The effect of Orem’s self-care model on self-esteem and resilience among hospitalized patients with major depressive disorder: a randomized controlled trial

Abstract

Background

Major Depressive Disorder (MDD) is a debilitating psychiatric condition that severely impairs patients’ self-care capabilities, self-esteem, and resilience. Dorothea Orem’s Self-Care Deficit Theory offers a systematic nursing framework to transition patients from passive care recipients to active self-managers. This study aimed to evaluate the effects of a nursing intervention based on Orem’s self-care model on self-esteem and resilience among hospitalized patients with MDD.

Methods

This randomized controlled trial was conducted from February to May 2026 among 60 patients diagnosed with MDD who were hospitalized in the psychiatric ward of Shahid Madani Hospital in Khoy, Iran. Patients were selected via convenience sampling and randomly assigned to either the intervention group (n = 30) or the control group (n = 30) using block randomization. The intervention group received 5 sessions of a tailored self-care program based on Orem’s supportive-educative system, alongside routine clinical care. The control group received only standard hospital care. Data were collected at baseline (pre-test), immediately post-intervention (post-test), and at a one-month follow-up using the Rosenberg Self-Esteem Scale (RSES) and the Connor-Davidson Resilience Scale (CD-RISC). Data were analyzed using SPSS software via descriptive statistics and Repeated Measures ANOVA.

Results

Baseline demographic and clinical characteristics were homogeneous between the two groups (P > 0.05). Mauchly’s test confirmed sphericity for both self-esteem (W = 0.992, P = 0.788) and resilience (W = 0.953, P = 0.252) variables. The Repeated Measures ANOVA demonstrated a significant time-group interaction effect for both self-esteem (F = 10.11, P < 0.001, Partial Eta Squared = 0.15) and resilience (F = 6.59, P = 0.002, Partial Eta Squared = 0.10). At post-test, the intervention group exhibited significantly higher self-esteem (Mean = 18.33, 95% CI: [17.08, 19.58]) and resilience (Mean = 55.70, 95% CI: [52.00, 59.40]) compared to the control group (Self-esteem Mean = 12.03, 95% CI: [10.78, 13.28]; Resilience Mean = 42.07, 95% CI: [38.37, 45.77]) (P < 0.001), which remained stable at the one-month follow-up.

Conclusion

Psychiatric nurses can integrate this structured, low-cost, and empowering model into routine clinical practice to foster autonomy and reinforce essential psychological capacities—specifically self-esteem and resilience—in hospitalized psychiatric patients.

Trial registration

Iranian Registry of Clinical Trials, IRCT20250723066609N3. Registered on February 6, 2026.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-026-05046-4.

Introduction

One of the most common, limiting, and serious mental illnesses in the world is Major Depressive Disorder (MDD) [1]. Persistent depression, anhedonia, widespread feelings of worthlessness, cognitive deterioration, and a variety of crippling physical symptoms are its clinical characteristics [2]. Recent estimates from the Global Burden of Illness study indicate that MDD is one of the major causes of the world’s illness burden and is expected to overtake all other causes of disability by 2030 [3]. In Iran, similarly, epidemiological surveillance highlights an extremely alarming increasing trend in this disorder’s incidence, placing a significant financial and socioeconomic burden on the country’s healthcare system [4].

A significant percentage of patients with MDD do not receive an efficient or ongoing continuum of care, despite the availability and development of many therapeutic and psychopharmacological protocols [5, 6]. Systemic disparities in accessing specialized psychiatric services, a lack of mental health literacy, and ongoing social stigma are the main causes of this therapeutic gap [7, 8]. As a result, these people experience lengthy, incapacitating symptom trajectories and high rates of recurring relapses [9, 10]. In light of these difficulties, modern mental health research has made it a top goal to find and develop strong intrapersonal psychological mechanisms that can serve as protective limitations against the intensity of acute symptoms [11].

Self-esteem and resilience are two of these protective intrapersonal variables commonly acknowledged as fundamental elements influencing the long-term therapeutic management of MDD and predicting recovery trajectories [12, 13]. Self-esteem, which reflects an individual’s global evaluation of their inherent worth and competence, plays a vital role in maintaining psychological integrity [14]. Chronically low levels of self-esteem not only serve as an established cognitive vulnerability factor for the onset of depressive episodes but also exacerbate symptom severity by trapping the patient in maladaptive cycles of self-blame [15]. Conversely, psychological resilience is conceptualized as a dynamic capacity for adaptive functioning and cognitive flexibility, enabling individuals to regain psychological equilibrium after encountering severe life stressors and acute crises [16]. Patients possessing higher baseline resilience experience substantially lower psychological burnout and demonstrate superior clinical and therapeutic outcomes [17, 18]. Current empirical evidence confirms a synergistic, bidirectional interplay between self-esteem and resilience, suggesting that interventions targeted at elevating either construct can effectively disrupt the vulnerability cascade in depression, fostering sustained clinical recovery [19].

Given the chronic and highly recurrent nature of MDD, contemporary psychiatric care paradigms increasingly advocate for a crucial shift—moving away from models that view patients as passive care recipients toward evidence-based strategies that emphasize active, structured empowerment [20]. In this context, Dorothea Orem’s Self-Care Deficit Theory stands out as one of the most conceptually coherent and well-structured nursing frameworks focused on fostering client autonomy, personal responsibility, and enhancing self-care agency [21]. This theoretical framework posits that while individuals inherently possess the potential to develop and maintain adaptive self-care patterns, acute health crises—such as a severe episode of major depression—precipitate a profound “self-care deficit” where the individual’s therapeutic self-care demands vastly exceed their current self-care agency. Under these clinical conditions, psychiatric nursing interventions become essential, functioning as a “supportive-educative system” to act as a catalyst, mobilizing and rebuilding the patient’s latent psychological and behavioral capacities to systematically restore independence.

Although Orem’s self-care model is clinically effective in improving quality of life and reducing distress in a variety of chronic somatic illnesses, its practical application to deeply ingrained psychological constructs like resilience and self-esteem among patients with MDD—particularly during the acute inpatient hospitalization phase—remains largely unexplored. The vast majority of historical studies have focused almost exclusively on physiological parameters or superficial symptom metrics, leaving a distinct gap in the literature regarding how theory-driven, nursing-led self-care protocols affect internal psychological capacities. To create evidence-based, extremely economical psychiatric nursing procedures that can be easily incorporated into current mental health settings, this empirical gap must be filled.

While Orem’s self-care model has traditionally been applied to somatic conditions, its theoretical components are highly relevant to psychiatric populations, particularly those with Major Depressive Disorder (MDD). In acute depression, patients experience a profound self-care deficit characterized by learned helplessness, low motivation, and diminished personal agency. Within Orem’s framework, the supportive-educative nursing system does not merely address physical needs; it acts as a structured mechanism for behavioral activation and cognitive restructuring. By mobilizing the patient’s latent capacities through progressive, goal-directed daily routines, the intervention systematically rebuilds a sense of mastery and autonomy. Consequently, this increase in self-care agency directly reinforces the patient’s global self-esteem and enhances psychological resilience, allowing them to counter depressive cognitive distortions adaptively.

To provide a robust, evidence-based response to this clinical challenge, the present study was designed and executed to evaluate the explicit effects of a structured nursing intervention based on Orem’s Self-Care Model on self-esteem and resilience among hospitalized patients diagnosed with Major Depressive Disorder.

Methods

Study design and participants

This study was conducted as a parallel-group randomized controlled trial (RCT). The primary objective was to investigate the longitudinal therapeutic effects of a theory-driven nursing intervention, meticulously designed based on Dorothea Orem’s Self-Care Deficit Theory, on intrapersonal psychological mechanisms—specifically self-esteem and resilience—among hospitalized psychiatric patients diagnosed with Major Depressive Disorder (MDD). The trial was conducted between February 10, 2026, and May 20, 2026, within the acute psychiatric inpatient unit of Shahid Madani Hospital, a major referral medical center affiliated with Khoy University of Medical Sciences, located in Khoy, Iran.

The target population comprised adult patients hospitalized with a definitive clinical diagnosis of MDD. Participants were recruited utilizing convenience sampling based on the following pre-established inclusion criteria: a primary diagnosis of MDD established by a board-certified psychiatrist based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria; age ranging between 18 and 65 years; ability to communicate effectively in Persian or Azerbaijani; and a baseline clinical stability sufficient to actively participate in cognitive and educational sessions as determined by the attending treatment team. Patients were systematically excluded if they presented with secondary comorbid neurodevelopmental disorders, acute cognitive impairment, or active substance dependence (excluding nicotine). Furthermore, patients who experienced acute clinical deterioration requiring transfers to intensive care, or those who chose to withdraw their informed consent at any point, were excluded from the final analysis.

Sample size

The sample size for this randomized controlled trial was calculated using G*Power software (version 3.1.9.7) for a two-tailed independent-samples t-test to compare the means of two independent groups. Due to the paucity of identical clinical trials implementing Orem-based models for self-esteem and resilience specifically among acute psychiatric MDD inpatients, a conservative medium-to-large effect size (Cohen’s d = 0.55) was assumed. The mathematical parameters were formally verified using the standard sample size formula for two independent groups:

Where Z_1−α/2 represents the standard normal deviate for a two-tailed significance level of α = 0.05 (equal to 1.96), and Z_1−β represents the standard normal deviate for a statistical power of 1-β = 0.80 (equal to 0.84). The randomized allocation ratio was set at 1:1. By utilizing the standardized effect size, where , The parameters were substituted into the formula as follows:

This mathematical calculation yielded a required minimum sample size of 26 participants per group (52 in total). To proactively account for a potential 15% attrition and dropout rate during the longitudinal follow-up intervals, the final sample size was rounded up to 60 participants, with exactly 30 individuals systematically allocated to each study arm.

Sampling and randomization

Sampling was initially conducted using a convenience sampling approach from eligible patients with major depression admitted to the psychiatric ward of Shahid Madani Hospital in Khoy. After selecting 60 eligible patients, participants were randomly allocated into two groups: intervention (n = 30) and control (n = 30). To ensure an exact balance of members between the two groups throughout the recruitment process, a block randomization technique with a block size of 4 was used.

Allocation concealment and blinding

To guarantee allocation concealment and prevent selection bias, sequentially numbered, opaque, sealed envelopes (SNOSE) were used. These envelopes were prepared by an independent researcher who had no involvement in patient recruitment or clinical care. This study adhered to the Consolidated Standards of Reporting Trials (CONSORT) guidelines. Due to the educational and interactive nature of Orem’s self-care model intervention, blinding the patients and the intervention provider was not feasible; however, a single-anonymized design was rigorously maintained. The outcome assessor (the individual administering the questionnaires) and the data analyst were kept completely blinded to the group assignments. To maintain assessor blinding, the post-intervention and follow-up data collection sessions were conducted in a separate counseling room by an independent nurse who was not present during the intervention delivery and did not have access to the randomization log.

Ethical considerations and trial registration

This clinical trial was strictly conducted in adherence to the ethical tenets of the Declaration of Helsinki. The study protocol received formal institutional authorization and ethical approval from the Regional Research Ethics Committee of Khoy University of Medical Sciences (Approval Code: IR.KHOY.REC.1404.058). Before initiating any study procedures, the primary investigator provided comprehensive oral and written explanations regarding the study objectives, risk-benefit ratios, and the absolute confidentiality of personal data. All eligible participants provided written, voluntarily signed informed consent forms. Additionally, the trial was prospectively registered in the Iranian Registry of Clinical Trials (Trial ID: 88937, Registry ID: IRCT20250723066609N3) on February 6, 2026.

Instruments and data collection

Data collection was performed at three distinct temporal milestones: baseline (Pre-test / T₀), immediately post-intervention (Post-test / T₁), and at a one-month longitudinal follow-up interval (T₂). The comprehensive data collection toolkit consisted of three validated instruments:

1. Socio-demographic Checklist: A brief questionnaire developed by the research team to capture vital baseline clinical and demographic characteristics, including age, biological sex, marital status, educational attainment, employment status, duration of psychiatric illness, and history of previous psychiatric hospitalizations.

2. Orem’s Self-Care Assessment Form: This clinical blueprint was developed by the research team based on the conceptual framework of Dorothea Orem to systematically diagnose self-care deficits in hospitalized psychiatric patients. The form evaluates 12 core clinical components divided into three theoretical domains: Universal Self-Care Requisites (6 items covering somatic, sleep, hygiene, and social needs), Developmental Self-Care Requisites (3 items evaluating self-esteem, psychological resilience, and personal agency), and Health-Deviation Requisites (3 items assessing disease literacy, therapeutic adherence, and stress containment). Deficits are systematically identified using a dichotomous (Yes/No) checklist completed by the psychiatric nurse. Qualitative face and content validity were rigorously established by a multidisciplinary panel of five psychiatric nursing experts. Content Validity Index (CVI) and Content Validity Ratio (CVR) were calculated, yielding values above 0.85 and 0.80, respectively, confirming excellent content validity. Reliability was confirmed through an inter-rater reliability analysis during a pilot phase involving 10 non-sampled MDD patients, yielding a Cohen’s kappa coefficient of 0.88, indicating high stability and consistency.

   At baseline, the diagnostic assessment highlighted widespread, homogeneous self-care deficits in both groups. The majority of hospitalized patients exhibited severe biological disruptions under universal requisites (such as profound insomnia, disrupted nutritional patterns, and fatigue), severe intrapersonal capacity deficits under developmental requisites (characterized by chronically low self-esteem and weak psychological resilience), and inadequate stress containment under health-deviation requisites.

   These baseline diagnostic findings were explicitly used to tailor the subsequent five supportive-educative intervention sessions to each participant’s specific profile of deficits.

3. Rosenberg Self-Esteem Scale (RSES): Self-esteem was evaluated using the internationally recognized 10-item RSES. Items are scored on a 4-point Likert scale ranging from 1 (Strongly Disagree) to 4 (Strongly Agree), yielding a cumulative score ranging from 10 to 40. Higher composite scores directly correspond to more robust, positive global self-esteem. The psychometric validity and reliability of the Persian translation of the RSES have been extensively verified in the Iranian clinical context, demonstrating excellent internal consistency (α = 0.84) [20]. In the current study sample, the internal consistency of the Persian version of RSES was confirmed with a Cronbach’s alpha of 0.82.

4. Connor-Davidson Resilience Scale (CD-RISC): Psychological resilience was quantified using the standard 25-item CD-RISC [22]. Each item is evaluated on a 5-point Likert scale from 0 (Not true at all) to 4 (True nearly all the time), with total scores spanning from 0 to 100. Higher global scores denote superior psychological adaptation and structural resilience. The structural validity and reliability of the Persian version of this instrument have been thoroughly confirmed, with a reported Cronbach’s alpha of 0.89 [23]. For the current study sample, the Cronbach’s alpha for the CD-RISC was calculated as 0.86, indicating good reliability.

Intervention Protocol

Participants allocated to the control group received only the standard, routine psychiatric ward care, which included prescribed psychopharmacotherapy, basic clinical nursing care, and standard hospital discharge planning.

In contrast, participants in the intervention group received the standard ward care supplemented by a structured, theory-driven self-care program based directly on Orem’s supportive-educative system. This specialized intervention was delivered through 5 structured, face-to-face, interactive sessions conducted over consecutive days. Each session lasted approximately 45 to 60 min and was conducted individually in a quiet counseling room within the psychiatric ward. The programmatic content of the sessions was rigorously constructed to systematically address identified universal, developmental, and health-deviation self-care deficits (see Table 1):

Table 1.

Comprehensive structure and content of the Orem-based self-care intervention program

Session	Session Title	Core Educational & Behavioral Focus	Nursing System / Actions (Supportive-Educative Role)
Session 1	Orientation, Therapeutic Alliance, and Introduction to Self-Care	- Establishing trust and therapeutic rapport. - Defining Major Depressive Disorder (MDD) symptoms from a self-care deficit perspective. - Introducing Orem’s concepts of self-care agency and universal requisites.	- Facilitating emotional expression and validating patient concerns. - Evaluating individual knowledge gaps and baseline self-care capabilities. - Enhancing intrinsic motivation for active participation.
Session 2	Somatic and Physiological Self-Care Optimization	- Addressing universal self-care requisites: establishing stable sleep-wake cycles. - Optimizing nutritional habits and functional hydration. - Introducing low-intensity physical movement and basic behavioral activation.	- Collaborative goal-setting for maintaining physical routines. - Creating a structured daily activity log. - Counseling on the biological link between somatic health and mood regulation.
Session 3	Intrapersonal Capacity Building & Self-Esteem Enhancement	- Identifying maladaptive automatic thoughts and cognitive distortions. - Cultivating positive self-appraisal, practicing targeted self-affirmations. - Exploring hidden personal strengths, skills, and past achievements.	- Employing cognitive restructuring techniques within an educational framework. - Guiding the patient to substitute negative self-blame with constructive self-care agency. - Fostering a sense of personal worth and competence.
Session 4	Psychological Resilience & Adaptive Coping Mechanisms	- Defining psychological resilience in the context of psychiatric crisis. - Developing structured, proactive problem-solving strategies. - Training in stress-containment, relaxation skills, and health-deviation management.	- Conducting interactive role-playing for real-life stress scenarios. - Reinforcing active coping mechanisms over passive behavioral avoidance. - Promoting cognitive flexibility and emotional regulation.
Session 5	Evaluation, Relapse Prevention, and Sustainability Planning	- Reviewing and integrating self-care skills acquired across previous sessions. - Identification of personal early warning signs of depressive relapse. - Formulating a tailored, post-discharge individual self-care plan.	- Assessing the client’s independence and confidence in self-management. - Involving family/social support systems in the post-discharge continuum of care. - Providing a practical self-care educational booklet for longitudinal maintenance.

• Session 1 (Orientation & Orem Framework Introduction): Establishing therapeutic rapport, introduction to the clinical manifestation of MDD, and administering Orem’s Self-Care Assessment Form to systematically evaluate and identify the patient’s individual self-care deficits and baseline self-care agency.

• Session 2 (Somatic Self-Care Optimization): Focusing on physiological self-care, establishing stable sleep-wake cycles, optimizing dietary habits, and introducing light behavioral activation and structured physical movement.

• Session 3 (Intrapersonal Capacity Building): Focusing directly on bolstering self-esteem and resilience through structured cognitive-behavioral techniques, practicing self-affirmations, and identifying personal strengths.

• Session 4 (Coping and Stress Management): Training in proactive problem-solving, cognitive restructuring to manage negative automatic thoughts, and building adaptive stress-coping mechanisms.

• Session 5 (Evaluation, Relapse Prevention & Sustainability): Reviewing self-care skills, establishing a sustainable, personalized post-discharge self-care plan, and managing early warning signs of depressive relapse.

Statistical analysis

Statistical analyses were conducted using IBM SPSS Statistics (Version 26.0). Quantitative demographic and clinical data were summarized using descriptive parameters, including mean values, standard deviations (SD), frequencies, and percentage distributions. Baseline homogeneity between the intervention and control arms for categorical demographic variables was assessed using the Chi-Square or Fisher’s Exact test, and independent-samples t-tests were used for continuous variables.

To examine the primary hypotheses regarding the clinical efficacy of the Orem-based intervention over time, Repeated Measures Analysis of Variance (RM-ANOVA) was performed for both primary outcomes (self-esteem and resilience). The within-subject factor was Time (comprising three levels: baseline, post-test, and 1-month follow-up), and the between-subject factor was Group (Intervention vs. Control). Before conducting the RM-ANOVA, essential parametric assumptions were verified: normality of distribution was confirmed using the Shapiro-Wilk test, and the assumption of sphericity was explicitly evaluated using Mauchly’s test of sphericity. In cases where the sphericity assumption was violated, Greenhouse-Geisser corrections were applied to adjust the degrees of freedom. Pairwise post-hoc comparisons were executed using Bonferroni corrections to locate specific time-point differences. A two-tailed P-value of < 0.05 was established as the threshold for statistical significance.

Results

Baseline characteristics of the participants

A total of 60 hospitalized patients with Major Depressive Disorder (MDD) completed the trial. It was included in the final analysis (n = 30 in the intervention group and n = 30 in the control group) (Fig. 1). The overall mean age of the sample was 34.50 ± 9.30 years in the intervention arm and 36.07 ± 9.27 years in the control arm, demonstrating no statistically significant difference between the two groups (P = 0.516).

Fig. 1.

The study process based on the CONSORT flow diagram

In terms of baseline socio-demographic and clinical parameters—including biological sex (P = 0.795), marital status (P = 0.787), educational attainment (P = 0.862), occupational status (P = 0.953), place of residence (P = 0.754), and economic background (P = 0.857) —no statistically significant differences were observed. Furthermore, the groups were highly homogeneous regarding clinical baseline variables, such as the chronological history of depression (P = 0.592), prior exposure to formal self-care training (P = 0.640), and comorbid psychiatric histories (P = 0.718). Comprehensive baseline descriptive statistics and homogeneity analyses are detailed in Table 2.

Table 2.

Demographic and clinical characteristics of the participants

Variable	Category	Intervention Group (n = 30) No. (%)	Control Group (n = 30) No. (%)	P-value
Age (Year)	Mean ± SD	34.50 ± 9.30	36.07 ± 9.27	0.516a
Gender	Male	14 (46.7)	13 (43.3)	0.795b
	Female	16 (53.3)	17 (56.7)
Marital Status	Single	10 (33.3)	11 (36.7)	0.787b
	Married	20 (66.7)	19 (63.3)
Education	Illiterate / Primary	5 (16.7)	6 (20.0)	0.862b
	High School / Diploma	13 (43.3)	11 (36.7)
	Academic	12 (40.0)	13 (43.3)
Job Status	Unemployed	5 (16.7)	4 (13.3)	0.953b
	Housewife	10 (33.3)	12 (40.0)
	Employed	12 (40.0)	11 (36.7)
	Other	3 (10.0)	3 (10.0)
Residence	Urban	24 (80.0)	23 (76.7)	0.754b
	Rural	6 (20.0)	7 (23.3)
Economic Status	Income < Expenses	10 (33.3)	12 (40.0)	0.857b
	Income = Expenses	14 (46.7)	13 (43.3)
	Income > Expenses	6 (20.0)	5 (16.7)
History of Depression	Yes	18 (60.0)	20 (66.7)	0.592b
	No	12 (40.0)	10 (33.3)
Self-care Training History	Yes	3 (10.0)	2 (6.7)	0.640c
	No	27 (90.0)	28 (93.3)
Other Psychiatric History	Yes	4 (13.3)	5 (16.7)	0.718c
	No	26 (86.7)	25 (83.3)

a: Independent t-test; b: Chi-square test; c: Fisher’s Exact test

The effect of Orem’s Self-Care Intervention on Self-Esteem

The parametric Repeated Measures ANOVA revealed a significant within-subjects main effect of Time (F = 19.24, P < 0.001, ηp² = 0.25), indicating that global self-esteem scores changed substantially across the three temporal milestones. Crucially, a robust and statistically significant Time x Group interaction effect was observed (F = 10.11, P < 0.001, ηp² = 0.15), establishing that the structural trajectory of change in self-esteem differed fundamentally between the intervention and control arms over time. The between-subjects analysis further demonstrated a significant main effect for the Group factor (F = 59.04, P < 0.001, ηp² = 0.50). As displayed in Table 3, pairwise post-hoc comparisons using Bonferroni corrections confirmed that while baseline self-esteem scores were statistically equivalent between the two groups (P > 0.05), the intervention group exhibited a marked and clinical increase in self-esteem immediately post-intervention (18.33 ± 3.62) compared to the control group (12.03 ± 3.09). This therapeutic benefit was effectively sustained at the one-month longitudinal follow-up interval (18.00 ± 3.90 vs. 12.67 ± 4.24).

Table 3.

Self-esteem results

Group	Pre-test (Mean ± SD)	Post-test (Mean ± SD)	Follow-up (Mean ± SD)	RM-ANOVA Results
Intervention ( n = 30)	12.27 ± 2.82 (95% CI: 11.17, 13.37)	18.33 ± 3.62 (95% CI: 17.08, 19.58)	18.00 ± 3.90 (95% CI: 16.49, 19.52)	Time Effect: F = 19.24, P < 0.001, ηp² = 0.25 Group Effect: F = 59.04, P < 0.001, ηp² = 0.50 Interaction: F = 10.11, P < 0.001, ηp² = 0.15
Control ( n = 30)	11.37 ± 3.08 (95% CI: 10.27, 12.47)	12.03 ± 3.09 (95% CI: 10.78, 13.28)	12.67 ± 4.24 (95% CI: 11.16, 14.19)

Note: Values are expressed as Mean ± SD. F: F-statistic; ηp²: Partial Eta Squared

The effect of Orem’s self-care intervention on resilience

Regarding the psychological resilience domain, Mauchly’s test indicated that the baseline assumption of sphericity was satisfied (Chi-Square = 2.755, P = 0.252); hence, sphericity-assumed values were reported. The univariate analysis revealed a significant within-subject main effect for Time (F = 12.94, P < 0.001, ηp² = 0.18) and a significant Time x Group interaction effect (F = 6.59, P = 0.002, ηp² = 0.10). The between-subjects test verified a significant main effect for Group (F = 29.35, P < 0.001, ηp² = 0.34). As illustrated by the clinical data in Table 4, the mean resilience scores in the Orem-based intervention group increased from a baseline of 41.03 ± 9.31 to 55.70 ± 10.24 at the immediate post-test. This psychological adaptation remained stable through the one-month follow-up period (54.00 ± 11.99). In contrast, the control group exhibited negligible fluctuations across all assessment intervals (40.30 ± 8.13 → 42.07 ± 9.68 → 43.53 ± 10.29).

Table 4.

Resilience results

Group	Pre-test (Mean ± SD)	Post-test (Mean ± SD)	Follow-up (Mean ± SD)	RM-ANOVA Results
Intervention (n = 30)	41.03 ± 9.31 (95% CI: 37.78, 44.28)	55.70 ± 10.24 (95% CI: 52.00, 59.40)	54.00 ± 11.99 (95% CI: 49.85, 58.15)	Time Effect: F = 12.94, P < 0.001, ηp² = 0.18 Group Effect: F = 29.35, P < 0.001, ηp² = 0.34 Interaction: F = 6.59, P = 0.002, ηp² = 0.10
Control (n = 30)	40.30 ± 8.13 (95% CI: 37.05, 43.55)	42.07 ± 9.68 (95% CI: 38.37, 45.77)	43.53 ± 10.29 (95% CI: 39.38, 47.68)

Note: Values are expressed as Mean ± SD. F: F-statistic; ηp²: Partial Eta Squared

Discussion

This study demonstrated that an intervention grounded in Orem’s self-care model significantly improved self-esteem and resilience in patients with major depressive disorder (MDD) compared to a control group. Repeated-measures ANOVA revealed a statistically significant time x group interaction effect for both self-esteem (F = 10.11, P < 0.001, ηp² = 0.15) and resilience (F = 6.59, P = 0.002, ηp² = 0.10). These findings suggest that an empowerment-based approach can yield meaningful psychological benefits even in severe psychiatric conditions. Thus, Orem’s model may extend beyond physical disorder management to improve psychological and adaptive outcomes in psychiatric settings, as evidenced by the substantial group effect sizes observed here (ηp² = 0.50 for self-esteem and 0.34 for resilience).

The theoretical foundations of Orem’s self-care paradigm may account for the observed improvements [24, 25]. The paradigm places a strong emphasis on each person’s ability to recognize their own needs, take an active role in providing care, and adopt habits that promote health and wellbeing. Deep helplessness, low motivation, low self-esteem, and a sense of losing control over their everyday life are common symptoms among MDD patients [26]. Interventions that transition patients from passive recipients to active participants in their care can therefore restore autonomy, enhance perceived control, and reinforce personal value. Accordingly, the marked increase in self-esteem within the intervention group (from 12.27 ± 2.82 at baseline to 18.33 ± 3.62 post-test) likely stems from strengthened self-care agency, greater behavioral independence, and consistent engagement in health-promoting routines.

These findings regarding self-esteem align with previous literature [24, 27]. However, a crucial conceptual distinction emerges when contextualizing these results within the broader research literature. While prior applications of Orem’s model have predominantly targeted physiological outcomes in chronic somatic conditions such as asthma and hemodialysis [24, 25], the present study demonstrates its efficacy in a psychiatric context. In physical illnesses, self-care primarily facilitates disease management and physiological regulation; conversely, in MDD, Orem’s core components—particularly need recognition and corrective action—appear to function as cognitive-behavioral restructuring mechanisms. This interpretation aligns with self-efficacy theory, which posits that perceived personal competence is a prerequisite for sustained emotional and behavioral change in mood disorders. Consequently, self-care should not be viewed merely as a set of physical or habitual behaviors, but as a dynamic process that positively influences deeper psychological dimensions, including self-worth and emotional regulation [27, 28]. The effect sizes observed here are comparable to those reported in somatic populations, indicating that Orem’s framework is sufficiently adaptable to transcend physical disorder management and serve as a robust empowerment tool for psychological adaptation.

Another key finding was the significant improvement in resilience within the intervention group. Mauchly’s test indicated that the baseline assumption of sphericity was satisfied (Chi-Square = 2.755, P = 0.252); hence, sphericity-assumed values were reported. The analysis confirmed a significant time x group interaction effect (F = 6.59, P = 0.002, ηp² = 0.10). The intervention group’s resilience score rose from 41.03 ± 9.31 at baseline to 55.70 ± 10.24 post-test and remained stable at follow-up (54.00 ± 11.99), whereas the control group exhibited minimal change across assessments (40.30 ± 8.13 → 42.07 ± 9.68 → 43.53 ± 10.29). This trajectory holds considerable clinical relevance, as resilience is central to adapting to chronic psychiatric conditions, tolerating psychological distress, and restoring daily functioning. The observed gains likely reflect enhanced adaptive coping, increased perceived mastery, and reduced learned helplessness.

The improvement in resilience can also be understood within a broader conceptual framework in which self-care and resilience mutually reinforce one another [29–31]. Greater engagement in self‑care may increase adaptive capacity and coping ability, while stronger resilience may help maintain self‑care despite psychological challenges. The sustained effect observed at follow‑up in our study supports this bidirectional perspective [28, 30].

These findings are consistent with previous research showing that improved mental health indicators and decreased psychological vulnerability are associated with stronger self-care skills [25, 28, 32]. The observed increases in resilience and self-esteem are consistent with the broader paradigm linking self-care to psychological well-being, even though depression severity was not measured as an outcome, thereby limiting causal inference about symptom reduction [26, 30]. Standardized depression severity scores should be used as variables in future research to see if these psychological improvements are unrelated to improvements in mood symptoms.

The current results are also indirectly consistent with intervention studies in chronic physical illnesses [24, 29]. Thus, Orem’s model may extend beyond physical disorder management to improve psychological and adaptive outcomes in psychiatric settings, as evidenced by the substantial group effect sizes observed here (ηp² = 0.50 for self-esteem and 0.34 for resilience).

These findings have significant clinical implications for psychiatric nurses. Low motivation, poor treatment adherence, and social/behavioral withdrawal are common symptoms of MDD. Patients can successfully regain a feeling of personal agency by actively participating in goal-setting, daily self-monitoring, and skill-building through structured, step-by-step self-care protocols. With the help of Orem’s concept, nurses can promote active recovery and long-term self-management in addition to symptom management. Therefore, these findings can directly influence empowerment-based therapies, psychoeducational programming, and nurse care planning in psychiatric facilities [29]. It is important to note that the proposed relationship between improved self-care, cognitive-behavioral restructuring, and actual depressive symptom reduction remains speculative in this study. Since depression severity and self-care agency were not directly measured using standardized scales, these mechanisms are presented as plausible hypotheses rather than definitive causal conclusions. Future research is required to evaluate these mediating pathways objectively.

Limitations

Despite these promising outcomes, several limitations warrant acknowledgment. First, the study was conducted at a single center with a relatively modest sample size (n = 60), which may constrain the generalizability of the findings. Second, the follow-up period was short; extended longitudinal tracking is necessary to confirm the durability of improvements in self-esteem and resilience. Third, baseline depression severity was not objectively quantified using a standardized psychiatric rating scale. Since depression severity is a critical clinical variable that can significantly influence a patient’s baseline self-care agency and subsequent capacity to engage in supportive-educative sessions, the lack of this measurement limits our ability to analyze how the intervention’s efficacy might vary across strata of clinical severity. Future multi-center clinical trials should explicitly integrate standardized depression severity indices as potential moderators or covariates.

In conclusion, the implementation of a structured nursing intervention based on Orem’s Self-Care Deficit Theory successfully enhanced global self-esteem and psychological resilience among hospitalized patients diagnosed with Major Depressive Disorder (MDD). These significant psychological improvements remained stable over a one-month longitudinal follow-up period. Psychiatric nurses can integrate this practical, low-cost, and empowering model into clinical routines to foster autonomy and reinforce essential psychological capacities in acute inpatient mental health settings.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

A.D: Conceptualization, methodology, and design of the study M.A.S: Conceptualization, methodology, and formal statistical analysis A.S: Project administration and resources Z.H: Formal evaluation and data collection.

Funding

This work was supported by the Research and Technology Deputy of Khoy University of Medical Sciences, Khoy, Iran.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to hospital regulations and the sensitive psychological nature of patient data. Still, they are available from the corresponding author (Mir Amirhossein Seyednazari) upon reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Khoy University of Medical Sciences (with the code No. IR.KHOY.REC.1404.058). We obtained informed consent from participants to participate in the study. Participants were assured that their information was confidential. We observed the principle of participant anonymity throughout the study. Their job position was not affected by participation or non-participation in the study. The study and survey directly impacted no one.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.