Bridging gap between Theory and Practice

Background: Nurses are facing many challenges in this competitive era in health care settings and the one biggest challenge among the others is application of theoretical concepts into practice. Moreover, the knowledge about nursing theory and its application into clinical practice is the hallmark of evidence-based practice which is the focus of today’s health care environment. 
Method: A clinical scenario has been analyzed in the light of Nightingales’ theory. Based on the analysis of application of theory into clinical scenario, few recommendations have been set forth to be implemented for better outcomes of health and speedy recovery from illness with minimum risks. 
Results: A detailed analysis of clinical scenario showed explicit gap between actual practice and Nightingales’ theory. 
Conclusion: Florence Nightingale is regarded as a pioneer in the nursing profession. Nightingale has given her notes on nursing in the form of theory of environment which is very useful for nurses to apply those concepts into clinical practice in order to improve health care standards. Application of theoretical concepts in clinical practice would not only improve health outcomes but also minimizes risks and complications.


Clinical scenario
A 54-years-old male has presented in emergency room (ER) with a history of uncontrolled type II diabetes mellitus and hypertension and complain of severe pain in his right foot. On examination, it was identified that he has an abscess on his right foot with gas gangrene. He was admitted for antibiotic therapy and analgesics to relieve pain on immediate basis. He was planned for wound debridement in operating room (OR). His wound was debrided; abscess drained and dressing was applied. Patient was shifted to ward, but he didn't get relief from pain. He was shifted to surgical unit in a general ward where there was no vacant bed so he was lying on stretcher.
Next, a nurse approached the client and introduced herself and asked how could she help him? Next, she proceeded for history and physical examination. By taking history of patient, he stated, he was prescribed for oral hypoglycemic but he did not take on regular basis. There was no record of blood sugar level for last two years. He has no diet plan to control his blood sugar level. His hygienic condition was also very poor. He also stated that his wife is efficient in making different recipes and he enjoyed eating all the day. Patient stated that, "I am not following up my treatment plan because I cannot visit hospital due to transport problem". He stated that "I did not get bath for the last one week since the time I admitted in hospital". He also shared his concerns for his poor hygienic condition with the nurse as he stated, "I cannot move to bathing area and cannot bend to bathing tub and so on". He didn't get sleep enough for the last four days because of pain, fever and environmental change and so on. Patient has presented with continuous fever for the last one week; since he got abscess on his foot. His temperature didn't settle down during his stay at hospital even he took antipyretics for high grade fever. Patient also felt difficulty in moving from one side to another side since he is lying on a stature. On physical examination, the vital signs are: temperature 103F, pulse 110, and B.P 160/100mmHg. His blood sugar level was 567mg/dl.
Nurse has shifted the patient from stature to bed. She took complete history of patient and did physical examination and then developed nursing care plan by incorporating all the aspects of care from patient's own way of choice. She has given towel-bath to the patient as it doesn't need to move patient to bathing area and preserved his dignity. She also encouraged the client to take more fluid intake and kept patient's bed side window open for fresh and cool air to take ease breath and get relief from fever. She put on fan over patient's body. She also kept exposed patient's head, foot and extremities to evaporate heat from body. Moreover, she provided surface cooling by sponge bath for evaporation and conduction of heat. As patient's temperature became normal, nurse wrapped patient extremities by a towel so that he may not shiver due to environmental effect.

Overview of Florence Nightingale's theory Major Assumptions of Nightingale's Theory
Nightingale has focused on the four nursing meta-paradigm concepts in her notes on nursing are as following;

Nursing
Nursing is much different from other health professions. The main target of nursing is to abide the patient in such a state, which suits environment to act upon patient's health and recovery. Nightingale explained the term nursing in different perspectives. She described nursing as an intervention which is for promotion of health. The action for promotion of health can be possible by any person who is supposed to be a nurse.

Person
Nightingale referred the name of person to a patient. According to Nightingale's concept, People have diverse nature of group. Nurse should assess the patient from all perspectives of his health. Nurses should perform tasks for the patient and control patient's environment to enhance recovery. Nurse was taught to inquire the patient about his or her selection, which reveals the belief that Nightingale saw each patient as an individual. Nurses should not take the patient for granted. They should deal the patient as an individual not as a general.

Health
Nightingale proposed that conservation of health is only possible through prevention of disease by strict environmental control and social responsibility. She saw disease and illness as a reparative process that nature instituted when a person did not attend to health concerns. Nightingale considered disease as "the reaction of kindly nature against the condition in which we have placed ourselves" 1 .

Environment
"Poor or difficult environments led to poor health and disease" 2 . Environment could be changed to improve conditions so that the environment would permit healing to occur. Nightingale accentuated that nursing "to assist nature in healing the patient" 3 . Nightingale's notes on nursing contain her philosophical suppositions and opinions regarding all essentials found in metaparadigm of nursing. These essentials used in her conceptual model that has great efficacy in practice setting and bids framework for research conceptualization.

Nightingale's Major Concepts
Nightingale's theory focused on environment, although Nightingale not once used word environment in her notes on nursing. She did define and describe in detail the impression of airing, temperature, light, diet, sanitation, and clamor as constituents of surrounding that have come to be known as environment. She believed that healthy work surroundings were necessary for proper nursing care. Proper ventilation for patient seemed to be of greatest concern to Nightingale; her charge to nurses was "To keep the air he breathes as pure as the external air, without chilling him" 1 .
Nightingale's emphasis on proper ventilation indicates that she seemed to recognize this environmental component as a source of disease and recovery. The concept of light was also important in Nightingale's theory. In particular, she identified direct sunlight as a particular need of a patient.
Cleanliness as a concept is another important factor. In this regard, she specifically addressed the patient, nurse, and physical environment. Even if environment is well ventilated, the presence of organic material created a dirty area. Finally, Nightingale advocated bathing patients on a frequent even on daily basis. And their clothing should be clean, and nurses wash their hands frequently. Furthermore, Nightingale's idea of sanitation and disease prevention is also valued by Monteiro (1985) in reference of importance for public health nursing. Besides this, Nightingale also stressed on respect for every individual's ethnic and cultural background and focused on patients' values and beliefs for therapeutic purposes 4 . Andrew (1992) also supported Nightingale's concept of cultural competent care and states that nurses are the culturally sensitive care providers 5 .
Nightingale also included the concept of quiet and diet in her environmental theory. Nurse was required to assess the need for calm and quiet environment. Nurse should manipulate the environment as needed. She was also concerned about patient's diet. She instructed to nurses not only assess dietary intake but also meal schedule and its effect on patient's health. Another concept of Nightingale's writing was description of petty management. Nurse was to control the environment to protect the patient from receiving upset news, from seeing visitors who could negatively affect recovery.
Nightingale's writing shows three major relationships 1. Environment to patient 2. Nurse to environment 3. Nurse to patient She supposed that environment was the main aspect that produced illness in a patient and she observed disease as "the reaction of kindly nature against the condition in which we have placed ourselves" 1. She analyzed relationship between good environment and healthy status as well as potentially harmful environment and disease process. She focused nurse's practice to manipulate the environment for patient recovery from illness.
According to her discussion, nurse is a key element to control environment according to patient's need. Proper hand washing and cleanliness is also conveyed in her writing for nurse's daily practice. So there is durable relation between nurse and environment.

Ventilation and warming
According to Florence Nightingale's environmental theory, there is a concept of ventilation and warming. The above mentioned clinical scenario is deeply concerned with this concept of nightingale, because of poor ventilation patient had not relieved from fever; even though he is taking oral antipyretic medication for fever in routine as advised by doctor. There should be a proper ventilation to get relief from fever and also for fresh breath to relieve from pain. As nurse opened the window and kept it open for some time; patient has perspired and got relief from fever.

Light and noise
In the above mentioned case scenario, patient didn't sleep well as of noisy environment. It is obligation of a nurse to keep an eye on patient's comfort level, his rest and sleep time. According to Nightingale's theory; as the nurse put off lights of patient's bed side, he took rest and got fresh. He had no other issue related to