FLORENCE NIGHTINGALE

ENVIRONMENTAL THEORY

Background

 Florence Nightingale was born in Florence, Italy on May 12, 1820

 As she grew up, her father provided her with a very broad education. She was a part of a wealthy
family
 She was a British social reformer who founded modern nursing
 On 1851 - Florence Nightingale went to Kaiserwerth, Germany for training as nurse
 1854 - Florence Nightingale and 38 volunteer nurses were sent to Scutari to assist with caring of
the injured at the Crimean war
 Wrote “notes on Nursing” on 1859
 Often considered as the first nurse theorist and first nurse researcher
 Defined nursing as “the act of utilizing the environment of the patient to assist him in his
recovery‟‟
 She died in August 13, 1910

Major works

 Her biggest contribution was her unrelenting care given to the soldiers of the Crimean War even
though it took a toll on her own health
 She published two books to spread her ideas and opinions on reforms, namely „Notes on
Hospital‟ (1859) and „Notes on Nursing‟ (1859)

Evolution of Nightingale’s Theory

 Early in her work at the army hospital Scutari, nightingale noted that the majority of the
soldier’s deaths was caused by the conditions of hospital itself
 Nightingale found that open sewers and lack of wholesome food were more often the cause
of soldier’s death than their wounds; she implemented change to address these problems
 Nightingale instituted a system of care that reportedly cut casualties from 48% to 2% (George,
2011)
 This success gave her a strong data base on which to view nursing in her own unique way

Origin of Nightingale's Theory Concepts

 She believed that the environment could be altered to improve conditions so that the natural
laws would allow healing to occur
 This grew from empirical observation that poor or difficult environments led to poor health,
disease
 In her Crimean experiences, filth (dirt), inadequate nutrition, dirty water and inappropriate
sewage disposal led to the situation in which more soldiers died in the hospital than of the
battlefield wounds
Assumptions

 Natural laws
 Mankind can achieve perfection
 Nursing is calling
 Nursing is art and science
 Nursing is achieved through environmental alteration
 Nursing requires a specific educational base
 Nursing is distinct and separate from medicine

1. Natural Laws

 They are universal natural laws that govern the ways in which the world works. This is reflective
of Nightingale‟s profound belief in God
 She defined a law as “the thought of God” and discussed the predictability of nature

2. Mankind can achieve perfection

 This relates to her strongly held beliefs in self-determination, in self-realization, and that
ultimately, mankind does seek self-perfection, which means perfect health
 The route to perfection is through strict adherence to the natural laws
 The role of the nurse is to alter the environment in such a way as to obey the natural laws, and
thus provide the environment in which perfection might be achieved

3. Calling

 She defined a calling as doing work in such a way as to do what is right and best
 Nursing work is to be done with enthusiasm, and is so important it should be thought of as a
religious vow

4. Nursing is art and science

 By identifying nursing as having components of art and science, she provides the profession with
the expectation that nursing will be practiced by educated individuals using current research
and methods as well as compassion and common logic

5. Nursing is achieved through environmental alteration

 The core concept that is most reflective of Nightingales writings is that of environment
 Defined nursing as “the act of utilizing the environment of the patient to assist him in his
recovery”

6. Nursing requires a specific educational base

 Nursing cannot be taught by books alone

 Nurses need a combination of clinical and theoretical training

7. Nursing is distinct and separate from medicine

  Although the physician and nurse may deal with the same population, nursing is not to be viewed
as subservient to medicine, as the purposes of the two are distinctly different
 Nursing‟s focus is on caring through environmental alteration, whereas medicine‟s focus is cure
of the disease. Nursing and medicine are most effective when working in a collaborative manner

Nightingale's Environment Concept

 Environment reflects the core of her theory

 The environment is viewed as all the external conditions and influences affecting the life and
development of an organism and capable of preventing, suppressing or contributing to the
disease or death
 Nursing is a noncurative practice in which the patient is put in the best possible condition for
nature to act
 So, Nightingale focus on providing such things such as ventilation, clean air, water and
cleanliness as well as warmth so the reparative process that nature has instituted will not be
hindered
 The environment elements that disturb health are: dirt, dampness, chills, smells and dark

Nightingale’s Thirteen Canons

1. Ventilation and warmth

2. Health of houses

3. Petty management

4. Noise

5. Food intake

6. Food

7. Variety

8. Light

9. Bed and bedding

10. Cleanliness of rooms and walls

11. Personal cleanliness

12. Chattering hopes and advices

13. Observation of the sick

Major areas for concentration

Five components for healthy environment

  Proper ventilation
 Adequate light
 Sufficient warmth
 Control of effluvia
 Control of noise

Proper ventilation

 Fresh air, which is primary, can be achieved through open windows

 Stagnant and musty air breeds disease.
 Impure air need to be outlet, drafts from open window and door to be avoided and also dirty
furniture and carpet impure air

Warmth

 Vital heat should not be lost, which is essential to patient‟s recovery

 Therefore chilling to be avoided and hot bags, bricks, and drinks should be used to restore heat.

Effluvia (smells)

 Noxious body odours caused by disease to get rid of by providing care

 Utensils need to be odour free and out of sight
 Instead of using disinfectants offensive substance to be removed and sewer air is to be avoided

Noise

 The more the patient sleeps peacefully, the greater his ability to recover
 Therefore, whispering, walking lightly, or discussing a patient‟s condition just outside his room is
to be avoided, because intermittent sudden noise causes greater excitement than continuous noise

Light

 Light value second only to the need of fresh air

 Beds should be placed in such a position as to allow the patient to see out the window- the sky
and sunlight
 Nightingale discussed three type of environment: physical, psychological, and social. She put
more focus on physical environment
Nightingale’s Environmental Theory Model

Physical Environment

Health of houses, ventilation and warming, light, noise, bed and bedding, cleanliness of rooms and walls,
personal cleanliness, nutrition and taking of food

Psychological Environment

 Communication
 Advice
 Variety in environment

Social Environment

• Mortality data especially generations of families lived and died in poverty and prevention of
disease by organizing hospitals and house clean with appropriate supplies
Metaparadigms

Nightingale did not invent or define the four major concepts used to organize nursing theory

They evolved from the analysis of nursing curricula (Falco, 1989) as cited in (George, 2011)

1. Person

 Nightingale referred person as the patient. Human being is acted upon by the nurse and affected
by the environment
 He has vital reparative powers to deal with disease
 Recovery is within the patient's power as long as a safe environment for recuperation (healing)
exists

2. Nursing

 Nursing is a discipline distinct from medicine, The goal of nursing is to place the person in best
possible condition for nature to act
 Nursing ought to signify the proper use of fresh air, light, warmth, cleanliness , quiet and proper
selection and administration of diet for gaining vital power to the patient
 Nursing facilitates a person's reparative process by ensuring the best possible environment

3. Health

 Health is maintaining wellbeing by using a person's power to the fullest extent

 Health is maintained by controlling environment factors to prevent diseases

4. Environment

 Environment serves as the foundation of Nightingale's theory

 It involves those external conditions that affect the life and the development of the individual
 It includes everything from a person's food to a nurse's verbal and nonverbal interactions with the
person
 Nightingale writing reflect a community model in which all that surrounds human being is
considered in relation to their state of health

APPLICATION OF NIGHTINGALE’S THEORY IN NURSING SCOPE

A. Practice

 Nightingale‟s nursing principles still remain applicable today

 The environment aspect of theory remains as integral component in our current nursing
 As nurses approach practice in 21st century, the concepts continue to be relevant
 Modern sanitation and water treatment have fairly successfully controlled traditional sources of
disease, but contaminated water has again became a health issue for many communities in the
world
  Disposal of waste, including toxic wastes and use of chemicals also challenge health care
professionals to reassess the concept of healthy environment.

 Although such issues have been increasingly addressed by other disciplines, it is clear that nurse
and nursing play active role in providing direct care and ensure healthy environment for citizens

B. Education

 Nightingale‟s principle of nursing training provided a universal template for early nurse training
schools beginning with St. Thomas Hospital and Kings College Hospital in London
 With the Nightingale‟s model use as a guide three experimental schools established in United
States in 1873
 Nightingale believed that measurement of art of nursing could not be accomplished through
licensing examination but using test methods, including case studies
 Nightingale believed that good practice could result only from good education(training)
 The influence of training system and many of the principles can be still found in nursing program
today
 Nightingale advocated the nursing school‟s independence from a hospital so that the nursing
students would not be involved in hospital labor pool as a part of their training

C. Research

 Nightingale‟s theory cannot generate the nursing research used to test the modern theories but
her concepts have served as the basis for current research, which adds to modern nursing
science and practice
 Nightingale use brief case studies to illustrate a number of concepts that she described in her
“Notes on Nursing”
 The content seems most amenable to theory analysis
 Then, Nightingale formulated the “Grand Theory” that explains the totality of behaviors but the
Grand theory somewhat tend to be vague without specific definition of concept and relationship
between concepts
 Nightingale used brief case studies to illustrate a number of concepts
 Scholarly nurses have refined this technique for inclusion in text and research studies; such style
thus has an auspicious history in nursing literature

Nightingale’s Theory and the Nursing Process

1. Assessment

 In the assessment of the clients, nightingale advocated two essential behaviors by the nurse
 The first is to ask the client what is needed or wanted
 The second area of assessment that nightingale advocated was the use of observation, she used
precise observations concerning all aspects of the clients physical health and environment
 Nurses make the observation because clients may be too weak or shy to tell them
 Observations revolve around nightingale‟s environmental model , that is, the impact of the
environment on the individual
  For example, how to light , noise, smells, and bedding affect the patient?

2. Nursing Diagnosis

 Nursing Diagnosis are based on analysis of the conclusions gained from the information in the
assessment
 Nightingale believed data should be used as the basis for forming any conclusion
 It is important that the diagnosis be the client’s response to their environment and not the
environmental problem
 Nursing diagnosis be the client‟s response to their environment to the health and well being of the
client

3. Planning

 It includes identifying the nursing actions needed to keep clients comfortable, dry, and in the
best state for nature to work on
 Planning is focused on modifying the environment to enhance the client‟s ability to respond to the
disease process

4. Implementation

 Implementation takes place in the environment that affects the client and involves taking action
to modify that environment
 All factors of the environment should be considered, including noise, air, odors, bedding,
cleanliness, light, and variety- all the factors that place clients in the best position for nature to
work upon them

5. Evaluation

 Evaluation is based on the effect of the changes in the environment on the client‟s ability to
regain their health at the least expense of energy
 Observation is the primary method of data collection used to evaluate the client‟s response to
the intervention

Application of Nightingale’s Theory in the Nursing Process

Mrs. Samjhana Gurung, age 48 years, has been admitted in female medical ward of morang sahakari
hospital with a diagnosis of fever. She had complaints of fever with chills and rigor, headache, malaise
and anorexia. She was in hospital for 2 days. Her lab report shows plenty of pus cells in urine RE and
waiting for blood and urine culture report, chest x-ray shown normal findings

Assessment

1. Physical Environment

 Presence of proper ventilation, but the environment is cool (ventilation)

 Having proper light but no direct sun light to the bed (light)
  Well facility for hot water but without purification (health of houses)

 Having only one piece of biscuit with milk, one full cup of dal and 1 glass of plain water during 6
hours period (nutrition)
 Bed is clean & tidy but presence of food particles and cover of medicines, pieces of papers and
dust inside the locker (bed and bedding)
 Ward toilet drainage system is good but presence of food particles and dust in the pan & around
the pan (health of houses)
 Room environment is clean and ward is swiped frequently (cleanliness of rooms and walls)
 Patient bed is near nursing station (noise)

2. Psychological Environment

 Patient has never been admitted in hospital before

 Feeling uncomfortable and unable to sleep well
 She is very active woman and feels her time is wasted since the admission

3. Social Environment

 Patient told that her home environment is clean

 No history of illness like her in the family or neighborhood

Nursing Diagnosis

 Altered body temperature (101˚F) related to infection

 Altered nutrition less than body requirement related to inadequate intake of food
 Sleep disturbance related to strange and noisy environment
 Risk for infection related to unsafe drinking water, dust from locker, dirt from sink and outside of
the room (poor environmental sanitation)

Nursing Goal

 Temperature will be reduced to 99 ˚F within 20 minutes

 The patient‟s nutrition will be maintained during hospitalization
 The patient will have sound sleep at night for more than 6 hours
 The patient will be free from infection during hospital stay

Nursing Interventions

1. Reduce body temperature

 Maintain cross ventilation by opening doors and windows

 Remove the extra clothes and blankets.
 Provide cold sponge
 Provide plenty of fluids to drink

2. Maintain nutrition:
  Encourage patient for oral care
 Provide adequate diet by encouraging small frequent and nutritious feeding

3. Maintain sound sleep:

 Keep the patient in calm and comfortable position

 Avoid unnecessary stimulation and noise
 Keep the patient away from nursing station

4. Infection prevention

 Dispose waste properly

 Provide purified & boiling water for drinking according to patient demand
 Clean the locker routinely and keep all medicines in small paper box or medicine bag
 Inform visitor for proper waste disposal
 Keep the surrounding clean
 Provide sufficient support and advice related to disease process, diet therapy

Evaluation

Evaluation can be done through

 Vital signs of patient will be maintained within normal limits, weight maintained, patient feels
comfort as verbalized by sound sleep during days of hospitalization, no sign of infection
exhibited after nursing intervention

Strength and Limitation

Strength

 Nightingale‟s theory has been used to provide general guidelines for all nurses

 The relation concepts (nurse, patient and environment) are applicable in all nursing settings
today

 The ideas are basically simple to apply and easy to measure in terms of outcome
 The universality and timelessness of her concepts remain pertinent even today (hospitals, nursing
homes, schools, the individual homes) as before
 We are increasingly becoming aware of how environmental pollution affects our health in
negative way. For this reason we should give validity to this theory
 The assumption that the environment affects human is consistent with Nightingale explanation of
the purpose and goal of nursing and meaning of health

Limitations
 o Nightingale‟s theory are presented as truths rather than tentative, testable statements

o She advised nurses that their practice should be based on their observation and
experiences rather than systematic, empirical research

 She only focused on physical environment but other variables of human environment are
ignored e.g. genetic makeup ,psychosocial environment
 She rejected the germ theory and only relying on personal observation and experience
 The concept of “Nature alone cures” may be changed nowadays
 Deeply religious, she viewed nursing as a means of doing the will of God (Nursing is a divine
calling)
 She focused more on physical factors than on holistic concept of care of nowadays

Summary

 Nightingale‟s major focus was on the patient.

 Nursing was viewed as distinct from medicine and focused on providing an environment that
allowed nature to act on behalf of the patient
 Environmental factors involved clean air and water, control of noise, proper drainage, reduction
of chills, and a variety of activities
 She discovered thirteen canons of environment and explained five components for a healthy
environment
 Nightingale emphasized fresh air as primary and good lighting as secondary to the effective care
of the patient. Other theories most closely related to her writing are adaptation, need and stress
 In utilizing her theory within the nursing process, the focus is on how the environment affects the
patient
 Implementation involves adjustments to inadequate environments
 Nightingale‟s theory is as appropriate today as a theoretical base for practice as it was during her
time of practice in the mid-1800s
 It is the foundation on which all the other theories in nursing should be viewed

References

Adikari, R. D. (2010). Nursing Theories and Models (2nd ed.). Kathmandu:Makalu Publication House

Afsha, A., & Dildar M. (2016). Application of Nightingale Nursing Theory to the care of patient with
colostomy. European Journal of Clinical and Biomedical Sciences,
6(2),97101.doi:10.11648/j.ejcbs.20160206.17

Basavanthapa, BT.(2007). Nursing Theories (1st ed.). New Delhi: Jaypee Brother (P) Ltd.

Beatriz, A., & Brandao, A. (2015). The Florence Nightingale‟s Environmental Theory:A Critical
Analysis. Escola Anna Nery Journal, 19(3),doi: 10.5935/1414-8145.20150069

Gorge, J. B. (1991). Nursing Theories the Basic for Professional Practice (3rd ed.).Pearson, India.
Gorge, J. B. (2011). Nursing Theories the Basic for Professional Practice(6th ed.). India: Dorling
Kindersely Pvt. Ltd.

Rai,L.(2011). Nursing Concept Theories and Principles. (2nd ed.). Udaypur.

Sabza, S. & Pirani, A. (2016). Application of Nightingale‟s Theory in Nursing Practice. Ann Nurse
Practice. 3(1).

Terri Z. (2014). The Legacy of Florence Nightingale's Environmental Theory: Nursing Research
Focusing on the Impact of Healthcare Environments. National Institute of Health. 7(4).

Tomey, A. M. & Alligood, M. R. (1998). Nursing Theorists and Their Work. (4th ed.). Missouri: Mosby