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1 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 2 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. 3 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 4 5 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). NIGHTINGALE THEORY 6 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 NIGHTINGALE THEORY 7 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, NIGHTINGALE THEORY 8 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 NIGHTINGALE THEORY 9 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 10 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 NIGHTINGALE THEORY 11 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 NIGHTINGALE THEORY 12 (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. 13 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 14 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. NIGHTINGALE THEORY 15 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.