Essay – Florence Nightingale: Environmental Adaptation Theory and Dorothea Orem: Self-care Deficit Theory

Essay – Florence Nightingale: Environmental Adaptation Theory and Dorothea Orem: Self-care Deficit Theory
Revise the following student essay – Florence Nightingale: Environmental Adaptation Theory and Dorothea Orem: Self-care Deficit Theory as per the assessment brief below;
Assessment Brief

7.  Size of assessment
3500 – 4000 words

11.  The requirements for the assessment
The task is to write an essay of no less than 3500 words on the use of models and theories in nursing practice.
To do this you need to examine models and theories of nursing.  Within the course content we will look at a broad range of these as well as newer forms, such as decision algorithms and care pathways.  For the first part of this assignment you will be asked to look at 2 theories, and using an evidence-base, draw out the strengths and weaknesses of each.  While some of what you present needs to be descriptive, it is important to demonstrate critical thinking and skills of analysis.
In addition you will be asked to apply one model or theory to your own area of practice using a case study approach.  In order that the reader can understand the background to the case study it may be useful to write this briefly within an appendix.  Again by using an evidence-base (some of which you will have found in the first part of the essay), apply a rationale for choosing this model to your own area of practice.  As well as evidence-based material, you can use your own reflective account of why you think/feel that this model would be most appropriate.  It is important that within your essay you make it transparent what is your own opinion and what is coming from the literature evidence.
Learning outcomes 1-4 are assessed via the academic essay. This should focus on the application of a model and/or theory to your own area of practice, and you should critically reflect upon the care management provided.
Learning outcome 5 is linked to your on-line activities and discussions in moodle.

12.  Special instructions
·   Formative detailed feedback is offered on an essay patch (template in moodle).  This should be submitted to the drop-box within the ‘assessment” section of Moodle no later than 24th October 2016.  Individual electronic feedback will be on the 4th Nov.
·   Summative work is due on the 5th December 2016.
·   Coursework should be submitted with the appropriate, completed cover sheet attached/embedded in the file.
·   Retain an electronic of your coursework.

13.  Return of work
Feedback on your essay patch will be available through Moodle by 4th November.
Feedback on your summative assessment will be via Moodle by the 10th January 2017.

14.  Assessment criteria
This essay should cover learning outcomes below.  To be deemed ‘satisfactory’ you should:

Discuss and critique 2 different models and /or theories, providing an overview of strengths and weakness of each
Provide an evidence-based rationale for the application of one of these models/theories to own area of practice.
Cite appropriate literature correctly.


Student Essay – Florence Nightingale: Environmental Adaptation Theory and Dorothea Orem: Self-care Deficit Theory – FOR REVISION
Table of Contents
                                                                                                            Page number
Introduction                                                                                                   2
Review of Models
Nightingale’s Environmental Adaptation Theory                                   3
Orem’s Self-Care Deficit Theory                                                   6
Case Study
Introduction                                                                                       10
Case Study                                                                                       11
Assessment                                                                                      11
Diagnosis                                                                                          12
Implementation                                                                                14
Evaluation                                                                                         15
Conclusion                                                                                                   16
References                                                                                                   17
Bibliography                                                                                                 20
Appendix 1: Case Study                                                                             22
Nursing is a profession that is vital to the delivery of health care. In the first century of nursing, much of the knowledge and practices of nursing were unspoken and implied. Nurses were trained as apprentices to physicians, learning by practice at the bedside of patients, depending on knowledge handed out by physicians (Risjord, 2009). Later on, it became clear that a distinct body of knowledge was vital for effective practice of the nursing profession. Florence Nightingale, known as the pioneer of modern nursing, attempted to describe the previously implicit nature of nursing in the late nineteenth century. Through her Notes on Nursing: What It Is and What It Is Not, Nightingale (1969) identified the role of nurses. She stated that the function of nursing is to ensure that the patient is in the best state to allow the reparative process of nature to be enacted (Nightingale, 1969). Her work was important because it identified the scope of a nurse’s work, paved the way for nurse training, and explicitly described an area of practice that differed from that of physicians – physicians addressed bodily problems and diseases, while nurses were concerned with the patient’s environment (Risjord, 2009).
The twentieth century saw the establishment of nursing as a profession, and not merely as a vocation. Nursing organisations such as The British Nurses Association petitioned for the registration, licensure, training, and working conditions of nurses (Risjord, 2009). This drive to professionalise nursing catalysed nursing research, and the dissemination of nursing knowledge. Early versions of nursing frameworks were published from the 1950s to the 1970s, such as Orem’s work in 1971, and Neuman’s work in 1972 (Alligood, 2013). These frameworks were a precedent to the Theory Era in 1980, which saw a proliferation of nursing literature, journals, conferences, and programs. It was during this era that Fawcett (1984) developed a metaparadigm of nursing knowledge, identifying four key aspects in the nursing profession: person, environment, health, and nursing. This metaparadigm has since been widely used as a common context to understand various theories and bodies of knowledge in nursing (Alligood, 2013).
The nursing profession relies heavily on nursing knowledge and theories. Clarke and Lowry (2012) state that the continued evolution of the nursing profession is dependent on the development of theories in nursing science. However, there have always been concerns about how theory relates to practice.
Nightingale once addressed nurses, expressing that theory is useful when carrying out practice, but theory without practice is “ruinous to nurses” (Vicinus & Nergaard, 1990). Further, Conant (1967) articulated the concern that nursing theory and research were neither sufficient nor relevant to the nursing practitioner. She argued that theory should support practice, and should be evaluated according to its contribution to practice (Risjord, 2009). This essay will review two theories, discussing the development, central concepts, and core issues of each. This essay will include a critique of the theories, discussing its practical applications. The second part of the essay will examine a case study together with applying Nightingale’s environmental adaptation theory.
Review of Models
Florence Nightingale: An Environmental Adaptation Theory
Nightingale’s theory is environmentally centred. This is evident in her writings, and in her book Notes on Nursing: What It Is and What It Is Not (Nightingale, 1969). Her previous experience in modifying the poorly sanitised environment of the soldiers under her care was the basis of her knowledge, and fuelled her mission to improve environmental conditions in hospitals and health care centres. A devoutly spiritual person, Nightingale believed in the restorative power of nature, and hence believed that the environment of a patient should be changed in order to affect the work of nature (McKenna, 1997).
Nightingale’s nursing environmental theory has four key elements, which align with the four aspects of the nursing metaparadigm. First, the environment in Nightingale’s philosophy is anything that can be altered to position the patient in the best possible situation or condition for nature’s restorative process (Selanders, 1998). The environment includes two components: the physical and psychological environment. The physical environment pertains to ventilation, warmth, light, nutrition, medicine, stimulation, room temperature, and activity (Nightingale, 1969). Nightingale focused on ventilation, in particular, because she recognised the surroundings as a source of recovery and disease—hence, she provided ways to manipulate the surroundings and measure body temperature (Pfettscher, 2013). The psychological environment refers to an avoidance of ‘chattering hopes and advices’—Nightingale believed that this made light of the condition of the ill, exaggerated the probability of their recovery, and mocked their sickness (Nightingale, 1969). Second, the person in Nightingale’s theory refers to the patient receiving care (Alligood, 2014). Nightingale believed that the person is a complex creature, comprising physical, emotional, mental, social, and spiritual components (Reed & Zurakowski, 1996). However, Nightingale described a passive patient, who the nurse was responsible for. Third, health in Nightingale’s theory is implied to be the prevention and promotion of health, as well as nursing patients from sickness to health (Alligood, 2014). Nightingale envisioned that health could be maintained through environmental control and social responsibility (Pfettscher, 2013). Finally, Nightingale believed that nursing was a spiritual calling. She believed that all women would be nurses, at some point in their life, by attending to another person’s health (Nightingale, 1969). Trained nurses, however, needed scientific principles, and skills in observing and reporting patients’ health status.
Nightingale’s theory, in practice, includes the essential elements cited above. The diagnostic assessment would include an evaluation of the physical and psychological environment of the patient. The goal of the nurse, according to Nightingale, is to assist nature’s reparative process. The
A review of Nightingale’s theory shows that much of the core principles that she proposed are still applicable today. Nightingale’s theory is useful because it details aspects of the patient’s environment that need to be considered in order to optimise recovery. Nightingale’s conceptualized environment also focussed on health institutions, by taking into account the social, physical and psychological components that need to be understood as interrelated (Almeida, Enders, & De Carvalho Lira, 2015). However, having been written decades ago, her theory lacks some scientific basis, as evidenced by her rejection of the germ theory of disease (Risjord, 2009).
In addition, Nightingale’s theory may be critiqued using the eight-point criteria proposed by Johnson and Webber (2010). It can be observed that Nightingale’s theory is succinct and clear, and features understandable language. The theory has a high consistency, and its limits, as pertaining to nursing, are clearly defined. Nightingale took care to define important concepts; however, because it was written over 150 years ago, some notions may be out dated, such as Nightingale’s statement that only women are nurses. The theory’s concepts surrounding environmental hygiene clearly led to proposals such as cleaning to avoid morbidity. The theory’s underlying knowledge leads to an explanation of phenomena, and its hypotheses help to interpret propositions. Finally, the theory has clearly shown a strong support for nursing practice, and in fact serves as a major influence for the nursing profession today (Medeiros, Enders, & Lira, 2015).
Dorothea Orem: Self-care Deficit Theory
Dorothea Orem’s Self-Care Deficit Nursing Theory is one of the nursing theories that is widely utilised in nursing practice (Im & Chang, 2012). Orem’s nursing experience, wherein she aimed to improve the quality of nursing in general hospitals, led to the development of Orem’s notions of nursing practice (Berbiglia & Banfield, 2013). Orem focused on three questions: what do nurses do, why do nurses do what they do, and what are the results of nursing interventions (Orem & Taylor, 1986). Orem first developed a definition of nursing’s goal, which is to ‘overcome human limitations’ (Orem, 1959), and of nursing’s concern, which is man’s need for self-care and the opportunities to manage it in order to prolong life and health, recover from illness, or cope with the effects of these (Orem, 1959).
This initial definition eventually developed into a theory. Orem’s model supports the nursing practice through three central theories: the Theory of Self-Care Deficit, the Theory of Self-Care, and the Theory of Nursing Systems. Self-care pertains to deliberate actions done by individuals to maintain physical, social, and psychological wellbeing (Berbiglia & Banfield, 2013). Hence, the Theory of Self-Care posits that mature individuals consciously perform actions and behaviour that affect their survival, wellbeing, and quality of life (Berbiglia, 2014). However, self-care deficit occurs when a person is unable to perform self-care due to age or related factors (Berbiglia & Banfield, 2013). Thus, the Theory of Self-Care Deficit states that nursing is necessary because of the inability of some individuals to administer self-care due to their limitations (Berbiglia, 2014). This creates a need for nursing. Therefore, the Theory of Nursing Systems is an explanation of how persons with self-care deficits can be supported through nurses and the nursing process (Renpenning & Taylor, 2003).
Figure 1:
Orem’s Conceptual Framework for Nursing
Orem’s Nursing Systems can be further classified into three categories: a wholly compensatory system, a partly compensatory system, and a supportive-educative system. The wholly compensatory system compensates for the patient’s self-care deficit and provides complete care for the patient. The partly compensatory system compensates for the patient’s self-care limitations, and provides assistance as needed. The supportive-educative system is one where the nurse guides and supports the patient in regulating and exercising the self-care agency, and where the patient is the one accomplishing self-care (Orem, 2001).
Basic Nursing Systems (Orem, 2001).
Figure 2:
Orem’s theory, in practice, proceeds from four different operations: diagnostic, prescriptive, regulatory, and control, with each operation encapsulating phases in the theory (Berbiglia, 2014). First, Diagnostic operations starts with establishing the relationship between the nurse and the patient, and proceeds with the nurse identifying self-care difficulties. The patient’s self-care agency is ascertained through an evaluation of the individual’s self-care practices and the effects of related limitations (Berbiglia, 2014). Next, Prescriptive operations involves planning, and refers to the course of action taken by the nurse and client. Prescriptive operations specify aspects of care for the patient (Cavanagh, 1991). Regulatory operations pertain to practical activities, which are completed in order to fulfil what has been prescribed. Regulatory operations are equivalent to ‘intervention’ or ‘treatment’, and emphasises the development of the patient’s self-care agency. Finally, evaluation occurs during Control operations. The effectiveness of the previous phases are evaluated and appraised (Berbiglia, 2014).
Figure 3: An overview of the nursing process using Orem’s model of nursing (Cavanagh, 1991).
A review of Orem’s theory demonstrates that it revolves around the concept and development of the patient’s self-care agency. Rather than emphasising the patient’s illness, it underscores the path to recovery. Hence, attention is not on the nursing intervention, but rather, on how the nursing process can quicken the functions of the client’s self-care agency (Berbiglia & Banfield, 2013).
Case Study
According to Nightingale’s Environmental Adaptation Nursing Theory
(Case: Appendix 1)
The application of Nightingale’s environmental theory requires the use of her thirteen canons and the nursing process (Bolton, 2014). Nightingale’s thirteen canons include ventilation and warmth, light, cleanliness of rooms and walls, health of houses, noise, bed and bedding, personal cleanliness, variety, chattering hopes and advices, taking food, what food, petty management, and observation of the sick (Selanders, 1998). An assessment according to Nightingale’s thirteen canons is done first, after which a plan of action is outlined based on the evaluation. Careful observation and thorough documentation is done as well, to ensure the continuity of the plan.
Nightingale’s environmental theory was chosen for this case study because of its emphasis on the patient’s environmental factors and their effect on the patient. The case study deals with a patient suffering from osteoarthritis of the knee, and who will be undergoing total knee replacement. It would be important to modify aspects of the patient’s environment – pre-, intra-, and post-operation– so as to mitigate further injury to the knee, facilitate recovery, and maximise the effects of treatment to ensure quality of life. Hence, Nightingale’s environmental theory is appropriate to use for this case study.
Case study
Nursing Diagnosis
Nursing Intervention
Knee replacement is a major surgical operation that necessitates inpatient physiotherapy and outpatient rehabilitation (McDonald, Hetrick, & Green, 2008). Surgery is stressful, and can compromise the patient both physically and psychologically – pain perception and anxiety is often heightened when the patient feels a lack of control over the situation (Bastian, 2002). This anxiety may affect the patient’s physical recovery and psychological wellbeing, prolonging it and thereby increasing the cost of care (McDonald, Hetrick, & Green, 2008). Hence, the nurse’s role is vital in preparing the patient for surgery through education, decreasing the risk of post-surgical complications.
According to Nightingale’s theory, a nurse’s task after the initial observation and assessment would be to create and implement a plan of care (Bolton, 2014). Alex’s plan of care, pre-operation, would be to advice the scrub nurses at the local hospital to take into account environmental changes need to suit Mr. Tan’s physical and psychological and dietary needs prior to the surgery. These modifications should come before the perioperative duties of scrub nurses in order to put him in the best possible condition for nature to complete its reparative process after the operation.
Alex also constructs an educational plan for the scrub nurses to effect immediately after the post operation process to reduce the incidences of complications. This plan should also include preparation of the recovery room by the nurses to support a smooth recovery of Mr. Tan. Patients who are not educated properly may not follow post operation protocols and recommendations, resulting in injury or disease. This may be avoided through preoperative education. 
It can be seen from the above that nursing theories are a necessary knowledge base when providing care. Both theories discussed above provide structure and guidance when delivering care, although the methods are different. Nightingale’s theory emphasises adapting the environment in order to allow the patient to recover and achieve optimal health. Further, Nightingale posited that the nurse’s role is to place the patient in the best condition to avail of nature’s reparative process. On the other hand, Orem’s theory focuses on improving the self-care agency of the patient. According to Orem, this is done by determining a patient’s self-care deficit, and providing compensatory support to address this deficit and facilitate the development of a person’s self-care agency. Nightingale’s theory was chosen and applied to the case study cited above because of its emphasis on the environment and its effect on the patient’s health. As can be seen above, the patient in the case study needed much altering of his environment in order to prepare him for his operation, and facilitate his recovery both as an inpatient, and after being discharged from the hospital. The case study discussed above shows how the patient’s physical, mental, and emotional condition improved due to changes in his environment. Moreover, the case study examined above shows how the operating nurse successfully modified the environment and educated the patient in order to ensure his wellbeing and quality of life both prior to the surgery, and after the surgery. Essay – Florence Nightingale: Environmental Adaptation Theory and Dorothea Orem: Self-care Deficit Theory
This essay demonstrates the importance of nursing knowledge in practice. It is necessary for practicing nurses to be knowledgeable and informed about various nursing theories and models in order to be able to apply the appropriate one for each case. These theories are beneficial for guiding the professional nurse, offering a systematic framework for the delivery of care and intervention, and ensuring positive results.
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Appendix 1: Case study
Sixty- year old Mr. Tan has osteoarthritis of the left knee and would be undergoing a total knee replacement at the local hospital. Mr. Tan had been, when younger, an enthusiastic sportsman who lifted weights. This interest had led to a previous knee injury. Operating Theatre (OT) Nurse Alex is in-charge of Mr. Tan throughout his journey pre-operatively, intra-operatively and post-operatively. Essay – Florence Nightingale: Environmental Adaptation Theory and Dorothea Orem: Self-care Deficit Theory


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