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Florence Nightingale and the Environmental Theory

Helen McDonald
NUR 500 Nursing Theory
November 10, 2014
State University of New York Polytechnic Institute Utica Rome

Florence Nightingale is considered the founder of nursing. She felt a calling from God
early on in her life to become a caretaker and pursue nursing, despite her parents suggestion and
popular belief that nursing was not for someone of her class. She revolutionized nursing practice
and education. She advocated for nursing to become a profession. As a theorist she developed the
environmental theory. The theory is well known and practiced by all nurses, worldwide. This
paper will explore who Florence Nightingale was a person and as a theorist. It will investigate
her environmental theory and explain the functionality of the theory today.

Nursing Theorist information
Florence Nightingale was a holistic, creative visionary and innovator for nursing during
her more than 40 years of dedication and work. (Dossey, 2010, p. 15) She was and still is a major
inspiration and influence in the nursing profession. Her work continues to grow nursing as a
profession and respected career for women and men. She made significant modifications in
nursing and health practices that improved outcomes for healing. According to Dossey (2010),
Nightingale is considered the philosophical founder of modern nursing and the first recognized
nurse theorist (p. 14)
Nightingale was born to wealthy English parents in 1820. She was home schooled by her
father and she excelled academically. Her parents held high expectations for her future but as a
teenager she felt a divine calling from God to peruse nursing. (Life of Florence, n.d., para. 1)
Her parents discouraged her from following this future because they believed it was unbecoming.
At the time, nursing was in its dark ages. Nurses were poor, unskilled and were forced to do the
work because of social indiscretion or illegal activity. In 1851, she trained as a nurse in
Kaiserswerth, Germany at Pastor Theodore Fliedners hospital and school for Lutheran
deaconesses. She then trained with the Sisters of Mercy in Paris 1853. (Life of Florence, n.d.,
para. 2)
Nightingale was a nurse, an educator, administrator, communicator, statistician,
environmental activist, mystic, visionary, and healer (Dossey, 2010, p. 14). She developed
healthcare education and in 1860 she opened the Nightingale School in London. This established
nursing education and training model globally. (Selanders & Crane, 2012) She was an active
influence in nursing care protocols and medical reform of British soldiers in the Crimean War.

She innovated statistical wedge diagrams which we continue to use today in circular histograms
and circular statistical representation. She was admitted, as the first women, into the London
Statistical Society. (Dossey, 2010, p. 14) She influenced legislation reforms with papers and
documents supporting midwifery protocols. She developed better hospital data collection
systems and influenced its use with statistical data to influence positive change and better
outcomes. (Dossey, 2010, p. 14) She maintained position in the British Army as a recognized
health expert during her entire working career. She was the first women to receive the Order of
Merit in 1902, as well as numerous other awards. (Dossey, 2010, p. 14) She was an avid writer,
publishing over 100 books, official army reports and 10,000 letters which is the largest private
collection of letters in the British Library. (Dossey, 2010, p. 14) One of her more famous works
was Notes on Nursing written in 1859 which established some environmental hazards.
(DeGuzman & Kulbok, 2012, p. 343) These hazards continue to grow with evolving technology
and environmental changes in the world. (DeGuzman & Kulbok, 2012, p. 342)
Major elements, principles/concepts of theory
One of the first, and most recognized, theories Florence Nightingale developed was the
Environmental Theory. Her initial audience for this theory was not necessarily fixed on nurses as
we think of them today. Her book Notes on Nursing was intended for mothers, daughters, female
domestic servants or anyone whose responsibility or role was caring for the sick. (Davies, 2012,
p. 625) She intended to give hints and suggestions to these women and not directly make a guide
or manual for reference to teach the audience. According to Nightingales preface in the book,
she did not propose to teach nurses to nurse (as cited in Davies, 2012).

Florence Nightingales Environmental Theory was based on the environment and how
creating a specific environment allowed nature to take over and heal the body. (Davies, 2012, p.
625) She hypothesized that the environment played a key role in influencing the body to heal and
that illness was produced by environmental factors. She integrated the most basic needs of
humans into her work. (Dossey, 2010, p. 14) Her focus was on factors such as; ventilation,
temperature, noise, nutrition, bedding, light, cleanliness, personal hygiene, the hygiene of other
members in the household as well as their health and wellbeing that affected the individual.
(Davies, 2012, p. 625) These concepts were produced by her experience and observations
working with cholera patients during the 1854 epidemic, as a Superintendent and as a nurse in
the Crimean War from 1854-1856. (Davies, 2012, p. 625)
Nightingale encouraged the nurse to brighten the room of the sick. She said the room
should be attractive with pictures or plants. The patient should be able to look out the window at
nature. The atmosphere should be calm and quiet. Talking should be limited to exclude
conversation about the patients illness. The floor should not creek and the sound of walking
should not be heard. Clicking heals or shoes should not be worn. Food should be offered that is
appealing to the patient with variety. The patient should be able to eat whatever they feel like
having. This is because the body knows what it wants and needs and the patient will crave for it.
(Davies, 2012, p. 625)
Conditions where this theory has been operationalized
For the past 50 years, Florence Nightingale has influenced American nursing
philosophical and theory development. (Diener & Hobbs, 2012, p. 35) Nightingales

environmental theory has been used internationally and globally. The practice of the theory has
become second nature and during the 21st century it is often over looked.
Nightingales focused on environmental therapies such as; music, aromatherapy, touch,
pet therapy, light therapy, nutrition and exercise. (Dossey, 2010, p. 14) These focuses are still at
use today to improve patient outcomes. Hospice nurses incorporate the use of these therapies in
practice to improve the mental health and wellbeing of their patients.
Patient satisfaction surveys, such as the Press Ganey and Hospital Consumer Assessment
of Healthcare Providers and Systems (HCAHPS) focus parts of their surveys on environmental
factors from Florence Nightingales theory. These questions include how the patient rates the
cleanliness and noise levels of the environment. These consumer reports are used to compare
hospitals against each other. They are also used to help hospitals improve their health care
quality and environmental quality. (Hospital Consumer Assessment, n.d.)
Physical environments in the hospital are constantly being reformed to include the
practice of the theory. Physical atmosphere changes are made to create therapeutic work
environments as well as for the healing of patients. Walls are painted in soothing coolers.
Lighting is used consciously to provide optimum environments with changes in brightness
throughout the day. Calming music is used in both the patient rooms and work environments.
(Davila, Merrill & Baize, 2010, p. 46)
The theory is used in surgical services and hospital practices. A clean or sterile
environment is particularly important in prevention of the spread of pathogens and prevent
surgical wound infection. (Spruce, 2014, p. 139) The surgical and hospital staff needs to adhere
to cleanliness and wear clean attire. This includes use of hair nets, masks, eye protection and use

of clean scrubs and lab jackets. (Spruce, 2014, p. 139) Uniforms or scrubs should never be
reused and should be washed daily. Spruce (2014) suggests that laundry serves provide the best
means for effectively cleaning compared to using home washers and dryers. (p.139)
Major theoretical concepts and assumptions underlying these concepts
Nightingale refused to recognize the theory of contagion or infecting germs. She believed
that she saw diseases developing on their own due to lack of air, light and improper diet.
(Benedict, 2012, p. 19) She noted, graphically, how soldiers were dying from disease; such as,
typhus, typhoid and cholera. She noticed, during her work at Scutaria Hospital, the sewers
underneath the hospital were clogged with filth and the hospital was on top of a cesspool.
(Davies, 2012, p. 625) Nightingale believed in maismatism, an inaccurate theory that foul odor
caused disease. (Selanders & Crane, 2012) She therefore believed the toxic smell from the filth
of disease and mortality in the sewer were causing the spread of disease and death. (Davies,
2012, p. 625)
Its believed that the Victorians feared noxious smells and this was the foundation of
Nightingales idea of proper ventilation as well as clean and fresh air. Victorians were surrounded
by smells regardless of social status caused by inadequate sewers, and horse droppings. She
proposed then that windows needed to be open in the home of a sick person to allow fresh are to
sweep through and clean the area of illness; chamber pots and slop pails also needed to be
removed from the room to keep the air fresh and free of noxious smells. (Davies, 2012, p. 625)
From this, she proposed five vital points for a healthy home; pure air, pure water, efficient
drainage, cleanliness, and light. (Davies, 2012, p. 625)
Relating concepts to nursing metaparadigm

The nursing metaparadigm is comprised of four components; nursing, the person, the
society/environment, and health. (Chinn & Krammer, 2011, p. 45) The nursing component is
related to helping with interpersonal interaction between the nurse and an individual. (Chinn &
Krammer, 2011, p. 46) Medical task is integrated with primarily interpersonal interaction which
includes assessment, diagnosis, and medication administration. The interaction with the patient
differentiates nursing from other medical professions. (Chinn & Krammer, 2011, p. 46)
Nightingales theory engages the patient and the care taker in their own health promotion. The
nurse and the patient work closely together. Nightingale described nursing as a close relationship
with healing nurse-patient relationships (as cited in Diener & Hobbs, 2012, p. 35) She believed
it was the nurses role to provide an environment that enriched the bodys natural ability to heal.
(Davies, 2012, p. 625) She believed nurses should follow rules and be obedient. She felt they
should have autonomy to advocate for the patient and the nursing profession. (Selanders &
Crane, 2012)
The person component is the dimension wholeness. The person is seen as a sum of all its
parts and dealt with in a holistic approach. The person has a genetic makeup, role function, a
societal and cultural structure framework, interpersonal relationships, human experiences and
basic needs. All these parts are interrelated and work together and therefore all need
consideration when working with the person. (Chinn & Krammer, 2011, p. 46-47)
The society and environment component have heavy influences on the person and the
nurse together. The society and culture help determine the individuals belief in health and
healthy lifestyles and determine how much weight is placed on good health. Nightingales
primary focus and influence for her theory was on the environment. (Chinn & Krammer, 2011, p.

47) She believed the best way to heal and promote health was to alter the physical environment
for optimum condition for nature to repair the body. (Chinn & Krammer, 2011, p. 47)
The health component is the goal of nursing. (Chinn & Krammer, 2011, p. 47) Nursing
works within a health-illness continuum with different levels of prevention promotion and
healing. Health varies with time, age and life circumstance. (Chinn & Krammer, 2011, p. 48)
Florence Nightingale saw that health should be a priority for everyone. (Dossey, 2010, p. 15) She
believed that competent nursing care was a basic human right for all people. (Selanders & Crane,
Usefulness of theory and concepts to practice, education and leadership
The student nurse is taught early on about Nightingales environmental theory. They are
also taught how to implement the theory in their own practice. It is one of the basic nursing
knowledge sets that all other nursing education is built on.
One of Nightingales philosophies to empower the professional nurse was that decisionmaking should be based on empirical observation of the patient. (Selanders & Crane, 2012) The
nurse needs to make observations about the patient and the surrounding environment. The
observations can then be used to determine effective environmental interventions or nursing care
plan to produce positive patient outcomes.
Example of theory used in research of practice, education or leadership
The American Holistic Nurses Association (AHNA) utilizes Nightingales theory to
examine ideal healing environments. (Dossey, 2010, p. 15) Factors in the manmade environment
can influence the safety, health and wellbeing of the public. These include the presence, absence


and condition of sidewalks, handicap accessibility, cleanliness and maintenance of public spaces,
safety and security systems, and population size. Geographic information systems (GIS) have
allowed objective comparisons of these environment features and has helped link the
environment to diseases such as obesity, diabetes and cardiovascular disease. Links to
environmental causes of disease can help nurses advocate for changes in the communities
environment to improve the health of the community. Currently, there has not been enough
research to (DeGuzman & Kulbok, 2012, p 341, 346) The nurse could complete a study based on
this framework and make a compelling argument to local and state government and legislators to
advocate for changes in public environments. This would be an example of using the
environmental theory in research, practice and leadership. This would also educate the officials
in legislation and the public about the fundamental bases of nursing.


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