Surgical Site Infections (SSIs) account for 38% of nosocomial infections, and it is estimated that between 2% to 5% of the over 30 million patients who undergo surgery annually experience SSIs. The patient’s risk of developing SSIs is influenced by their postoperative environment, which encompasses the time from leaving the operating room (OR) until their final follow-up appointment with the surgeon. This duration can range from one week to several months (Brunner & Suddarth, 2008).
During the postoperative period, nursing care aims to restore the patient’s physiological equilibrium, relieve pain, prevent complications, and educate the patient about self-care (Brunner & Suddarth, 2008). A thorough assessment and prompt intervention are crucial for the patient’s quick and safe return to optimal function. According to The American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS), there has been a significant shift in the reasons for tonsillectomies in children over the past 30 years. Previously, approximately 90% of these surgeries were performed due to recurrent infection, but now it only accounts for about 20%. The majority of tonsillectomies (80%) are currently conducted to address obstructive sleep problems (OSA).
The rise in tonsillectomy rates is a significant trend in modern surgery, with an estimated 200,000 surgeries performed annually in the United States. Tonsillectomies account for approximately one-third of all operations conducted under general anesthesia. Additionally, there are notable factors related to age, geography, and social distribution that have prompted the Section of Epidemiology to dedicate an evening to studying this phenomenon.
According to Glover (2008), Nightingale’s theory places importance on environmental aspects such as ventilation, warmth, quiet, diet, and cleanliness. These elements continue to be integral components of present-day nursing care. Even in the 21st century, these concepts remain significant as society faces new challenges in disease control. For example, measures such as sanitation and water treatment help control the spread of diseases. In healthcare settings like clinics and hospitals, regulating room temperature for individual patients is also considered crucial. Despite advancements in technology for recovery, the environment still plays a vital role.
The theory of Florence Nightingale has been influential for many years and is still relevant today, albeit with some exceptions. Nightingale’s concept of the nurse, patient, and environment continue to be applicable in all nursing settings. She believed that disease was a natural response to poisoning or decay, or a reaction to unfavorable conditions.
Nightingale did not explicitly define nature in her writings. She frequently capitalized the word nature, implying its equivalence to God. However, when she used nature without capitalization, it is unclear if she intended a different meaning, potentially related to an organic pathological process. Nightingale believed that nursing’s role was to prevent any disruption to the reparative process and create ideal conditions for its improvement. She emphasized the importance of nurses being proficient in observing both their patients and the surrounding environment.
According to Nightingale, individuals have a desire for good health and would work together with the nurse and nature to facilitate healing or make changes to their environment to prevent illness. Nightingale firmly believed in the power of environmental modifications to prevent diseases, which is still a fundamental principle in modern sanitation practices (Octaviano & Balita, 2008). As nursing moves towards a caring approach, nurses are actively seeking innovative methods to create healing environments for patients, while also drawing upon nursing origins for guidance and knowledge.
The researcher, an infection control nurse at a regional hospital, was interested in investigating the efficacy of Nightingale’s theory, which suggests that her approach could aid in combating infection in contemporary healthcare facilities. Additionally, the researcher aimed to ascertain the feasibility of implementing Nightingale’s strategies within the context of the present-day hospital setting. Nightingale’s theory emphasizes the integration of mind, body, and spirit with environmental factors such as auditory, visual, olfactory, sensory, tactile, and cognitive modalities, forming a theoretical framework for implementing compassionate and healing practices in a transpersonal caring model. (Schmock, 2009)
This study aims to apply the environmental factors of Florence Nightingale to post-tonsillectomy patients in order to expedite recovery, reduce costs, and decrease the likelihood of readmission. The general statement of the problem is to determine the implementation of Florence Nightingale’s Environmental Theory on a post-tonsillectomy patient in September 2013. The specific objectives are to answer the following questions: 1. What is the complete health history of the post-tonsillectomy patient? 2.
What is the current situation of the environment for post-tonsillectomy patients in regards to: a. Ventilation & Warmth b. Light c. Cleanliness d. Health of Houses e. Noise f. Bed & Bedding g. Personal Cleanliness h. Variety i. Chattering Hopes & Advices j. Taking Food k. Petty Management l. Observation of the Sick.
What nursing and applied interventions are designed for the aforementioned environmental aspects?
How does the aforementioned environmental aspects influence the recovery of post-tonsillectomy patients? Significance of the Study
The study is beneficial to both the Post-tonsillectomy Patient and their Family. The patient will experience faster recovery during a critical phase of their hospitalization, enhancing their natural recovery using environmental factors and reducing additional hospitalization costs. The patient’s family will also benefit from this study as they will be educated on how to utilize the hospital and home environment to aid in the patient’s recovery, as they have close contact with the patient.
This study has implications for healthcare providers in terms of improving the external factors of the environment that could impact patients and their healing process. It serves as a foundation for patient care and promoting faster recovery. Nursing educators can also benefit from this study as it provides insights into environmental interventions for optimal health recovery. Additionally, future researchers can use this as a reference for their own studies, and nursing instructors can incorporate it into their lectures.
Researchers can benefit from this study by comparing and correlating findings and recommendations relevant to their own study. Community leaders can also find this study helpful in addressing concerns related to health, sanitation, and other environmental aspects in their communities. By being educated with this study, community leaders can educate the population about the importance of maintaining sanitation and hygiene in their own homes and surroundings, as well as inform family members who may require hospitalization.
Hospital Administrators are required to have knowledge about the optimal layout of hospital wards for the benefit of patients who are considered the institution’s priority. This study is particularly advantageous for Nursing Service personnel as it focuses on nurses’ implementation of the theory in patient care. The study’s scope and definitions of terms are discussed in Chapter 2, which includes a review of related literature.
This chapter presents the theoretical framework, conceptual literatures, and research studies that are relevant to the project paper. It includes the researcher’s viewpoint on concepts and studies that are considered important for the current study in terms of content, methodology, and procedures. The researcher’s analysis of the reviewed materials also serves as a basis for analyzing her own data and generating interpretations and recommendations based on the data results. There were multiple literatures related to Nightingale’s Environmental theory.
According to Dr Jack Gilbert, Florence Nightingale’s nursing skills were developed on the dirty and disorderly battlefields of the Crimean war. However, he claims that she could still provide valuable lessons in infection control to modern hospitals. Dr Gilbert, who leads an international project to classify all known microorganisms, suggests that hospitals could reduce infection rates by being slightly less focused on sterility. He believes that overly sterile conditions in wards and operating theatres might be harmful as they eliminate organisms that naturally prevent the growth of dangerous microbes.
Dr. Gilbert explained that opening windows in wards can increase the number of beneficial bacteria, which play a crucial role in controlling harmful microorganisms. He emphasized the presence of a thriving bacterial community in hospitals, and warned against using excessive antibiotics and sterilization agents as they can eliminate this protective layer. In the absence of beneficial bacteria, harmful bacteria can easily proliferate and cause infections in hospitals.
Florence Nightingale emphasized the significance of allowing fresh air in patients’ rooms and keeping their windows open in her 1860 work, “Notes on Nursing.” Recent research conducted by scientists at the University of Oregon showed that clinics with open windows exhibited a greater diversity of bacteria compared to those with sealed windows, which had a higher proportion of potentially harmful germs. Prof Mark Enright, a microbiology expert at Bath University, acknowledged the importance of maintaining good air flow in hospitals but cautioned against labeling them as excessively clean.
(Collins, 2013) The concept of the environment influencing healing has been acknowledged since Florence Nightingale (1970), a notable figure in nursing, cared for soldiers during the Crimean War. Presently, modern critical care units are being planned to promote healing using a comprehensive approach that considers the needs of patients and their families. The connection between humans and the different environments they encounter has long been recognized. Florence Nightingale was famous for her focus on hygiene and other environmental elements that contribute to the health and recuperation of patients.
She was a leader in improving sanitation and ventilation, as well as bringing forth the body-and-mind connection. She recognized the importance of the environment in a patient’s healing process. Nightingale influenced healthcare by changing the patient’s visual perspective, using color and natural light effectively, and reducing excessive noise. She passionately believed that nurses should create an environment that promotes healing. Environmental Noise
“Unnecessary noise, or noise that creates an expectation in the mind, is that which hurts a patient. Such unnecessary noises undoubtedly induced or aggravated delirium in many cases.” (Nightingale, 1970) Noise is a pervasive environmental stressor that exists in the hospital setting. In various hospital wards, examples of unpleasant noises include the buzzing of medical equipment, gurgling of chest tubes, discussions between staff members, the sound of pagers and intercom systems, the ringing of telephones, the opening and closing of doors, cabinets, and supply carts, and even the clattering noises produced by the wheels of passing carts.
Creating a healing environment in the critical care setting involves addressing unfamiliar and surprising noises that can be distressing, especially for patients already under physiological strain. To achieve this, various design elements need to be taken into account, including flooring, ceiling material, and the placement of doors and nursing stations (Mazer, 2002).
To establish a healing environment among the staff, it is important to promote behaviors that reduce excessive noise. This can be achieved by keeping hallway conversations at a low volume, particularly during nighttime. Over-the-bed conversations should be avoided, and pagers should be set to vibrate mode. It is also advisable to refrain from using overhead paging and to turn off any unused biomedical equipment. Additionally, equipment that emits unnecessary loud noise should be adjusted or repaired as needed (Petterson, 2000). Another crucial aspect is providing adequate access to natural light for patients, as it is second only to their need for fresh air. Direct sunlight is particularly beneficial.
According to Nightingale (1970), the importance of light in treating diseases is crucial. Light, similar to sound, can have favorable or unfavorable impacts on both the body and mind. All living organisms require light for survival as it helps regulate the 24-hour circadian rhythm. Natural light or full-spectrum light is considered ideal due to its healing properties, which explains why it is incorporated into various disease treatment methods. Different types of light are accessible and researchers are exploring diverse therapies centered around light.
Researchers at the Baylor Research Foundation are currently conducting a study on the use of photodynamic therapy for treating viruses. They are also exploring the potential of light therapy for seasonal affective disorder and insomnia (Starkweather et al., 2005). With technological advancements, smaller components and systems, and a variety of lighting options, there are now multiple choices for lighting available. This makes it easier to meet the lighting requirements of patients and caregivers. The Importance of Color in the Environment
“Although our limited understanding acknowledges that form, color, and light have a tangible physical impact on us, some believe it is solely psychological. However, these elements actually affect our bodies as well. Introducing patients to diverse forms and vibrant colors can be beneficial for their recovery.” (Nightingale, 1970) The interdependence of light and color implies they cannot exist separately; instead, they mutually enhance vitality and liveliness.
In the visible spectrum of light, there are seven colors: red, orange, yellow, green, blue, indigo, and violet. All of these colors are present in visible light. The body and mind’s reaction to color is affected by cortical activation, the autonomic nervous system, and hormone activation. Color evokes emotional responses that can result in feelings of calmness or agitation and can either increase or alleviate stress levels. Additionally, color has the ability to influence an individual’s emotional state by inducing cheerfulness, agitation or calmness (Starkweather et al.).
Nightingale allegedly employed vibrant flowers as a means of therapy to aid in recovery. Throughout history, different civilizations have utilized color for its therapeutic properties. Color possesses electromagnetic energy that can have a healing impact comparable to that of sunlight. The discipline of chromotherapy implements color as a therapeutic instrument in the treatment of diverse ailments (Fontaine et al., 2001). Scientific research is still in its early phases in exploring the healing potential of color. By incorporating color intentionally, it is possible to supplement the existing lighting in patient rooms and foster a healing environment.
Environmental Landscape “That they [patients] should be able, without raising themselves or turning in bed, to see out a window from their beds, to see sky and sunlight at least, if you can show them nothing else, I assert to be, if not of the very first importance for recovery, at least something very near to it. ” (Nightingale, 1970) Staring at the same four walls can negatively impact a patient’s recovery just as much as the disordered environment in critical care.
In order to create a healing environment in critical care, it is important to consider both the design of the physical space and the emotions of the individuals within that space. Ulrich’s groundbreaking study in 1984 discovered that patients who had a view of a window recovered faster after surgery compared to those without a view. This indicates that modifying the healthcare environment can decrease stress and have a beneficial impact on medical outcomes, such as quicker recovery, shorter hospital stays, and reduced costs.
Air Quality is crucial for patient care. It is essential to maintain pure air for the patient, as stated by Nightingale (1970). The sense of smell is closely tied to the environment, and scents can evoke physiological responses and feelings. Buckle (2001) notes that scents can stimulate the olfactory system and elicit immediate reactions.
The role of smell in human perception and reaction to environments is important. The smells commonly associated with hospitals can create strong reactions, causing anxiety and increasing heart rate and respiration. These reactions can be triggered by the basic medicinal smells present in hospitals, as well as by the presence of offensive odors such as blood, vomit, feces, and infections. It is recommended to promptly remove offensive odors from the environment and ensure cleanliness.
There is a growing body of research indicating that incorporating pleasant odors like vanilla, lavender, and mint can replace unpleasant smells. This research suggests that creating a more humane environment in medical and nursing care settings can enhance healing for patients, families, and providers. By addressing environmental stressors in critical care units, we have the potential to prevent negative effects on patients in the Critical Unit and alleviate stress among staff.
(Rubert, 2013) Research Literature Synthesis Chapter 3 METHODOLOGY This study aims to utilize the Environmental Theory of Florence Nightingale in order to support a post-tonsillectomy patient in achieving a quicker recovery by employing the environment to enhance their healing process during the implementation and nursing process. The researcher created a checklist of canons for assessment, which was directly derived from Nightingale’s Environmental Theory (Nightingale, 1969).
The purpose of the interview is to evaluate the patient’s environment and determine the level of control needed for a smooth recovery. This includes assessing the patient’s preferences during the perioperative phase. The principles of Nightingale’s Environmental Theory are followed, as outlined in Table 1: Nightingale’s Environmental Theory 13 Canons of Nightingale Nursing Process & Thought Done (Nightingale, 1969). These principles include checking the patient’s body temperature, room temperature, ventilation, and foul odors. Additionally, a plan is developed to ensure the room remains warm and comfortable for the patient.
Ensure that the patient’s room is well-ventilated and free of odor to maintain their body temperature. Also, check for adequate light in the room, as sunlight is beneficial. Implement appropriate lighting without direct exposure to the patient. Keep the room clean and free from dust, dirt, and dampness. Additionally, examine the surrounding environment for fresh air, pure water, proper drainage, cleanliness, and adequate light. Take measures to remove garbage and stagnant water while ensuring clean water and fresh air. Lastly, check the noise level in the room.
Surroundings: Try to keep noise level to a minimum.
Bed & Bedding: Check bed and bedding for dampness, wrinkles, and soiling. Keep the bed dry, wrinkle-free, and at the lowest height for comfort.
Personal Cleanliness: Strive to keep the patient dry and clean at all times. Frequent assessment of the patient’s skin is vital for maintaining good skin integrity.
Variety: Aim to create variety in the room and with the client. This can be achieved through cards, flowers, pictures, and books. It is also encouraged to have friends or relatives engage in stimulating activities.
Avoid talking without giving factual advice and respecting the patient’s personal space. Monitor the patient’s diet and document their intake at each meal. Ensure continuity of care by documenting the care plan and evaluating the outcomes. Observe and record any observations of the patient’s condition. Continuously observe the patient in their environment and adjust the care plan as necessary.
On September 16, 2013, during the patient’s admission, a one-on-one interview was conducted at the Medicare Surgical Ward where the patient was confined. The environment was assessed and necessary alterations were made in preparation for the patient’s scheduled operation on September 17, 2013. Table 2 displays the assessment of the patient’s environment using Nightingale’s Environmental Theory and lists the alterations/actions taken. Specifically, some windows in the ward were opened to allow fresh air to come in, ensuring proper ventilation and warmth.
In the room, there are 2 ceiling fans. The patient’s temperature is normal – 37.2? C. To increase ventilation, all windows were opened. The patient’s family was advised to bring an additional electric fan. The room is illuminated by 4 T5 fluorescent lights. Sunlight enters the ward through the windows. Some dust and cobwebs were observed on the window panes and jalousies. The housekeeping staff was instructed to clean the entire ward and remove the dust. The comfort room has a clogged drainage, which needs attention. The water used in the comfort room has been treated.
The garbage bins are almost full. The hospital engineering personnel was informed about the clog and made immediate actions to fix it. Housekeeping personnel emptied the garbage bins.
Noise: Minimal noise noted from nurses station across the ward. Nurses were asked to avoid making irrelevant noise during patient’s stay.
Bed and Bedding: Bed is clean; terminal cleaning performed before patient was placed. New and clean bed cover and pillow case used by patient. Instructed folks to keep the bedding wrinkle-free and to change it if become soiled.
Personal Cleanliness
The patient is clean and has intact skin. The patient and their family were instructed to maintain the patient’s personal cleanliness. The bedside table is stocked with alcohol and other medical supplies. Various fruits were arranged on the bedside table to add color. There was conversation, hope, and advice given to the patient that were factual and relevant to their condition. The patient is following the ordered diet and was encouraged to continually eat foods within that diet and consume an adequate amount. The patient’s data and progress are recorded appropriately as part of the petty management. Observations of the sick are also conducted.
During the patient’s hospital stay, the researcher observed and visited the patient and environment daily. In the Evaluative Phase, an assessment tool was used to determine the relevance of the client’s environment to their postoperative condition. The nurse assisted in evaluating the client’s environment in relation to their condition. The evaluation of the patient’s response was conducted on their last day of hospitalization. Chapter 4 covers discussions and findings, including the demographic profile of the participant: Name: HM, Age: 38 years old, Gender: Male, Civil Status: Married, Occupation: Jeepney Driver, Educational Attainment: College Level.
Ethnic-Group:Visayan-Negrosanon Religion:Roman Catholic Language:English, Tagalog, Hiligaynon Chief Complaint:Pain upon swallowing Medical Diagnosis:Chronic Hypertrophic Tonsillitis Operation:Tonsillectomy Bilateral with Pharyngoplasty B. Comprehensive Health History This study was conducted when the client was confined in the hospital where he was admitted and treated. The nurse-researcher and patient interaction took place in the Medicare Surgical Ward of the institution. The first interview occurred upon the patient’s admission on September 16, 2013 at 11 o’clock in the morning with the patient himself as the primary informant.
Mr. HM, a 38-year-old Filipino male, is a resident of Victorias City and works as a jeepney driver. He is married and has three children. Mr. HM is described as a serious individual who prefers activities such as watching television or reading the newspaper over socializing. He occasionally drinks alcohol but does not smoke. According to the client’s history, he enjoys eating sweet foods and has experienced recurring sore throat infections for the past three years.
Despite the given conditions, he chose not to seek consultation but instead opted to gargle with water and salt whenever the condition arises. On September 13, 2013, Mr. HM experienced yet another sore throat and expressed, “It’s so hot during the day and suddenly it pours down with rain. It’s so difficult to drive in this weather, it feels uncomfortable and my throat hurts.” In response, he gargled with water and salt again. The following day, while having lunch at home, he noticed that his sore throat had worsened. Swallowing his food became extremely painful for him.
On September 14, 2013, the family and patient sought medical advice from a doctor due to concerns about the patient’s health. Subsequently, the doctor diagnosed the patient with Chronic Hypertrophic Tonsillitis and recommended a tonsillectomy. The patient and his wife made the decision to proceed with the operation without delay. Considering that postoperative patients require attentive and thorough care from nurses during the critical phase of their recovery, it is vital not to overlook the physical environment in which the patient is placed. Various elements in the environment can significantly impact the patient’s healing process.
During this phase, it is crucial to prevent complications such as infection, as it can worsen the patient’s condition and potentially result in death if not treated promptly. The environment plays a significant role as a source of infection. Nurses must ensure that the patient’s surroundings are devoid of any factors that might impede a fast and successful recovery. The implementation of Canons based on Florence Nightingale’s Environmental Theory resulted in positive outcomes for the patient. Upon discharge from the institution, the patient had achieved speedy recovery and remained free from postoperative complications, including infection.
The overall care of patients should be approached holistically by nurses, taking into consideration their surroundings and physical environment. This aspect should be prioritized by nurses. In this study, the nursing process successfully achieved the set goal within the specified timeframe. To conclude, Florence Nightingale’s Environmental Theory has proven to be effective, particularly when utilized with postoperative patients.
Patients in the postoperative phase already have breaks in their skin, which is their primary defense against pathogens. Therefore, it is crucial that the surrounding environment is free from harmful pathogens that could enter the patient’s wound and result in severe complications, hindering their quick recovery and healing. In line with this recommendation, wards for postoperative patients should be kept clean and adhere to standard environment protocols for patients recovering from surgery.
Patient’s Family. It is important to educate the family on the proper care of hospitalized members and the environment they are in. Healthcare Providers. Healthcare workers should know and apply proper care to the healthcare environment and follow rules and regulations set by organizations and committees to maintain a clean and hygienic patient environment. Nursing Educators. Educators should teach students about how the environment can affect a patient’s condition and recovery.
During their student days, nursing students are taught the importance of caring for the environment to benefit their patients. Researchers should study Florence Nightingale’s theory, as it remains applicable in the Modern Nursing era and has been found to aid in patient recovery. Community leaders should also apply this theory in their own environments, as post-hospitalization environments play a significant role in patient wellbeing and it is recommended to maintain sanitation and cleanliness in these areas.
Hospital administrators need to enforce strict standards for cleanliness in the hospital environment. The administration should strongly support the Infection Control Committee, whose goal is to minimize infections within the hospital. The Nursing Service personnel are responsible for educating their nurses on integrating Nightingale’s Environmental Theory into patient care.
