Medical - Surgical Nursing Journal 2017; 6(1): 14-20.

Published online 2017 September 27 Original Article

Effect of Orem-based self-care education program on disease-related

problems in patients with multiple sclerosis: A clinical trial
Hanieh Dahmardeh1, Toktam kianian1, Seyyed Abolfazl Vagharseyyedin2
1. Instructor, Department of Nursing, Community Nursing Research Center, School of Nursing and Midwifery, Zahedan University of Medical
Sciences, Zahedan, Iran
2. Assistant Professor, Department of Nursing, School of Nursing and Midwifery, Birjand University of Medical Sciences, Birjand, Iran

*Correspondence: Toktam kianian, Community Nursing Research Center, Zahedan University of Medical Sciences, Zahedan, Iran.
Email: t.kianian67@gmail.com

ARTICLE INFO ABSTRACT

Article history: Background: Globally, multiple sclerosis (MS) is one of the leading causes of disability
Received: 25 June 2017 and is associated with a wide range of complications. Therefore, identifying patient
Revised: 19 August 2017 needs and providing education based on an appropriate nursing model seems crucial.
Accepted: 21 August 2017 In this study, we aimed to evaluate the effect of Orem-based self-care education
program on MS complications.
Methods: This clinical trial was conducted on 88 MS patients, who were members of
Key words: MS Association of Zahedan, Iran, during 2014-15. The subjects were randomly
selected through convenience sampling method and divided into intervention and
Self-care control groups (n=44). In total, nine 45-minute group training sessions were held for the
Orem’s self-care model
intervention group based on the patient needs and Orem’ model. Before and three
Multiple sclerosis
months after the intervention, the form of assessment of disease complications was
completed by both groups. Data analysis was performed in SPSS, version 16, using
Chi-squared test, as well as paired and independent t-tests.
Results: After the intervention, all the reported complications, including balance
disorder, muscle cramp, fatigue, urinary incontinence, constipation, fecal incontinence,
myasthenia, reduced memory, and double vision, significantly improved (P<0.001),
except for blurred vision.
Conclusion: Implementing self-care programs based on Orem’s model ameliorated
disease complications in MS patients. Thus, we recommend healthcare organizations
use this self-care program as an easy and beneficial intervention.

1. Introduction third cause of disability within the age range of 20-

40 years, which is the most active and productive
Multiple sclerosis (MS) is a chronic progressive period of human life.8, 9
disease of the central neural system, associated with Early onset of MS and high levels of disability
a wide range of complications and disabling impose financial burdens and adverse effects to
symptoms, which decrease the individual and social patients, their family members, healthcare systems,
performance of patients.1 and societies.3 The primary symptoms of this disease
The prevalence rate of MS was reported to be include visual disturbance, pain, urinary
2.5 million individuals worldwide.2-4 Up until 2011, incontinence, and weakness,10 which have a
41.81 out of 100 individuals suffered from this significant impact on the independence and ability
disease in Iran.5 Given the wide range of of individuals for active cooperation in the family
complications associated with MS, early diagnosis of and society and all aspects of their daily lives.11
this disease seems to be critical.1, 6 Therefore, self-care education is of paramount
In previous evaluations performed in Sistan and importance for these patients and plays an
Baluchestan Province, the prevalence of MS was important role in the prevention of hospital
13.96 cases per 100,000 of the population.7 readmission and enhancement of self-confidence.1
However, these statistics require accurate Self-care model
evaluations and providing proper solutions to Orem’s self-care model is the foundation of
enhance the quality of life among patients with MS clinical work in nursing care, which is a suitable
essentially because MS has been identified as the

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 Dahmardeh H et al.

clinical guide for designing and implementing self- The sample size was estimated at 38 according
care programs. This model is applied as a to the study by Aghabagheri et al 19. However, the
conceptual framework to guide self-care programs.8 total sample size was calculated at 44 with regards to
In this model, patients are not considered as passive 15% possibility of sample attrition. In addition,
individuals, who are only the receivers of healthcare sample size was calculated according to the sample
services, but rather, they are deemed as strong with size formula for estimating the difference in means
high accountability and ability to perform between two independent populations as follows:
healthcare-related tasks.12 Accordingly, the proposed
program for a patient must be based on the self-care
needs of that patient and his/her abilities.
Orem’s self-care model has been employed in
various studies conducted on MS patients, and its In total, 88 individuals were recruited through
effect was approved on improved physical and convenience sampling method and randomly
mental aspects of quality of life and decreased divided into intervention and control groups. To this
fatigue.8, 11, 13, 14 Madani et al. (2008) ascribed that end, 88 numbers were prepared according to
self-care programs could diminish a number of MS random number table and with respect to the
complications. However, no indication was made to number of samples. After referring the eligible
Orem-based self-care education program in the patients to the association, they were assigned a
mentioned study. Given the fact that in Orem’s number according to the order of their referral.
model human is recognized as active and powerful, According to this randomized allocation of numbers,
education of this important issue only through direct the patients were assigned to the intervention and
education by the researcher is not sufficient. In fact, control groups.
active participation of patients and obtaining their The inclusion criteria were age range of 20-50
opinions is crucial for providing an accurate self-care years, literacy, wheelchair independence, lack of
program to empower patients and boost their acute stage of the disease, and lack of diagnosis of
strength.15 other chronic or acute physical or mental disorders,
On the other hand, Edmonds et al. (2010) such as severe depression or speech or auditory
regarded non-use of group techniques and impairment, confirmed according to medical records
professional teams as one of the most common and examinations.
drawbacks of healthcare systems in provision of The exclusion criteria were the incidence of
education for patients with MS. They also serious physical-mental complications and disorders
emphasized on the necessity of patient-healthcare during the intervention, lack of participation in more
provider communication to provide supportive than one educational session, lack of regular
care.16 Furthermore, Plow et al. (2011) marked that implementation of the educational program at
while there are various interventions for home, or lack of daily completion of the record
improvement of disease self-management among sheet of the Orem-based self-care program.
MS patients, there is still a need for the use of
systematic methods with a specific combination.17 2.3. Instruments
Given the importance of self-care education
based on nursing theories and models,18 and with The data collection tools included a
regards to the various needs of patients in different demographic characteristics form, needs assessment
societies and the growing trend of MS in Sistan and form, and record sheet of the self-care training
Baluchestan6, this study aimed to determine the program. The demographic characteristics form
effect of Orem-based self-care education program contained items on age, gender, educational level,
on disease-related problems in patients with MS. marital status, and disease duration, which was
completed by all the participants before the
2. Methods intervention.
The needs assessment form included a list of
2.1. Design
common complications among MS patients,
This clinical trial was conducted on MS patients gathered by evaluation of various studies8, 20, 21 and
referring to the MS Association of Zahedan, Iran, based on the opinions of professors of Birjand
during 2014-15. University of Medical Sciences, in order to be used
to detect the problems patients commonly face and
2.2. Participants and settings take the necessary measures. These complications
include double vision, blurred vision, balance
disorder, muscle cramp, fatigue, constipation,
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 Dahmardeh H et al.

urinary and fecal incontinence, myasthenia, and evaluate the patient needs and design an
reduced memory. Patients were required to educational program according to their
determine the severity of their problems using four requirements.
alternatives (1=always, 2=frequently, 3=rarely, In this study, the independent variable was
4=never). In this scale, higher scores were indicative Orem-based self-care education program. The self-
of fewer problems. care program was in the form of the conceptual
Content validity of the needs assessment form Orem’s model designed according to the
was approved by using the opinions of 10 faculty educational needs of the subjects, which were
members of School of Nursing and Midwifery, determined by filling out the needs assessment form.
Birjand University of Medical Sciences. Its reliability We strived to keep patients active during the
was confirmed using test-retest method through educational course, the content of which was
providing the scale for 10 patients before the study confirmed by 10 faculty members, including two
and completing the form by the same individuals neurologists, of Birjand University of Medical
after a 10-day interval. Reliability of the needs Sciences.
assessment form was estimated at 0.89. The record The educational content was provided
sheet of the Orem-based self-care program was according to Table 1. In total, nine 45-90-minute
designed according to the educational program sessions were held for the intervention group by the
aligned to the needs stated by the patients in the researcher and under the supervision of a
pretest. neurologist for three weeks at the location of the
Record sheet of the self-care training program. association.8
This sheet contained the actions necessary to The program was based on discussions,
eliminate the needs and problems of the patients, questions and answers, reflecting on the experiences
such as bowel disorder (bowel retraining, high-fiber of the patients, as well as rectifying wrong behaviors
diet and plenty of fluids, laxatives and suppositories, and substituting them with correct ones. In the first
abdominal massage, activity and physical exercise), session, the order of content presentation was
urinary disorders (bladder retraining, training explained to the patients, and they were asked to
habitual urination, pelvic floor muscle exercises, prepare their questions prior to each session.
intermittent catheterization, and energy retention), In addition to presenting the content by the
visual impairments (sorting the objects in one researcher through lectures, visual aids, and
second, use of blindfolds, accessibility of objects, performing exercises in each session, patients
more use of other senses, analysis of tasks ), directly asked their questions from the neurologist,
memory impairments (use of notepads, repetition of who was present in the classes. Meanwhile, the
content, logical categorization of content, content patients were asked to share their experiences about
summarization, and coding the information), active the methods used to deal with their problems,
and resistance training, coordination and balance followed by other patients expressing their opinions
exercises, and exercises to reduce muscle cramps, in in this regard. Further, the present physician
front of all of which was days of the week, so that proposed his scientific opinions and confirmed,
patients could record the actions performed in their rejected, or corrected the opinions of the patients.
specific days. In terms of physical exercises, the patients were
required to perform the exercises with the researcher
2.4. Data Collection in order to reduce fatigue. During this time, any
wrong movement was corrected by the neurologist
In order to control the effect of communication
and researcher. At the end of each session, the
between the participants of the control and
patients were asked to briefly review the educational
intervention groups, a pretest was performed on the
contents of that session or voluntarily perform some
control group, which only received the routine
of the exercises.
training of the association. A posttest was conducted
In the final session (ninth session) and after
three months after the intervention, followed by
complementary explanations, the record sheet for
requiring the subjects of the intervention group to
the self-care program was provided for the patients,
complete a needs assessment form after providing
and the method to complete the form was explained
general information about the study and its goals. In
to the subjects in detail. After ensuring accurate
addition, the subjects were divided into two groups
implementation of the program and its recording on
of 19 and 20 due to the large number of patients
the sheet, the patients were followed up for three
and to enhance the quality of the educational
months and had the support of the researcher.
program. The educational program was carried out
During this time, in addition to phone calls by
on separate days for the two intervention groups.
the researcher, Thursdays were allocated to patient
The educational program was held one week later to
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 Dahmardeh H et al.

visits to resolve their problems. At the end of the association in order to complete the problem
three months, the patients were called to visit the determining form one more time (Diagram 1).
Table 1. Educational content of the designed sessions
Sessions Educational content
First Introduction, explanation of the nature, goals, and time of the study
Explanation about the disease and its causes, symptoms, treatment methods,
Second
diagnostic methods, and problems of multiple sclerosis (MS)
Third Self-care skills to treat impaired physical activity and muscle weakness
Fourth Self-care skills related to fatigue
Causes of muscle cramps and treatment methods and self-care skills for
Fifth
impaired physical mobility
Sixth Self-care program for urinary and fecal incontinence
Seventh Self-care skills for impairments in physical and perceptual functions
Eighth Self-care skills for mental disorders
Review of contents of the previous sessions and answering the questions of
Ninth
the participants

Eligible individuals (N=88)

Random allocation

Control (N=44) Intervention (N=44)

Pretest Pretest

Routine training of the association Routine training of the association + nine educational sessions

Exclusion from the study

Lack of regular participation in the educational Three months after the Exclusion from the study
classes (N=2) intervention Lack of visiting the association for post-test (N=5)
Lack of visiting the association for posttest (N=3)

Post-test analysis (N=39) Post-test analysis (N=39)

Diagram 1. Research stages

2.5. Ethical considerations for the subjects of the control group at the end of the
educational program.
To observe the ethical principles, the study
objectives were explained to the patients 2.6. Statistical analysis
individually, and it was marked that their
participation in the study was voluntary and had no Data analysis was performed in SPSS, version
effect on their treatment process. Moreover, written 16 using, Kolmogorov-Smirnov (to evaluate the
informed consents were obtained prior to initiating normal distribution of the variables), Chi-square test
the study, and educational pamphlets were provided (for evaluation of the difference between the study
groups in terms of gender, educational level, and

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 Dahmardeh H et al.

marital status), independent t-test (to assess the the study due to the long interval between sampling
difference between the two groups regarding age and beginning of the intervention, were replaced
and disease duration), and paired t-test (for with other subjects.
comparison of problems caused by MS in the study Information related to demographic
groups before and after the intervention). In characteristics of the subjects is shown in Table 2,
addition, P-value less than 0.05 was considered according to which no statistically significant
statistically significant. difference was observed in the demographic and
disease-related characteristics of the participants
3..Results between the control and intervention groups.
After the intervention, disease complications,
Out of the 88 subjects, 78 were able to complete such as balance disorder, muscle cramps, urinary
the study protocol. Five subjects were excluded from incontinence, constipation, fecal incontinence,
the intervention group due to lack of regular myasthenia, reduced memory, and double vision,
participation in the educational sessions and lack of significantly improved (P<0.001). According to this
visiting the association after the test, and five table, while the mean score of double vision
participants of the control group were excluded from increased after the intervention, this increase was
the study due to lack of visiting the association for not significant (Table 3).
the posttest. It should be mentioned that three
participants, who were unwilling to cooperate with
Table 2. Demographic characteristics of the participants
Group Intervention Control P
Variable N(%) N(%)
Male 8(20.5) 13(33.3)
Gender 0.2*
Female 31(79.5) 26(66.7)
Elementary 5(12.9) 7(17.9)
Educational level Secondary 13(33.3) 9(23.1) 0.56*
Higher education 21(53.8) 23(59.0)
Single 9(23.1) 8(20.5)
Marital status 0.78*
Married 30(76.9) 31(79.5)
Mean age (year) M±SD 34.1±8.2 35.6±8.4 0.43**
Disease duration (year) M±SD 5.72±4.92 4.81±3.58 0.35**

*Chi-squared; **Independent t-test

Table 3. Comparison of the problems caused by diabetes in the study groups before and after the intervention
Problems Group Pre-intervention Post-intervention P*
Intervention 3.05±1.23 3.28±1.09 0.06
Blurred vision
Control 3.48±0.60 2.87±1.21 0.12
Intervention 1.66±0.89 1.74±0.90 <0.001
Myasthenia Control 3.28±0.64 1.84±0.96 0.63

Intervention 1.48±0.82 1.82±0.94 <0.001

Muscle cramp Control 3.28±0.68 1.79±0.97 0.90
Intervention 1.05±0.22 1.12±0.33 <0.001
Fatigue Control 2.94±0.75 1.38±0.74 0.05
Intervention 2.74±0.81 2.86±0.74 <0.001
Urinary incontinence Control 3.76±0.48 2.74±0.78 0.88
Intervention 2.71±0.91 2.79±0.86 <0.001
Constipation
Control 3.82±0.38 2.94±0.79 0.23
Intervention 3.33±0.62 3.43±0.59 <0.001
Fecal incontinence
Control 3.89±0.30 3.23±0.70 0.49
Intervention 1.41±0.90 1.74±1.09 <0.001
Muscle weakness Control 3.46±0.68 1.64±0.01 0.66
Intervention 2.0±1.02 3.28±0.60 <0.001
Memory loss Control 3.28±0.60 2.25±1.01 0.27
Intervention 2.53±1.21 2.64±1.15 <0.001
Double vision
Control 3.53±0.64 2.66±1.08 0.92
*Paired t-test

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 Dahmardeh H et al.

4. Discussion One of the major limitations of the present study

was individual differences of the patients and
According to the results of the present study, completing the record sheet of the program at home
Orem-based self-care training program could by the participants, which might have been affected
ameliorate the disease complications, such as by various factors. However, these factors were
myasthenia, muscle cramp, fatigue, renal attempted to be controlled through regular follow up
incontinence, constipation, fecal incontinence, of the patients, weekly visits at the association, and
muscle weakness, memory loss, and double vision. phone calls. On the other hand, the researcher was
Madani et al. (2008) reported that not able to invite a control group from another
implementation of a self-care program for MS center due to lack of access to MS patients.
patients for one month significantly decreased some Therefore, sampling was first carried out for the
complications, including muscle cramp, fatigue, control group in order to prevent communication
constipation, and forgetfulness.9 The significant between the control and intervention groups.
changes in only four disease complications in the
mentioned study might be due to differences in the 5. Conclusion
study populations and demographics of the subjects,
type of intervention, and duration of follow-ups. In According to the results of the current study,
the current study, we attempted to hold patient- implementation of the Orem-based self-care
oriented sessions, so that they were able to obtain program diminished MS complications. Accordingly,
information from experiences of each other in the it seems necessary to design educational programs
presence of a physician and an informed individual for these patients based on their educational needs
(the researcher). After the intervention, the patients and patient training principles and using Orem’s
were followed up for three months. model, so that it could be used as a nursing
Consistent with our study, Afrasiabifar et al. intervention to improve disease complications and
(2016) performed Orem-based self-care education promote health in MS patients.
and follow-up of patients for one month, indicating
that the program caused a reduction in fatigue.22 Conflicts of interest
Moreover, Masoudi et al. (2008) introduced the The authors declare no conflicts of interest.
Orem-based self-care program, which is based on
the educational needs of patients, as a valuable Authors’ contributions
nursing intervention to improve fatigue in patients.23
Some studies also highlighted the positive effect of Hanieh Dehmardeh: study design, data
Orem-based self-care program on physical and collection, participation in the compilation of the
mental aspects of quality of life among MS article, Toktam, Kianian: participation in data
patients.8,11 analysis, research compilation, Seyyed Abolfazl
Moreover, Beer et al. (2012) underscored the Vagharseyyedin: study design, data analysis,
necessity of alignment of goals and therapeutic participation in research compilation.
methods to individual needs in a review study, and
Acknowledgments
regarded them as important factors in the
improvement of disability, increased participation, This article was extracted from a master’s thesis
and enhancement of quality of life among patients by the first author, performed after obtaining the
with MS.24 These results were in congruence with ethical license with the code of 94-01 and ethical
our findings since the quality of life is an internal code of 1394-01-01 from the Ethics Committee of
and general concept, which can be affected by the Birjand University of Medical Sciences and with the
disease-related problems. financial support of the Deputy of Research and
Altay et al. (2013) also reported that Orem- Technology of the mentioned university. In addition,
based self-care education played a significant role in this study was registered at Iranian Registry of
adjustment of patients with their current situation, Clinical Trials with the code of
which led to their independence.25 The results of the IRCT2015050522100N1. Hereby, we extend our
mentioned study confirmed our findings regarding gratitude to the Research Deputy of Birjand
the importance and status of Orem-based self-care University of Medical Sciences for their financial
program in the improvement of complication caused support and all the physicians and patients for their
by MS. cooperation with this study.

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 Dahmardeh H et al.

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How to cite: Dahmardeh H, Kianian T, Vagharseyyedin SA.

Effect of Orem-based self-care education program on disease-
related problems in patients with multiple sclerosis: A clinical
trial. Medical - Surgical Nursing Journal 2017; 6(1): 14-20.

20
Medical - Surgical Nursing Journal 2017; 6(1): 14-20.