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Running head: NIGHTINGALE THEORY
A Critique of the Environmental Theory by Florence Nightingale
Virginia C. Petrikonis
University of Virginia
GNUR6050
Fall 2011
On my honor as a student, I have neither given nor received inappropriate aid on this
assignment.
Virginia Petrikonis
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NIGHTINGALE THEORY
Abstract
Florence Nightingale developed the first model of nursing care that is grounded in the belief that
alteration of the environment will prevent disease (Nightingale, 1859). This paper critiques
Nightingale’s Environmental Theory and reviews its relevance to nursing using a guide for
critical reflection of theory (Chinn & Kramer, 2008). In critiquing the Environmental Theory,
several strengths and weaknesses are found. While Nightingale’s theory lacks a common
structure and explicit definitions of concepts, she provides descriptions and examples of nursing
that represent a holistic view of nursing that focuses on interpersonal interactions between the
nurse and the patient (Nightingale, 1859). In addition, Nightingale emphasizes the need for
observation and data collection, which has evolved into what is now known as evidence-based
practice. The Environmental Theory has led to improving healthcare, the development of nursing
schools, and the improvement of sanitary conditions of hospitals (Tourville & Ingalls, 2003). The
Environmental Theory, a result of Nightingale’s work as a nurse, has proven to be an invaluable
and enduring contribution to the field of nursing.
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NIGHTINGALE THEORY
A Critique of the Environmental Theory by Florence Nightingale
Florence Nightingale never formally developed a nursing theory, but some reviewers
credit her as the first nursing theorist (Tourville & Ingalls, 2003). Parker & Smith (2010) explain,
“The remainder of all nursing theory may be viewed as mere branches and ‘acorns,’ all fruit of
the roots of Nightingale’s ideas” (pp. 46-47). Nightingale is unique because she never produced a
formal theory, but she did develop the first model of nursing care. A product of the Victorian
age, Nightingale did not theorize in a way that we are familiar with today, yet she is still viewed
by many as the founder of modern nursing (Parker & Smith, 2010). Through published works,
Nightingale was able to lay a theoretical framework for nursing. In Notes on Nursing,
Nightingale (1859) describes the concepts she believes are the foundation of nursing practice
through the development of the Environmental Theory. Furthermore, Nightingale contributed to
values that nursing has placed on theoretical development and implementation into nursing
practice (Clements & Averill, 2006).
The purpose of this paper is to evaluate Nightingale’s Environmental Theory and review
its relevance to modern nursing using a guide for critical reflection of theory by Chinn and
Kramer (2008). It is important to first understand a theory so that it can be analyzed. In critiquing
a theory, description and reflection are imperative if a nursing theory is to be applied to practice
and research (Chinn & Kramer, 2008).
Summary of Environmental Theory
Nightingale’s Environmental Theory is grounded in the belief that keeping people
healthy is dependent upon environmental control (Nightingale, 1859). Nature is seen as the great
healer, which is able to cure disease (McCabe, 2000). Nightingale (1859) states that “nature
alone cures” and the goal of the nurse “is to put the patient in the best condition for nature to act
NIGHTINGALE THEORY
upon him” (p.102). The main idea found within the Environmental Theory is to manipulate the
environment so that the best possible health outcome is achieved. If one manipulates the
environment in a positive manner, health ensues. During the Victorian age, people believed that
germs led to disease. Nightingale was skeptical of the relevance of the germ theory and
maintained that environmental manipulation, such as hygienic practices, are the most relevant
way to prevent or decrease disease (Nightingale, 1859).
Nightingale defines disease as a reparative process in her published works (Nightingale,
1859). Nightingale (1859) states, “Shall we begin by taking it as a general principle – that all
disease, at some point or other of its course, is more or less a reparative process, not necessarily
accompanied with suffering: an effort of nature to remedy a process of poisoning or decay…”
(p. 1). Since the environment is seen as the main agent acting upon the patient to produce
disease, the nurse is viewed as a change agent of both the environment and the patient (Wagner
& White, 2010). Nightingale’s focus on caring through environmental alteration was in direct
opposition to medicine’s focus to cure disease (Selanders, 2010). Nightingale (1859) goes on to
explain, “…the symptoms or the sufferings generally considered to be inevitable and incident to
the disease are very often not symptoms of the disease at all, but of something quite different –
of the want of fresh air, or of light, or of warmth, or of quiet, or of cleanliness, or of punctuality
and care in the administration of diet, of each or of all of these” (pp. 1-2).
Nightingale describes 13 canons, or concepts, that are of utmost importance in order to
keep a patient healthy through environmental means (Figure 1). The core of the Environmental
Theory is assessment so that a nurse is able to evaluate the environment’s positive and negative
effects on a patient. In order to assess a patient, Nightingale underscores the importance of
experience and observation, which she believes is the only reliable way to obtain and validate
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NIGHTINGALE THEORY
information (Parker & Smith, 2010). Nightingale presents the patient as the integral component
of the total environment with the patient at the center of the Environmental Theory (Clements &
Averill, 2006). Thus, Nightingale used a patient-centered approach that involved the concept of
caring for the whole person (Tourville & Ingalls, 2003). The concept of caring for the whole
person presents nursing as a helping process and a holistic art. Thus, according to Nightingale
nursing is seen as both an art and science (Parker & Smith, 2010).
The Environmental Theory has established a significant impact on nursing ever since
Nightingale created it. The elimination of risk factors and germs have proven to decrease
morbidity and mortality such as through the use of hand washing, which can actually be
attributed to Nightingale with her influence on hygienic practices (Nightingale, 1859).
Nightingale also demonstrated how to assess, analyze, implement, and evaluate nursing practices
through detailed organization, which has provided a framework for nursing research (Clements
& Averill, 2006). Ultimately, the Environmental Theory focuses on the ability to maintain and
restore health through environmental control (Parker & Smith, 2010).
Critique
Clarity
The environment is the major concept found within the Environmental Theory.
Nightingale describes 13 canons, or sub concepts, that are required in order to manipulate the
environment to keep patients healthy (Nightingale, 1859). In this manner, the view of person and
environment is compatible. While no hierarchical arrangement is made, Nightingale sees
ventilation as the most important concept (Selanders, 2010). Nightingale (1859) states, “The very
first canon of nursing, the first and the last thing upon which a nurse’s attention must be
fixed…is this: to keep the air he breathes as pure as the external air, without chilling him” (p. 5).
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No specific hierarchy is created within the 13 canons, but certain canons, such as ventilation and
light, are viewed as most important (Nightingale, 1859). In addition, no specific definitions are
given for the concepts found within the Environmental Theory. With no distinct definitions
provided, it is possible for different nurses to make varying and potentially detrimental
inferences for each of the 13 canons. While some of the concepts are straightforward and perhaps
do not need definition, such as light and personal cleanliness, other concepts are not as concrete
and would benefit from definition, such as chattering hopes and advices (Figure 1). However, all
13 canons are explicitly described in Notes on Nursing, which Nightingale (1859) wrote in order
to teach nurses how to function within their career. While the Environmental Theory is
somewhat lacking in terms of clarity, Nightingale did produce a general guideline with helpful
examples within it that explains how each of the 13 environmental canons can affect health in a
useful manner (Nightingale, 1859).
No common structure is found within the Environmental Theory. The theory is based
upon the concept of the environment along with the 13 canons that describe how to effectively
alter the environment to prevent disease (Nightingale, 1859). A caring relationship is what links
the 13 canons together in a linear fashion with the objective of environmental control. Overall,
the structure moves all concepts toward health and includes health promotion, disease
prevention, health restoration, and rehabilitation (Selanders, 2010). Although Nightingale goes
into great detail to explain the 13 canons, the lack of specific definitions of concepts and the lack
of common structure provide a weakness for the Environmental Theory in terms of clarity.
The underlying assumption of the Environmental Theory is that the patient will remain
free of disease by means of a healthy environment (Nightingale, 1859). This assumption can be
derived from various contexts such as when Nightingale (1859) states, “If a patient is cold, if a
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patient is feverish, if a patient is faint, if he is sick after taking food, if he has a bed-sore, it is
generally the fault not of the disease, but of the nursing” (p. 2). In this manner, it is assumed that
the patient is able to recover from disease, the nurse is able to manipulate the environment, the
environment is able to cure, and health can be achieved. These assumptions are located before
theoretical reasoning with no hierarchical arrangement as all assumptions are equally valuable
and necessary throughout the Environmental Theory (Nightingale, 1859). At the time
Nightingale developed the Environmental Theory, the underlying assumptions were not factually
verified. However, it has now been proven that not all disease can be prevented through
environmental manipulation, such as genetic diseases (Selanders, 2010). Therefore, the
assumptions found within the Environmental Theory are a major weakness of the theory.
Simplicity
The major relationship found within the Environmental Theory is the nurse-patient
relationship where the nurse places the patient in the best possible condition for nature to act
(Selanders, 2010). This relationship implies a helping, or caring, relationship and emphasizes
interpersonal relations. All 13 canons, the sub concepts of the overall concept of the
environment, focus on the environment by means of a caring relationship. The caring
relationship found within all 13 canons is uniformly directed at preventing disease by means of
environmental manipulation with the ultimate goal of health and wellness (Nightingale, 1859). In
addition, all 13 canons can be combined without losing theoretical meaning. In fact, some of the
canons overlap such as bed and bedding and light (Figure 1). The Environmental Theory
describes nursing actions, explains the importance of nursing actions, and predicts that health
will ensue if a nurse positively alters a patient’s environment, which furthermore creates
meaning for the necessity of adhering to the 13 canons (Nightingale, 1859). In this manner,
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Nightingale creates guidelines for the implementation of a simple goal. Thus, the Environmental
Theory is fairly simplistic in its approach to nursing.
Generalizability
The overall purpose of the Environmental Theory is to provide a direction for nursing
through environmental adaptation and manipulation so that the person receiving care attains
positive health changes (Nightingale, 1859). The theory is specific to nursing because the nurse
is viewed as the change agent (Wagner & White, 2010). In order to effectively produce change,
nurses must first understand both the patient’s condition and the environment (Selanders, 2010).
The Environmental Theory is broad in scope and can be applied to a plethora of nursing
domains. Specifically, the Environmental Theory is used in pediatric acute care settings with the
use of contact precautions. Pediatric acute/chronic nurse practitioners must be knowledgeable in
terms of understanding various modes of transmission of infectious agents so that they are able
to appropriately place orders for children and adolescents to be placed on contact precautions.
For example, standard precautions are supplemented with transmission-based precautions in
order to reduce the risk of contact, droplet, or airborne transmission. In these instances, use of a
mask, respirator, gown, gloves, and/or protective eyewear is necessary (“Infection Prevention,”
2007). While it is clear that the Environmental Theory has many positive benefits in terms of
health and wellness and can be applied to the majority of nursing care, it is not applicable to all
instances of nursing because environmental manipulation is not able to counteract certain disease
processes such as genetic and autoimmune disorders (Selanders, 2010). However, the application
of the Environmental Theory with adherence to the 13 canons is able to improve quality of life
for nearly all patients.
Accessibility
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The concepts found within the Environmental Theory are broad in scope and accompany
a holistic view of health (Dossey, 2005). The holistic view of nursing can be applied to a variety
of nursing domains. For example, the Environmental Theory includes the sub concept of variety
and can be used in pediatric nursing by stimulating children with art and décor, and providing
them with games in their hospital rooms in an effort to prevent boredom that can benefit children
psychologically. Nightingale did not differentiate between physical, emotional, and social
aspects of the environment, but discussed them all as one entity (Wagner & White, 2010).
Nightingale also did not provide definitions within the Environmental Theory, but she did
explain each of her concepts and how to use them within the field of nursing (Nightingale, 1859).
While the main concept, the environment, is abstract, the 13 sub concepts are highly empiric
concepts that represent objects, properties and events. Nightingale wrote in great detail about the
importance of observation and writing down observations (Nightingale, 1859). The concept of
observation developed into assessment, diagnosis, planning and implementation that are all used
in nursing practice today (Salotti, 2003). Nightingale’s work underscores the importance of
nursing research. In fact, Nightingale has been credited with being a pioneer in the pie graph
display when she utilized a pie graph to compare death rates among military hospitals in the
Crimean War (Kudzma, 2006). Nightingale proved to be a brilliant statistician in her work with
William Farr, and her belief in the necessity to collect data and evaluate statistics has developed
into evidence-based nursing practice (Parker & Smith, 2010). The Environmental Theory has
proven its accessibility over time and is still used today.
Importance
The overall purpose of the theory is to provide a direction for nursing through
environmental adaptation and manipulation so that the person receiving care attains positive
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NIGHTINGALE THEORY
health changes (Nightingale, 1859). The purpose of the Environmental Theory is consistent with
nursing in that it aims to create a better quality of life for all patients. In this manner, the
Environmental Theory is futuristic. For example, Nightingale used sensory observation to
recognize that washing was a significant and therapeutic nursing intervention (Clements &
Averill, 2006). Over time, research has proven that contaminated hands are the predominate
mode of transmission of infectious agents (“Infection Prevention,” 2007). Nightingale (1859)
clearly stated, “Every nurse ought to be careful to wash her hands very frequently during the
day” (p. 72). Hand washing has transformed into a form of primary prevention and is used
throughout the field of nursing. Nursing is vital to the Environmental Theory because the nurse is
viewed as the change agent in terms of altering the environment (Wagner & White, 2010). The
Environmental Theory is broad in scope and can be applied to a plethora of nursing domains. It
is used regularly within the field of nursing, nursing education, and nursing research (Selanders,
2010). Therefore, the Environmental Theory is vital to the field of nursing.
Summary & Conclusion
The overall focus of Nightingale’s Environmental Theory is to prevent disease through
alteration of the environment (Nightingale, 1859). This concept demonstrates an altruistic action
that is consistent with the field of nursing. One of the biggest overall weaknesses of the theory is
the assumption that disease is always a direct result of the environment (Nightingale, 1859).
While disease can be caused by environmental factors, it is also caused by other factors such as
genetics and trauma (Selanders, 2010). In addition, the Environmental Theory is limited to the 13
canons that were created during the Victorian era, and it is necessary to adapt or alter these sub
concepts to better meet present day issues. For example, while air quality is important, especially
for patients with chronic lung disease such as asthma, it can be detrimental to use external air
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quality as a standard particularly in regards to pollution. Nightingale (1859) appears to write
almost exclusively from the context of the Crimean War in Notes on Nursing, which limits her
scope of practice since it seems to be based on only one experience. Even so, the applicability of
the 13 canons to various other nursing contexts is possible. It would be more beneficial if the 13
canons had explicit definitions so that individual inferences are not possible. Additionally, the
definition of health is not explicitly stated. Nightingale explains health as the process of being
well and having the ability to use every power an individual possesses (Selanders, 2010). From
this statement, various inferences and assumptions regarding the meaning of health result as
health is defined in an abstract manner. Nightingale also never clearly defines the construct of
caring even though it can be seen in her actions (Parker & Smith, 2010). Fortunately,
Nightingale’s actions are well documented and seem to speak volumes even when her written
definitions are lacking.
The Environmental Theory was formed as a result of Nightingale’s work as a nurse. The
environment is an umbrella concept found within Nightingale’s Environmental Theory that grew
out of her empirical observations such as her observation that unsanitary conditions led to
disease and death among British soldiers during the Crimean war (Selanders, 2010).
Nightingale’s framework for nursing emphasized the utilization of empiric knowledge and
statistics (Chinn & Kramer, 2008). A major strength of the Environmental Theory is its reliance
on observation and data collection, which has transformed into evidence-based practice. Another
strength of the Environmental Theory is how it gives nurses an active role while also
encouraging patients to take a key role in their health with the need for self-healing (Parker &
Smith, 2010). This type of active nursing promotes compassion, support, and the giving of time
and self while also encompassing knowledge, skills, and expertise in a variety of settings
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(Wagner & White, 2010). In this manner, nursing is seen as both an art and a science.
Furthermore, the Environmental Theory promotes the necessity of an expanding body of nursing
knowledge that is distinctly separate from medical knowledge (Macrae, 1995). Moreover, the
greatest overall strength is Nightingale’s creation of holistic nursing care. In this manner, nurses
become therapeutic partners with their patients while utilizing nursing knowledge, theory,
research, expertise, intuition, and creativity (Dossey, 2005).
While several weaknesses are present in the Environmental Theory, its strengths
definitely outweigh its weaknesses. The generic vision of Nightingale makes her theory
applicable to everyone, particularly nurses (Dossey, 2010). The Environmental Theory has
proven to be timeless with its theoretical principles of nursing lasting throughout time (Bunkers,
2008). Nightingale’s wisdom and vision have proven to be applicable from the mid-Victorian era
to the present (Selanders, 2010). Perhaps Tourville and Ingalls (2003) explain the significance of
Nightingale’s Environmental Theory best, “The foundation of all model or theories is
Nightingale and the metaparadigms of person, environment, health, and nursing. It is through her
work and teachings of caring, being accountable, seeking ways to improve avenues of care, and
emphasizing the professionalism of nursing that nursing has reached its present high standards”
(p. 30). Nightingale is certainly worthy of praise and gratitude for her creation of a nursing
theory that continues to shape nursing practice.
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NIGHTINGALE THEORY
References
Bunkers, S. S. (2008). The timelessness of nursing theory. Nursing Science Quarterly, 21(3),
211-212.
Chinn, P.L. & Kramer, M.K. (2008). Integrated Theory and Knowledge Development in Nursing
(Seventh Edition). St. Louis, MO: Mosby Elsevier.
Clements, P. T., & Averill, J. B. (2006). Finding patterns of knowing in the work of Florence
Nightingale. Nursing Outlook, 54(5), 268-274.
Dossey, B. (2005). Florence Nightingale and holistic nursing. Imprint, 52(2), 58-60.
Dossey, B. M. (2010). Florence Nightingale's vision for health and healing. Journal of Holistic
Nursing, 28(4), 221-224.
Infection prevention and control in pediatric ambulatory settings (2007). Pediatrics, 120(3), 650665.
Kudzma, E.C. (2006). Florence Nightingale and healthcare reform. Nursing Science Quarterly,
19(1), 61-64.
Macrae, J. (1995). Nightingale’s spiritual philosophy and its significance for modern nursing.
Journal of Nursing Scholarship, 27(1), 8-10.
McCabe, P. (2000). Naturopathy, Nightingale, and nature cure: A convergence of interests.
Complementary Therapies in Nursing & Midwifery, 6(1), 4-8.
Nightingale, F. (1859). Notes On Nursing: What It Is And What It Is Not. New York, NY: Barnes
and Noble.
Parker, M.E. & Smith, M.C. (2010). Nursing Theories and Nursing Practice (Third Edition).
Philadelphia, PA: F.A. Davis.
NIGHTINGALE THEORY
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Salotti, R. (2003). Notes On Nursing: What It Is And What It Is Not. New York, NY: Barnes and
Noble.
Selanders, L. C. (2010). The power of environmental adaptation: Florence Nightingale's original
theory for nursing practice. Journal of Holistic Nursing, 28(1), 81-88.
Tourville, C., & Ingalls, K. (2003). The living tree of nursing theories. Nursing Forum, 38(3),
21-30.
Wagner, D. J., & White, B. (2010). An exploration of the nature of caring relationships in the
writings of Florence Nightingale. Journal of Holistic Nursing, 28(4), 225-234.
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Figure 1
Nightingale’s 13 Canons
Ventilation & Warming
Health of Houses
Petty Management
Noise
Variety
Taking Food
What Food?
Bed and Bedding
Light
Cleanliness of Rooms and Walls
Personal Cleanliness
Chattering Hopes and Advices
Observation of the Sick
Viewed as the first rule of nursing. Describes how air
inside should be as pure as air outside and includes
taking patient outside and/or opening windows.
Describes the maintenance of pure air, pure water,
efficient drainage, cleanliness, and light.
Describes the management of a house, including
designation of tasks, and underscores the role and
importance of management.
Describes the elimination of unnecessary noise and
prevention of unnecessary waking so that patients get
proper rest.
Describes the providing of a variety of settings to
stimulate patient and prevent boredom and
underscores the importance of psychological benefits,
aesthetics, and holistic care.
Describes the importance of food, nutrients, and
nourishment as well as noting amount of food ingested.
Describes the providing of a variety of foods to meet
patients’ nutritional needs in order to repair waste.
Describes the importance of clean bed linens as well as
airing out sheets and placing patients in sunlight with a
view.
Viewed as the second most important canon. Describes
placing patients in the sunlight and going outside
and/or opening window(s) when possible.
Describes the importance of hygiene and emphasizes
the maintenance of a clean environment.
Describes the importance of clean clothes and clean
skin since toxins can be removed via skin.
Describes the opportunity for nurses to distract
patients and help with coping, but should be kept to a
minimum as it uses up a patient’s energy and nurses
need to maintain boundaries.
Viewed as the most important nursing lesson in
regards to nursing education. Describes the importance
of observation and experience as key components to
nursing care.
Note. Description of 13 canons is from Nightingale, F. (1859). Notes On Nursing: What It Is And
What It Is Not. New York, NY: Barnes and Noble.