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Nursing Science Quarterly 24(2) 96 –100 © The Author(s) 2011 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0894318411399457 http://nsq.sagepub.com

Theoretical Concerns

The purpose of this column is to examine the concept of environment from the perspective of Orem’s self-care deficit nursing theory (SCDNT). Although the meaning of the con- cept of environment is not explicitly articulated in Orem’s work, the SCDNT rests on the philosophic system of moder- ate realism (Banfield, 2001; Taylor, Geden, Isaramalai, & Wongvatunyu, 2000). Based on this philosophic system, as well as on statements found in Orem’s work, the position of the SCDNT on the metaparadigm concept of environment can be described. In terms of the theoretical structure of the SCDNT, environment is incorporated into the basic condi- tioning factors. An exploration and analysis of the basic con- ditioning factors reveals the role that environment plays in the theory. Orem also identified the creation of a develop- mental environment as one of the ways of helping. These topics are addressed here. Suggestions for further conceptu- alization of the ideas related to environment in contemporary nursing and research possibilities are offered.

Overview of Orem’s SCDNT Beginning in the 1950s until shortly before her death in 2007, Dorothea E. Orem worked to develop and refine her ideas about nursing as a body of knowledge and as a field of practice. The SCDNT presented her perspective regarding the human requirements for nursing, as well as the processes for the provision of the required nursing care. The focus, or proper object, of nursing is the requirements of individuals for self-care and their capabilities to meet these require- ments. Orem claimed that the SCDNT is applicable to all

instances of nursing. This theory may be used with individuals, families, and communities (Taylor, 2001; Taylor & Renpenning, 2001).

The SCDNT, considered to be a general theory of nursing, consists of three specific theories that describe the concep- tual elements and the proposed relationships between these concepts. The conceptualization of self-care as a human reg- ulatory function involving deliberate action to promote life, health, development, and well-being is articulated in the the- ory of self-care. The self-care requisites are the purposes to be achieved through the engagement in self-care. The three categories of self-care requisites are the universal, develop- mental, and health deviation. The concept of therapeutic self-care demand refers to the totality of the self-care requi- sites particularized for the individual and the ways selected to meet each of these requisites. The theory of self-care defi- cit includes the concept of self-care agency, meaning the capability to provide the required self-care, and the concept of self-care deficit. A self-care deficit is said to exist when the therapeutic self-care demand is greater than the self-care agency. It is the existence of a self-care deficit that indicates the need for nursing. The theory of nursing system describes and explains the design and the product of systems of

1Assistant Professor, Madonna University

Contributing Editor: Martha Raile Alligood, RN, PhD, Professor, East Carolina University College of Nursing, Health Sciences Building, #3146, Greenville, NC 27858-4323 Email: [email protected]

Environment: A Perspective of the Self-Care Deficit Nursing Theory

Barbara E. Banfield, RN; PhD1

Abstract

In this column the author presents an examination of Orem’s conceptualization of environment as a metaparadigm concept, the role of environment in the theoretical structure of the self-care deficit nursing theory, and the creation of a developmental environment as one of the ways of helping another. Suggestions for further work related to the conceptualization of environment and the organization of existent knowledge are provided. Application of the concept of nursing agency and the environmental factor of healthcare system illustrate the utility of self-care deficit nursing theory in relation to the recommendations for changes in nursing education and for redesign of the healthcare system.

Keywords

environment, Orem, self-care deficit nursing theory

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nursing care. The concept of nursing agency refers to the capability of the nurse to design and produce nursing sys- tems in order to achieve nursing outcomes.

Both self-care and nursing care are forms of deliberate action. “Deliberate action refers to actions performed by individual human beings who have intentions and are con- scious of their intentions to bring about, through their actions, conditions or states of affairs that do not at present exist” (Orem, 2001, pp. 62-63). In the case of self-care, the person engages in internally-oriented actions to bring about condi- tions in self and in externally-oriented actions to bring about new or changed conditions in the environment. The overall goal of self-care is to promote life, health, development, and well-being. The actions of nurses are directed toward bring- ing about new or changed conditions in the patient and the patient’s environment in order to meet the person’s therapeu- tic self-care demand and to regulate the development and exercise of the person’s self-care agency.

Moderate Realism and the Concept of Environment The four metaparadigm concepts of human beings, environ- ment, health, and nursing represent the domain of nursing knowledge on the most abstract level (Fawcett, 2005). The extant grand nursing theories present various philosophic perspectives on these four metaparadigm concepts. For some of these extant theories, the philosophic foundations have been clearly articulated; for others, the philosophic assump- tions are largely implicit (Sarter, 1988). In order to clarify the philosophic underpinnings of the SCDNT, an inquiry process was conducted (Banfield, 1998). The philosophic inquiry involved the examination and analysis of Orem’s work and the work of authors whom she had cited. The find- ings of the inquiry revealed that the SCDNT and Orem’s position regarding nursing as a practical science is based on the philosophy of moderate realism.

Moderate realism, one of a number of realist positions, is associated with the philosophy of St. Thomas Aquinas (Wallace, 1979). According to this philosophic system, there is a real world that exists. This world or reality exists inde- pendent of the thoughts of the knower. The moderate realist position does not discount that individuals may have differ- ing perceptions of reality. However, the perceptions of indi- viduals do not determine the nature of reality. “To exist is to have a being which is independent of thought; and what depends on thought for its being is no thing but a mere idea, like a unicorn” (Macmurray, 1957, p. 80).

Although Orem did not specifically address the topic of the nature of the world or environment, statements she made reflect the moderate realist position. In relation to features common to all types of care situations, Orem (2001) stated that “care demands that the care agent view the person being taken care of objectively to determine presenting conditions

and needs . . .to some objectively discernible reality” (pp. 26-27). With regard to mental health, she spoke of func- tioning within a veridical or reality frame of reference (Orem, 2001; Orem & Vardiman, 1995). This statement conveys the understanding that there exists a reality that is independent of the thoughts of the person. Phrases used by Orem (2001) that are consistent with the philosophic position of moderate realism include “concrete situations of human living” (p. 16), “reality situations of daily living” (p. 46), “concrete nurs- ing practice situations” (p. 17), and “persons in time-place localizations” (p. 71).

In relation to ontology of the SCDNT, Orem identified four categories of entities: (a) persons in space-time localiza- tions, (b) properties of these people, (c) motion or change, and (d) products into being (Orem, 2001, p. 141). These cat- egories are reflective of the philosophy of moderate realism.

Human beings exist in their environments (Orem, 2001, p. 79). “In our existence, we are parts of the world, depen- dent upon it for the support and the resistance which make our action possible” (Macmurray, 1957, p. 220). Although human beings exist in their environments, they can isolate themselves from the world in thought (Macmurray, 1957). “For purposes of understanding, environmental features can be isolated, identified, and described, and some environmen- tal features are subject to regulation or control” (Orem, 2001, p. 79). The categories of environmental features identified by Orem are physical, chemical, biologic, and social.

The nature of the relationship between the person and the environment is one of mutual influence. “As is well known, environmental conditions can positively or negatively affect the lives, health, and well-being of individuals, families, communities; under conditions of war or natural disaster, whole societies are subject to disruption or destruction” (Orem, 2001, p. 79). Human beings also influence the envi- ronment. In relation to deliberate action, persons reflect on themselves as well as on their environments to identify pos- sible courses of action to achieve desired results. Both self- care and nursing-care are forms of deliberate action. The intention behind many of the self-care actions is to influence or alter environmental factors. The same is true for many of the deliberate actions that make up the nursing system. The actions of the nurses are directed at influencing human and environmental conditions in order to meet the patient’s thera- peutic self-care demand and regulate the development and operability of the patient’s self-care agency.

Environment Within SCDNT Within the SCDNT, the concepts of therapeutic self-care demand, self-care agency, and nursing agency are conceptu- alized as properties or attributes of persons. Therapeutic self- care demand and self-care agency are regarded as patient variables because these properties vary at points in time. In

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the case of nursing agency, it is viewed as a nurse variable because this property of nurses varies at points in time. In relation to this idea of variables, Orem (2001) stated “recog- nition and acceptance of the patient and nurse variables must be accompanied by continuing recognition and acceptance that it is persons who are nursed and persons who provide nursing” (p. 167).

A number of factors thought to condition or influence the patient variables and nurse variable have been identified. To date, 10 factors have been identified: (a) age, (b) gender, (c) developmental state, (d) health state, (e) pattern of living, (f) healthcare system factors, (g) family system factors, (h) sociocultural factors, (i) availability of resources, and (j) external environmental factors (Orem, 2001, p. 167). Col- lectively, these factors are referred to as basic conditioning factors. It is important to note that these basic conditioning factors are not regarded as determinants of the patient and nurse variables; rather they are thought to influence or affect the values of the variables under certain circumstances at points in time. The interaction of the factors with each other is recognized. The list of basic conditioning factors is not viewed as finalized. It is possible that additional condition- ing factors will be identified. It is also possible that factors will be identified that condition only the patient variables and only the nurse variable.

These 10 basic conditioning factors fall into one of three categories (Orem, 2001). The factors of age, gender, and developmental state are descriptive of the individuals. The factors that relate the individuals to their families are family system factors and sociocultural factors. The remaining fac- tors, health state, pattern of living, healthcare system factors, availability of resources, and external environmental factors, locate individuals in their worlds.

From a conceptual point of view, the factors that relate the individuals to their families and the factors that locate indi- viduals in their world can all be considered part of the envi- ronment. Orem (2001) identified a number of features that are relevant to the person’s therapeutic self-care demand. She referred to these features as environmental features and grouped them into the two categories of (a) physical, chemi- cal, and biologic features; and (b) socioeconomic-cultural features. These environmental features are also relevant to the person’s self-care agency and the nurse’s nursing agency.

The basic conditioning factors condition the values at which the self-care requisites are to be met and the ways in which these requisites can be met. The relationship between the environmental factors and most of the self-care requisites is readily apparent. For example, one of the universal self- care requisites is “the prevention of hazards to human life, human functioning, and human well-being” (Orem, 2001, p. 225). Clearly, all of the basic conditioning factors can have an influence on this requisite. In order to meet this self- care requisite, the person needs to engage in behaviors that will regulate self and the environment.

The individual’s self-care agency can be evaluated in terms of its development, operability, and adequacy. The basic conditioning factors condition the development or operability of the self-care agency. For example, the influ- ence of family system factors on the development of the per- son’s capability to engage in self-care could be positive or negative. Family system factors such as the valuing of a healthy diet and active lifestyle would foster the develop- ment of self-care agency. Family system factors such as sub- stance abuse by the parents and domestic violence in the home would likely interfere with the development of the child’s self-care agency. The basic conditioning factors can condition the operability of the developed self-care agency. For example, a lack of available resources would condition the operability of the person’s self-care agency. A natural disaster, such as a hurricane, would affect the therapeutic self-care demand and self-care agency of the persons living in the area. The adequacy is determined by a comparison of the persons’ capability to perform self-care and their need for self-care. A self-care deficit is present when the person is not capable of meeting the need for self-care. The existence of a self-care deficit is indicative of the need for nursing care.

There are also factors that condition nursing agency. The current list of basic conditioning factors was developed on the basis of their conditioning of the patient variables. These 10 basic conditioning factors are believed to condition the self- care agency and the therapeutic self-care demand of the nurse. However, the relationships between these specific factors and the concept of nursing agency have not been examined. It may be that there are different or additional factors that condition the nursing agency. As with self-care agency, nursing agency can be evaluated in terms of development, operability, and adequacy. The development of nursing agency is the expected outcome of nursing education. Experience and ongoing edu- cation result in the further development of nursing agency. As is the case with self-care agency, nursing agency may be developed but not operable. The basic conditioning factor of healthcare system factors conditions or influences the devel- opment and operability of nursing agency. An examination of the environment of the healthcare system can help in the iden- tification of factors that serve to promote or hinder the devel- opment and operability of nursing agency. The adequacy of nursing agency is judged in relation to the requirements for nursing of the specific population being served.

Orem (2001) described five ways of helping another per- son: (a) acting or doing for another, (b) guiding another, (c) providing physical or psychological support, (d) providing a developmental environment, and (e) teaching. The selection of method(s) is based on the nature of the self-care deficit. The helping method of providing a developmental environ- ment “requires the helper to provide or help to provide envi- ronmental conditions that motivate the person being helped to establish appropriate goals and adjust behavior to achieve results specified by the goals” (Orem, 2001, p. 58).

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Recommendations for Further Development of Environment within SCDNT

The development of a comprehensive definition of environ- ment from the perspective of the SCDNT would be useful in terms of promoting understanding of the theory. The exami- nation and analysis of those authors whom Orem cited, as well as an examination of current ideas on environment from the perspective of moderate realism would help to ensure that the definition is consistent with the philosophical system that is foundational to the SCDNT. An explicit definition of envi- ronment would allow nurses to gain a clearer understanding of the theory. It would also serve as a basis for further knowl- edge development related to the person-environment rela- tionship and to the influence of environmental factors on the patient variables and the nurse variable.

In addition to development of a definition, some of the material presented regarding environmental factors needs clarification. For example, 10 basic conditioning factors are identified and grouped into three categories. A list of environ- mental features is also included. There seems to be much overlap between the basic conditioning factors and the envi- ronmental features listed. Examination and synthesis of this material into a more concise description would contribute to the clarity of Orem’s work. This will be particularly useful for nursing work related to caring for families and communities.

The SCDNT addresses the substance of nursing as a body of knowledge and as a field of practice. In terms of the form of nursing science, Orem (1988, 2001) identified nursing as a practical science, meaning that the knowledge is developed and structured for the sake of the work to be done. This view of nursing science reflects the moderate realist position. The practical science of nursing is made up of speculatively prac- tical nursing science, practically practical nursing science, and applied nursing sciences. The speculatively practical nursing science consists of three nursing practice sciences and three foundational nursing sciences. In addition, stages of development of nursing science have been identified. What is needed is the organization of existent knowledge according to the structure identified by Orem. As knowledge is organized, areas requiring additional development and research can be identified and addressed. A body of knowl- edge organized around the nursing practice sciences and foundational nursing sciences will be useful for the educa- tion of nurses and for the provision of nursing care.

Using the Conceptualization of SCDNT for Examination of Healthcare System Factors

The basic conditioning factor of healthcare system factors is useful for looking at the healthcare system. The healthcare system is the environment in which the provision of nursing

care takes place. The Institute of Medicine (IOM) (2001) has called for a redesign of the country’s healthcare system. The need to shift the focus of the healthcare from acute care to the management of chronic health problems has been recog- nized. Six aims for healthcare have been identified: (a) safe, (b) effective, (c) patient-centered, (d) efficient, (e) timely, and (f) equitable. The basic conditioning factor of healthcare system factors presents a useful perspective in terms of mak- ing sense of the anticipated changes.

According to the conceptualization of the SCDNT, the changes in the healthcare system will condition or influence the patient’s therapeutic self-care demand and self-care agency. In relation to a shift in focus from acute care to man- agement of chronic health conditions, it needs to be recog- nized that patients manage their chronic health conditions, not physicians or other healthcare providers. They do this through self-care aimed at meeting the health deviation self- care requisites. Will the changes in the healthcare system influence the self-care requisites or the means by which these requisites can be met? Will the patients need to further develop their self-care agency? From the perspective of the SCDNT, it is nurses who will help patients develop their capabilities to meet their self-care requisites.

The anticipated changes in the healthcare system will also condition the nursing agency of the nurses. The IOM (2001) recommendations for the redesign of the healthcare system are not the only call for change. Benner, Sutphen, Leonard, and Day (2010) called for radical change in the way nurses are educated. This change is needed to prepare nurses to function effectively in an increasingly complex healthcare system. The IOM (2010) just released a report regarding the future of nursing. The report calls for changes in the partici- pation of nurses in the healthcare system. All of these recom- mendations can be examined from the perspective of nursing agency and the conditioning influence of the healthcare sys- tem factors. In terms of adequacy of nursing agency, what level of nursing agency will be required for nurses to func- tion as full partners in the redesigned healthcare system? What capabilities will nurses need to develop in order to pro- vide quality care to persons who have requirements for nurs- ing care? What capabilities will nurses need in order to be leaders in the redesigning of a healthcare system that recog- nizes the value of nursing’s contribution to the health and well-being of the population?

Conclusion The metaparadigm concept of environment as conceptualized within Orem’s SCDNT reflects the philosophy of moderate realism. According to the perspective of the SCDNT, self- care and nursing care are forms of deliberate action. Many of the actions of the patient and nurse are directed at regulating or modifying environmental conditions. A number of environmen- tal factors are conceptualized as basic conditioning factors that condition or influence the patient variables of therapeutic

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self-care demand and self-care agency and the nurse variable of nursing agency. In order to promote greater understanding of Orem’s SCDNT, additional work related to the concept of environment is needed. Using the perspective of the SCDNT to make sense of the healthcare system illustrates the contin- ued relevance of nursing theory.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

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