these important self-care requisites.
Orem proposed nursing is required when an individual cannot continuously maintain the
quantity and quality of self-care necessary to sustain or recover from disease, injury, or illness
(Orem et al., 2001). Through instruction guided by health care professionals, the participants
will receive information and advice concerning self-care management for this disease. However,
NIHCE reported that these alone are ineffective at bringing change and that nurses utilizing the
evidence-based behavior approach with support will produce positive outcomes (Clark, 2014).
According to Orems theoretical framework, when an individual is affected by these self-care
deficiencies, the goal of nursing is to help the individual to whatever extent possible to regain
their self-care capacity. The participants need self-management education according to the ADA,
as well as subsequent and on-going support. Thus, nurses must assist the patient in maintaining
the benefits of educational interventions. On-line based interventions will provide ongoing selfmanagement support that could allow sustained improvements, as well as long-term
improvements in outcomes (Haas et al., 2014; Hunt, 2013; Oyelana, 2008).
Orems theoretical framework supports a holistic view of self-management and addresses
a wide range of patients needs including education, lifestyle changes, medicine management,
emotional management, and social support groups. It also addresses interactions between the
participants and the health care professionals (Src & Kizilci, 2012). The goal in the

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application of the SCDT is to care for the participants based on the type of nursing system
appropriate to meet their self-care requisites.
Conclusion
The DSC program will provide the optimum effect in achieving regulation of self-care
agency and meeting their therapeutic self-care demands with Orems theoretical framework.
These participants could require adjustments in their diet, physical activity, and use of
medications to regulate their blood glucose to meet their self-care requisites. Moreover, they
will learn how to evaluate themselves, decide what actions need or must be taken, and carry out
those actions. The DSC program offers a variety of ways to enhance and support selfmanagement, whether online or in person. Research suggest that the self-management included
in this program combined with adequate support will improve self-care and reduce the
development of comorbidities (Hunt, 2013; "Standards of Medical Care in Diabetes-2014,"
2014; Src & Kizilci, 2012).

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