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Nightinale’s theory and implications to nursing

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    Nursing is a profession that involved in identifying its own unique body of knowledge essential to nursing practice. To identify the knowledge base, nurses should develop and recognize theories that are specific to nursing. Parker and Smith (2010) define theory as a set of concepts, definitions and propositions that project a systematic view of phenomena by designating specific interrelationships among concepts for purposes of describing, explaining, predicting and controlling phenomena. Nursing theory is an organized framework of concepts and purposes designed to guide the practice of nursing (Mosby’s Medical Dictionary, 2009).

    Through nursing theory, nurses will be more knowledgeable so that it guides them in daily practice. It also enhances the care of patients and guide inquiry to advance science. Nursing theory is a conceptualization of some aspect of reality that pertains to nursing which is articulated for the purposed of describing, explaining, predicting or prescribing nursing care. Nursing theories address the phenomena of interest to nursing; which including the focus of nursing; the person, population nursed the nurse; the relationship of nurse and nursed; and the purposes of nursing. Nursing theory is essential to the continuing evolution of the discipline of nursing. The primary purpose of nursing theory is to improve nursing practice. Therefore, the health and the quality of life of persons, families, and communities served. Nursing theories provide coherent ways of viewing and approaching the care of persons in their environment. When a theoretical model is used to organize care in any setting, it strengthens the nursing focus of care.

    It also provides consistency to the communications and activities related to nursing care. The development of many nursing theories has been enhanced by reflection about actual nursing situations. The everyday practice of nursing will enriches nursing theories. When we as a nurse think about nursing, we must consider the content and structure of the discipline of nursing. Even some time we do not conceptualize them theoretically; their values and perspective are often consistent with particular nursing theories. The use of a nursing theory in daily practice will results in a more scholarly, professional practice. Creative nursing practice is the direct result of ongoing theory-based thinking, decision making, and action (McKenna & Slevin, 2008). In daily practices, we as nurses are guided by our values, beliefs and knowledge so that we can integrate other health sciences and technologies as the background. Nursing theory will be useful if it brought into practice.

    In many nursing situations, nurses can be guided by nursing theory; for example when giving nursing care to the clients in the ward. Nursing theory can change nursing practice by providing direction for new ways of being present with clients. It help nurses realize ways of expressing caring and provides approaches to understanding needs for nursing and also designing care to address client’s needs. Nursing theorists have built on the metaparadigm and on the work of Nightingale, whether or not they were conscious of doing so (Parker, 2005). The Nightingale’s history and her contributions to nursing world will be discussed in the next chapter.

    Biography of Florence Nightingale
    Florence Nightingale was born in Florence, Italy on May 12, 1820. She is a daughter to well-educated, wealthy English family. Her education included the mastery of several ancient and modern languages, literature, philosophy, history, science, mathematics, religion, art and music. She decided at a young age that she was ‘called’ to do something special with her life. She believed that God called her to be a nurse and that He had natural laws that were to be followed. When she chooses nursing, it was an unpleasant surprise for her family since nursing was then an occupation of the lower classes. As a well-travelled young woman of the day, in 1847 she arranged to visit Kaiserswerth, where she received 3 months’ training in nursing.

    In 1853, she studied in Paris with the Sisters of Charity, after which she returned to England to assume the position of superintendent of a charity hospital for ill governesses. (Blais, Hayes, Kozier & Erb, 2006). During the Crimean War, there was a public outcry about the inadequacy of care for the soldiers. The death rate estimated at 43%, was attributed to wounds, infection, cholera, inadequate nutrition, lack of drugs and lack of care. Florence Nightingale was asked by Sir Sydney Herbert of the War Department to recruit a contingent of female nurses to provide care to the sick and injured in the Crimea. In spite of opposition from the Army medical officers, she and her nurses transformed the environment by setting up diet kitchens, a laundry, recreation centers and reading rooms and organizing classes. She trained the orderlies to scrub the wards and empty wastes.

    In the course of 6 months, the mortality rate decreased to 2 % (Donahue, 1996, cited from Blais, Hayes, Kozier & Erb, 2006). When she returned to England, Nightingale was given an honorarium of £4500 by a grateful English public. She later used the money to develop the Nightingale Training School for nurses which open in 1860. The aim of nursing education was to train women to become nurses in order to serve society for the alleviation of the suffering of the sick, for the amendment of the living conditions of the poor, and for the improvement of the health of the population (Parker, 2005). The efforts of Florence Nightingale and her nurses changed the status of nursing to a respectable occupation for women. Nightingale provided the nursing profession with the philosophical basis. Her ideas about nursing have guided in theoretical thought and actual nursing practice throughout the history of modern nursing. Her writings and idea focus in the importance of caring for the ill person. In her view, the person was a passive recipient of care, and nursing’s primary focus was on the manipulation of the person’s environment to maintain or achieve a state of health. Nightingale’s achievements have included her many writings, such as ‘Notes on Hospitals’ and ‘Notes on the Sanitary State of the Army in India’. She also compiled statistics and much evidence for the Royal Commission. Hospitals were set up world-wide financed by the Nightingale Fund.

    Nightingale was a believer in research. She presented her own empirical evidence based on her own experiences and observations, as established facts. Her gathering of statistical data was used to give credence to her hypotheses on her epidemiological studies. She laid the foundations for a recognized system of nurse training, not only in this country, but abroad. However, those nurse educators, who followed in Florence Nightingale’s footsteps in teaching young (and from an increasingly higher social class) women in the art of nursing, failed to differentiate between the goals and focus of nursing and of medicine. The medical model tended to neglect the patient as a human being. Florence Nightingale’s vision of health care included professional nursing for the sick and the poor. Although bed-ridden for much of her later years, she worked prolifically into her eighties, gathering data and expounding her nursing theories. She continued to campaign to improve the health standards, publishing 200 books, reports and pamphlets. She believed that infection arose spontaneously in dirty and poorly ventilated places. Her belief led to improvements in hygiene and healthier living and working environments. In 1910, Florence Nightingale died in London at the age of 90 years.

    The Origin of the Model (The Influenced of Florence Nightingale on the Early Development of Nursing Theory) Nightingale did not believe in the germ theory. Her experiences in the Crimean War magnified her interest in the principles of sanitation and the relationship between environment and health. A person’s health was the direct result of environmental influences, especially cleanliness, light, pure air, pure water and efficient drainage. Nightingale believes through manipulating the environment, nursing aims to discover the laws of nature that would assist in putting the patient in the best possible condition so that nature can affect a cure. Nightingale views ‘nursing’ as both an art and science. The art is the practice which means the interaction between nurse and client, whereas the science related to the empirical, or scientific, knowledge of nursing. In addition, theory is identified as being useful to guide practice, education and research (Daniels, 2004).

    Nightingale’s principles regarding environment, health and nursing were implemented in America at the turn of the 20th century. With the development of hospital-based schools of nursing, Nightingale’s principles of sanitation were used to clean up the rat-infested, dirty hospitals of the day. As Nightingale’s ideas were put in use, hospital became a place for people to recover rather than a place to die. When, for a variety of reasons, hospitals did not hire their own nursing graduates, nurses applied Nightingale’s principles in the community to the development of public health nursing. The Henry Street Settlement founded by Lillian Wald is an excellent example of Nightingale’s theory in practice. Private duty nursing and public health nursing remained the primary focus of nursing practice until World War II.

    At this time, a tremendous increase in scientific knowledge and technology was affecting health care. As the practice of medicines became more scientifically based, more clients were cared for in hospital settings. Nursing practice likewise became centered in the hospital rather than the home. With this development, it became clear that nursing did not have an adequate theory base to organized new knowledge and guide nursing practice. Nursing began to develop its knowledge base further by incorporating Nightingale’s principles into modern nursing theory.

    Major Component of the Model (Nightingale’s Thirteen Canons Central to the Environmental Model of Nursing) Nightingale believed healthy surroundings were necessary for proper nursing care and healing and environment was the main focus of the theory. In Nightingale’s writing, Even she did not plan to develop a theory but she rather sought to describe nursing and delineate general rules for nursing practice, which make her model descriptive and practical. Nursing care using Nightingale’s model is centered on her 13 canons, which include the following precepts (Butts & Rich, 2010). 1. Ventilation and warmth

    The interventions subsumed in this canon include keeping the patient and the patient’s room warm and keeping the patient’s room well ventilated and free of odors. Specifics instructions included to ‘keep the air within as pure as the air without’. Nightingale emphasized on proper ventilation as she believed air the patient breathes can be a source of disease and recovery. Nurses were instructed to manipulate the environment continually to maintain ventilation and patient warmth by using a good fire, opening windows and properly positioning the patient in the room (Alligood 2006). As in our practice, we checked the client’s body temperature, room’s temperature, ventilation and odours.

    2. Health of house
    This canon includes the five essentials of pure air, pure water, efficient drainage, cleanliness and light.

    3. Petty management
    Continuity of care for the patient when the nurse is absent is the essence of this canon.

    4. Noise
    This is including the avoidance of sudden noises that startle or awaken patients and keeping noise in a general to a minimum. Nightingale believed noises in the surrounding areas could harm the patient and should be avoided
    as possible. 5. Variety

    This canon refers to an attempt to provide variety in the patient’s room so as to avoid boredom and depression.

    6. Food intake
    Interventions are including the documentation of the amount of foods and liquids that the patient ingested.

    7. Food
    This canon refers to try to include food according patient preferences. Nightingale concerned about the patient’s diet. She instructed nurses to assess not only dietary intake but also the meal schedule and its effect on the patient (Alligood, 2006).

    8. Bed and bedding
    The interventions in this canon include comfort measures related to keeping the bed dry and wrinkle-free and lowest height to ensure comfort.

    9. Light
    The instructions contained in this canon relate to adequate light in the patient’s room. In her theory, Nightingale paid importance to the concept of light, especially the sunlight. Hence in order to achieve beneficial effects of sunlight, nurses were instructed to move and position patients to expose them to sunlight (Alligood, 2006).As in our practice, we check the room for adequate light (sunlight is beneficial to the patient), we create and implement adequate light in the room without placing the patient in direct sunlight.

    10. Cleanliness of rooms and walls
    This canon focuses on keeping the environment clean.

    11. Personal cleanliness
    This canon includes measures such as keeping the patient clean and dry. Cleanliness played a critical component of Nightingale’s environmental theory. To her even if the environment was well ventilated and had proper lighting; a dirty environment could act as a source of infection through the organic matter it contained. Therefore, high emphasis was laid upon proper handling and disposal of bodily excretions and sewage. High importance was also given to proper and frequent hand washing between patient cares.

    12. Chattering hopes and advice
    Instructions in this canon include the avoidance of talking without reason or giving advice that is without fact. As a nurse, we should respect and care for the client’s dignity.

    13. Observation of the sick
    This canon includes instructions related to making observations and documenting observations.

    Metaparadigm in Nursing According to Florence Nightingale
    Nightingale’s environment model of nursing represented a landmark for the development of nursing science. This model provided the foundation for the discipline’s four metaparadigm concepts of person, environment, health and nursing. Nursing

    Florence Nightingale considered that nursing is very essential for everybody’s well being. One of her masterwork, Notes on Nursing, provided essential principles for rendering and implementing an efficient and effective nursing care. Moreover, she instilled an ideal attitude of thinking and acting like a real nurse. Person

    Nightingale viewed a person as a patient. She believed that nurses should perform tasks to and for the patient as well as control the patient’s environment to facilitate easy recovery. Predominantly, she explained a passive patient in this relationship. However, when there are definite references to the patient performing self-care when possible, the nurse is particularly instructed to ask the patient about his or her preference. However, Florence Nightingale gives emphasis to the nurse who is in control of the patient’s environment. Health

    Florence Nightingale’s statement regarding health is “being well and using every power that the person has to the fullest extent.” In addition, she defined diseases as “a reparative process that nature instituted from a want of attention.” She believed that prevention of diseases through environmental control will greatly uplift the maintenance of health. Furthermore, she illustrated modern public health nursing and the more modern concept of health promotion. She compared these concepts of nursing as different from caring a sick patient to living better and increasing recovery.

    Nightingale’s statements about conditions in the community are also applicable to her theory. She believed that the sick, poor people would benefit from environmental improvements that addressed their physical and mental aspects. She stressed that nurses could have a special role in uplifting the social status of the poor by improving their living situations. Moreover, she view the concept of environment as “those elements external to and which affect the health of the sick and healthy person” and includes ‘everything from the patient’s food and flowers to the patient’s verbal and non-verbal interactions with the patient’ (Pfettscher, 2006).

    Assumption of Nightingale’s Environmental Model of Nursing Nightingale did not explicitly state any theoretical assumptions but a number of assumptions can be extracted from her work. Philosophical assumptions that can be extracted include: 1) nursing is a calling; 2) nursing is an art and science; 3) person can control the outcomes of their lives and therefore, can pursue perfect health; 4) nursing requires a specific educational base: and 5) nursing is distinct and separate from medicine (Butts & Rich, 2010). The following assumptions also may be inferred from Nightingale’s work: 1) maintaining a clean room, bedding, and clothes aids in patient recovery; 2) noise can be harmful to patients; and 3) managing the environment improves the health of the patients (Parker, 2005).

    Propositions of Nightingale’s Environmental Model of Nursing The primary relationship statements that nurses can derive from the writing of Nightingale include 1) the person is desirous of health, so the nurse, nature, and the person will cooperate in order for all reparative processes to occur and 2) the nurse’s role is to prevent the reparative process from being interrupted and to provide conditions to optimize the reparative process (Butts & rich, 2010). 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. Mankind can achieve perfection relates to her strongly held beliefs in self-determination and in self-realization. Ultimately, mankind does seek perfect health; so the route to perfection is through strict adherence to the natural laws. Nightingale’s view the role of nurse was to alter the environment as to obey the natural laws to achieve a perfect environment. She defined a ‘calling’ as doing work in such a way as to do what is right and best.

    Thus, nursing work has to be done with enthusiasm. Nightingale’s 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. Nursing cannot be taught on theory only but need a combination of clinical and theoretical training. The physician and nurse sometimes deal with the same client but nursing is not to be viewed as subservient to medicine. Nursing’s focus is on caring through environmental alteration, whereas medicine’s focus is cure of the disease. Thus, nursing and medicine are most effective when working in a collaborative manner. Published Research Related to the Model

    Published research related to Nightingale Environment Model is entitled ‘Environmental Theory Applied to the Home Environment of Children Exposed to HIV at Birth. It was published on May 2011. This study was based on the theoretical framework of Florence Nightingale’s Environmental Theory, in combination with the photovoice resource. Participants was 10 HIV-positive mothers and caregivers to children exposed to the virus at birth and up to five years old, living in the urban region of Fortaleza, Ceara, Brazil. The general objectives are getting to know the home environment of children exposed to HIV at birth from an Environmental Theory perspective. The hypothesis is: the home environment of children exposed to HIV at birth presents risk situations for the development of health problems.

    The proposal is to suggest fresh air and cleanliness that can improves health. Another published research related to Nightingale’s environment model entitled ‘The Nightingale theory and intentional comfort touch in management of tinea pedis in vulnerable populations.’ It was published in Journal of Holistic Nursing on December 2010. Vulnerable populations, specifically migrant farm workers and persons experiencing homelessness, are often at an increased risk for foot infections. This risk is related to their working and living conditions, socioeconomic status, limited access to health care, frequent exposure to wet environments, limited access to clean and dry socks and shoes, bathing or laundry facilities, and daily routines that requires them to be on their feet for long periods of time. After years of caring for these populations and hundreds of clinical encounters, an evidence-based, effective method of foot care that incorporates intentional comfort touch has been developed.

    This article describes methods for mitigating the severity of fungal growth, decreasing the risk of secondary infections, and improving skin integrity by manipulating the micro-environment of the patients’ feet. This includes fundamental aspects of hygiene as described by Florence Nightingale’s Environmental Theory that suggests that direct sunlight, fresh air, and cleanliness improves health.

    The Strength of Nightingale’s Environment Theory

    The Nightingale model is still utilized today in nurses’ daily practice. Nightingale’s model focuses primarily on the patient and the environment. The primary function of the nurse in Nightingale’s view is to manipulate the physical and social factors that affect health and illness so as to enhance patient recovery. Florence Nightingale’s theory contains three major relationships which are environment to patient, nurse to environment and nurse to patient. She view environment as the main factor acting on the patient to produce an illness state and regarded disease as ‘the reactions of kindly nature against the conditions in which we have placed ourselves.’ The nurse as manipulator of environment and actor on the patient is described when Nightingale said nursing ‘ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet and the proper selection and administration of diet- all the least expense of vital power to the patient.’ Nightingale’s theory conceived of health care not merely as the treatment of disease but the elevation of good health and quality of life in general. The theory emphasized the environmental aspects of care, especially those that nurses could provide, such as constructing a clean, sanitary treatment environment. Her conception of care was patient-centered. An important tenet of the theory is that the patient should be enabled and encouraged to take an active role in his own healing.

    The Limitations of Nightingale’s Environment Theory
    Nightingale’s theory conceives of the patient as a central agent in his own healing. This may be effective in some cases, but is limited in cases in which the patient is incapacitated or otherwise incapable of working toward his own healing. Some patients may be physically unable to engage to the degree the theory advocates, while others may be psychologically incapable, or may be overwhelmed by the pressure of taking such an active role. The Nightingale’s environment theory emphasis on environmental measures which are: clean air and water, drainage, light and warmth. Those may be effective to an extent but is inherently limited. Healthy environmental conditions can only go so far in treating disease and illness. It says little about the application of medical technology, which was rudimentary but nonetheless existent in Nightingale’s time.

    Her writings and idea did not focus on the nature of the person, but did stress the importance of caring for the ill person rather than caring for the illness. In Nightingale’s view, the person was a passive recipient of care, and nursing’s primary focus was on the manipulation of the person’s environment to maintain or achieve a state of health. Some of Florence Nightingale’s practices and beliefs have been largely discounted today, such as the pathology of dirt and dampness, her disregard to the germ theory, and the fact that the patient was non-participative of his/her method of care. This lack of holism was perhaps in keeping with her time.

    Application of Nightingale’s Model in Nursing Practice.
    Nightingale environmental model is based on the idea that the impetus for healing lies within the individual human being. The focus of care is to place the individual in an environment that is supportive to that healing
    process. Her 13 canons speak to areas that require the attention of the nurse, such as cleanliness, ventilation, warming, light, noise, variety, nutrition, chattering hope and advices, and observation of the sick. To utilize this theory in the nursing practice, the nurse should provide clean environment to prevent infection. There are five stages in nursing process. It begins with assessment; follow by nursing diagnosis, planning, implementation and lastly evaluation. In assessment stage, Nightingale advocates two essential behaviors by the nurses. The first one is nurses may ask the client what is needed or wanted. For example, the nurse may ask many questions to know the actual status of the client. Nurses should avoid asking leading questions. Otherwise, ask clients using precise questions with knack.

    The second area of assessment she advocates was the use of observation. Nurses should used precise observations concerning all aspects of the client’s physical health and environment. Subjective data and objective data should be used to present nursing process. Nursing diagnoses are based on an analysis of the conclusion gained from the information to the assessment. Nightingale believed data should be used as the basis for drawing any conclusion. It is important that the diagnosis in the client response to their environment and not the environmental problem. Nursing diagnosis reflect the importance of the environment to the health and well being of the client. Planning includes identifying the nursing actions needed to keep clients comfortable, dry and in the best state for nature to work on. The value of informed action, based on extensive knowledge is well illustrated by Nightingale’s personality. Planning focused on modifying the environment to enhance the clients, ability to respond to the disease process. Implementation takes place on the environment that affects client. It involves taking action to modify the environment.

    The factors of the environment that should be considered are; noise, air, odors, beddings, cleanliness and light. All these factors place clients in the best positions for nature to work upon them. Evaluation is based on the effects of the changes in the environment on the clients’ ability to regain their health with minimum expense of energy. Observation is primary method of data collection based to evaluate the client’s responses to the intervention. The Nightingale’s environment theory would be applicable in my workplace that is Neonatal Intensive Care Unit (NICU). In NICU, there’s a lot of sick ventilated baby and premature baby that need a lot of care. To protect them from noise, all health care providers (HCP) must keep their voice low at bedside. Nurses should not stand over warmer when giving report. Staff radio/tapes/TVs should not be permitted. Patient’s radios, cassettes, tapes, etc should be keep at an appropriate volume for infant’s corrected gestational age. Nurses should answer all alarms promptly. When at bedside, silence alarms before procedures. When handling the close incubators, nurses should close incubator doors quietly. Nurses and all HCP cannot place charts or equipment on top of incubators unless absolute necessary. To prevent infection from NICU, all HCP should perform two minute wash of their hands and arms up to the elbow at scrub sink before beginning patient care.

    They must wash hands prior to and after each procedures using hospital-approved antiseptic soap, waterless gel or foam. Staff must wear gloves per standard precautions. Change gloves and wash hands between each new patients encounter. Nursing personals take the initiative to contact infection control practitioner if there is suspected need for special isolation. Nursing staff should clean the equipment used by patients. Nursing staff is responsible to clean equipment (monitors, oxygen saturation monitors, IV pumps, bedside carts etc) between patient use (Guha & Srivastana, 2006). Nurses should make sure all patients bedside neat, clean and appropriately stocked. Upon discharge or transfer, nurses should remove all personal belongings from bedside cart. Waste management should be handled properly. All needles, syringes and sharps are placed intact into secured container provided by bio system personnel; body fluid waste is placed in red trash bag and double bagged to prevent leakage (Guha & Srivastana, 2006).

    Nightingale’s theory attempts to provide general guidelines for all nurses worldwide. Her general concepts that are still pertinent today are relationships between nurse, patient and environment. The theory is specifically directed toward the nurse, who always cares for humans’ health. Florence Nightingale is the reason why nursing is considered a profession today and recognized that educated nurses is professional nurse. Although Nightingale’s theory was developed long ago in response to a need for environmental reform, the nursing principles are still relevant to medicine and science; many of the concepts in her theory have been used to provide general guidelines for nurses for over 150 years (Pfettscher, 2006). The groundwork for the evolution of the modern discipline of nursing today is laid because of Nightingale’s personality and social position combined with historical circumstances. Nursing for Florence Nightingale was the “centering force” meaning that her expression of spiritual values.

    We as nurses should look to Florence Nightingale for inspiration, for she remains a role model par excellence. She is the one who responsible for transform values of caring into an activism and also transforms our current health-care system to more humanistic. Her activism situates her in the context of justice-making. Justicemaking is a manifestation of compassion and caring, for it is actions that bring about justice (Boykin & Dunphy, 2002). Generally, Nightingale’s theory has been used to provide general guidelines for all nurses. The universality and timeless of her concepts remain pertinent. The relation concepts (nurse, patient and environment) are still applicable in all nursing setting today. Thus, nurses should be professionals in their own right and should make willing to make changes in order to improve the hospital environment in its broadest sense. Florence Nightingale’s contributions to nursing theory, research, statistics, public health and health care reform continues to inspire us today.


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