Florence Nightingale: Environmental Theory and Biography

Nightingale's Environmental Theory is the oldest idea you act on every shift without naming it: change the patient's surroundings to let the body heal. Air, water, drainage, cleanliness, light. She built nursing's first theory out of what she saw kill soldiers at Scutari, and the profession traces back to her.

Biography of Florence Nightingale

Florence Nightingale (12 May 1820 – 13 August 1910) shaped modern nursing practice and set the standards the profession still works from. She is the first nurse theorist, known for the Environmental Theory that pushed nursing toward sanitary conditions for patient care, and she is recognized as the founder of modern nursing. During the Crimean War she tended wounded soldiers at night and became "The Lady with the Lamp."

Early Life

Nightingale was born May 12, 1820, in Florence, Italy, the younger of two children in a British family that moved in elite social circles. Her father, William Shore Nightingale, was a wealthy landowner who had inherited two estates: Lea Hurst in Derbyshire and Embley Park in Hampshire.

Her mother, Frances Nightingale, came from a family of merchants and prized socializing with people of standing. Nightingale herself was reportedly awkward in social settings and avoided being the center of attention. Strong-willed, she often clashed with her mother, whom she found controlling, while still wanting to please her. "I think I am got something more good-natured and complying," she wrote of the relationship.

Education

Nightingale was raised on the family estate at Lea Hurst, where her father gave her a classical education that included German, French, and Italian, and she excelled in mathematics. She took up philanthropy young, ministering to the ill and poor in the village near the estate. At seventeen she decided to dedicate her life to medical care for the sick, a lifelong commitment to overhaul and sanitize England's appalling health-care conditions. Over her parents' objections, she enrolled as a nursing student in 1844 at the Lutheran Hospital of Pastor Fliedner in Kaiserswerth, Germany.

Personal Life

Announcing her decision to nurse in 1844 was not easy. Her mother and sister opposed the choice, against society's expectation that she marry and raise a family, but she held firm and worked to learn her craft. She rejected a suitor, Richard Monckton Milnes, 1st Baron Houghton, fearing that men would interfere with her work. Her father's income let her pursue her career and still live comfortably. Though she kept important friendships with women, including a correspondence with an Irish nun, Sister Mary Clare Moore, she preferred friendships with powerful men.

Environmental Theory

Nightingale's Environmental Theory defined nursing as "the act of using the patient's environment to assist him in his recovery." The nurse configures the environment for the gradual restoration of health, on the principle that external factors in the patient's surroundings affect the life or biologic and physiologic processes and the patient's development. She identified five environmental factors: fresh air, pure water, efficient drainage, cleanliness or sanitation, and light or direct sunlight.

Works

From her observations in the Crimea, Nightingale wrote Notes on Matters Affecting the Health, Efficiency, and Hospital Administration of the British Army, an 830-page report analyzing her experience and proposing reforms for military hospitals. It sparked a restructuring of the War Office's administrative department, including a Royal Commission for the Health of the Army in 1857.

In 1860 she published Notes on Nursing, outlining nursing principles. It is still in print and translated into many languages. In all, she published some 200 books, reports, and pamphlets. With money from the British government she funded the founding of St. Thomas' Hospital and, within it, the Nightingale Training School for Nurses.

In the 1870s she mentored Linda Richards, "America's first trained nurse," who returned to the United States equipped to build high-quality nursing schools and went on to become a pioneer in the United States and Japan. In the early 1880s, Nightingale wrote a textbook article advocating strict precautions to kill germs. Her work inspired nurses in the American Civil War; the Union government sought her advice on field medicine, and though her ideas met official resistance, they shaped the volunteer United States Sanitary Commission.

Appointments

In 1853, Nightingale took the superintendent's post at the Institute for the Care of Sick Gentlewomen on Upper Harley Street, London, holding it until October 1854.

In 1854, Britain was at war with Russia. Battlefield medical facilities were deplorable, so Minister at War Sidney Herbert, who already knew Nightingale, appointed her to oversee care of the wounded. She arrived in Constantinople, Turkey, with a company of 38 nurses. Female nurses in military hospitals proved a major success: sanitary conditions improved, nurses worked as capable assistants to physicians, and they raised morale by banking soldiers' wages home, writing letters to families, and reading to the wounded.

Crimean War

As newspaper reports described the lack of proper medical facilities for wounded British soldiers, Sidney Herbert asked Nightingale to oversee a team of nurses in Turkey's military hospitals. In 1854 she led an expedition of 38 women to take over the barrack hospital at Scutari, where she found disastrous sanitary conditions. She returned to England in 1856. In 1860 she established the Nightingale Training School for nurses at St Thomas' Hospital, London; once trained, the nurses were sent to hospitals across Britain to establish training on the Nightingale model.

Awards and Honors

Nightingale became "The Lady with the Lamp." During the Crimean War she made her rounds at night, first on horseback, then by mule cart, then in a hooded carriage, using an oil lamp to light her way. She stayed at Scutari for a year and a half. In the summer of 1856, with the conflict resolved, she returned to her childhood home at Lea Hurst to a hero's welcome she did her best to avoid.

The Queen rewarded her with an engraved brooch, the "Nightingale Jewel," and a prize of $250,000 from the British government. In 1883 Queen Victoria awarded her the Royal Red Cross. In 1904 she was appointed a Lady of Grace of St John's Order (LGStJ). In 1907 she became the first woman awarded the Order of Merit, and the following year she received the Honorary Freedom of the City of London.

Death

Nightingale fell ill in August 1910 and seemed to recover. A week later, on the evening of Friday, August 12, 1910, troubling symptoms returned, and she died unexpectedly at 2 pm the following day, Saturday, August 13, at her home in London, leaving a large body of work including several hundred unpublished notes.

She had asked for a quiet, modest funeral. Her relatives turned down a national funeral, and the "Lady with the Lamp" was laid to rest in the family plot at St. Margaret's Church, East Wellow, Hampshire.

In honor of the "Angel of the Crimea," the Florence Nightingale Museum sits on the site of the original Nightingale Training School for Nurses and houses more than 2,000 artifacts. Her name is universally recognized as the pioneer of modern nursing.

Memory

Nightingale has a memorial in St. Paul's Cathedral. A Florence Nightingale Museum is located at St. Thomas Hospital in London, where she founded the nursing school. The US Navy launched a namesake troop transport during World War II, the USS Florence Nightingale, which received four battle stars.

The Florence Nightingale School of Nursing and Midwifery continues at King's College London, and the Nightingale Building in the School of Nursing and Midwifery at the University of Southampton is named after her.

Hospitals

Four hospitals in Istanbul carry her name, all belonging to the Turkish Cardiology Foundation: F. N. Hastanesi in Şişli (the biggest private hospital in Turkey), Metropolitan F.N. Hastanesi in Gayrettepe, Avrupa F.N. Hastanesi in Mecidiyeköy, and Kızıltoprak F.N. Hastanesi in Kadiköy.

Audio

Nightingale's voice survives in a 1890 phonograph recording held in the British Library Sound Archive, made in aid of the Light Brigade Relief Fund: "When I am no longer even a memory, just a name, I hope my voice may perpetuate the great work of my life. God bless my dear old comrades of Balaclava and bring them safely to shore. Florence Nightingale."

Museums

Exhibits include folklore items such as her preserved pet owl, Athena, who lived in her pocket. Elizabeth Blackwell, America's first female doctor, opened the Women's Medical College.

In 1912 the Red Cross's International Committee instituted the Florence Nightingale Medal, awarded every two years to nurses or nursing aides for outstanding service. International Nurses Day and International CFS Awareness Day are celebrated on her birthday each year.

Nightingale's Environmental Theory

The Environmental Theory defined nursing as "the act of using the environment of the patient to assist him in his recovery." The nurse configures the surroundings for the gradual restoration of health, on the principle that external factors in the patient's environment affect the life or biologic and physiologic processes and the patient's development. Nightingale laid this out in Notes on Nursing: What It Is, What It Is Not. She is the first theorist in nursing and laid the foundation for the profession.

Major Concepts

Nursing

"What nursing has to do... is to put the patient in the best condition for nature to act upon him" (Nightingale, 1859/1992). Nursing, she wrote, "ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet, all at the least expense of vital power to the patient." She held that "the art of nursing, as now practiced, seems to be expressly constituted to unmake what God had made disease to be, viz., a reparative process."

Human Beings

Nightingale does not define human beings specifically. They are defined in relation to their environment and its impact on them.

Environment

Nightingale stresses the physical environment. Her writings reflect a community health model in which everything surrounding a person bears on their health state.

Health

Nightingale (1859/1992) did not define health specifically: "We know nothing of health, the positive of which pathology is negative, except for the observation and experience." Given her view that nursing's art is to "unmake what God had made disease," the goal of all nursing activity is client health. She held that nursing serves the healthy as well as the ill, and she treated health promotion as nursing work.

Subconcepts of the Environmental Theory

Health of Houses

"Badly constructed houses do for the healthy what badly constructed hospitals do for the sick. Once ensure that the air is stagnant and sickness is certain to follow."

Ventilation and Warming

"Keep the air he breathes as pure as the external air, without chilling him." Nightingale believed a person who repeatedly rebreathed his own air would become or stay sick. She worried about "noxious air," "effluvia," and foul odors from excrement, and she criticized "fumigations" because the offensive source, not the smell, must be removed. She also stressed room temperature: the patient should be neither too warm nor too cold, balanced between burning fires and ventilation from windows.

Light

Second to fresh air, the sick need light, and Nightingale noted patients want direct sunlight.

Noise

Patients should never be "waked intentionally" or accidentally during the first part of sleep. Whispered or long conversations about patients are thoughtless and cruel, and she viewed unnecessary noise, including the noise of female dress, as cruel and irritating.

Variety

She called for changes of color and form, such as brightly colored flowers or plants, and advocated rotating 10 or 12 paintings and engravings each day, week, or month for variety, along with reading, needlework, writing, and cleaning to relieve boredom.

Bed and Bedding

An adult in health exhales about three pints of moisture through the lungs and skin in a 24-hour period; that organic matter stays in the sheets unless bedding is changed and aired often. The bed belongs in the lightest part of the room, positioned so the patient can see out a window, and the caregiver should never lean against, sit on, or needlessly shake it.

Personal Cleanliness

"Just as it is necessary to renew the air around a sick person frequently to carry off morbid effluvia from the lungs and skin, by maintaining free ventilation, so it is necessary to keep pores of the skin free from all obstructing excretions." "Every nurse ought to wash her hands very frequently during the day."

Nutrition and Taking Food

People want different foods at different times of day, and frequent small servings may help more than a large breakfast or dinner. No business should be done with patients while they eat, since it distracts them.

Chattering Hopes and Advice

Falsely cheering the sick by making light of their illness and its danger does not help. The nurse should heed what visitors say, since sick people should hear the news that helps them get healthier.

Social Considerations

Look beyond the individual to the social environment in which they live.

Environmental Factors

Nightingale identified five environmental factors: fresh air, pure water, efficient drainage, cleanliness or sanitation, and light or direct sunlight.

1. Pure fresh air – "to keep the air he breathes as pure as the external air without chilling him."
2. Pure water – "well water of a very impure kind is used for domestic purposes. And when the epidemic disease shows itself, persons using such water are almost sure to suffer."
3. Effective drainage – "all the while the sewer may be nothing but a laboratory from which epidemic disease and ill health are being installed into the house."
4. Cleanliness – "the greater part of nursing consists in preserving cleanliness."
5. Light (especially direct sunlight) – "the usefulness of light in treating disease is very important."

These mattered enormously in Nightingale's time, when health institutions had poor sanitation and health workers had little training. She also emphasized a quiet, warm environment and attention to dietary needs through assessment, documenting the time of food intake and its effects. Deficiencies in these five factors produce illness, but the body can repair itself in a nurturing environment.

Analysis of the Environmental Theory

Today's environmental conditions run well past what is natural and nurturing: global warming, nuclear radiation threats, human-made calamities, and pollution. Against that backdrop, parts of Nightingale's model are in question. Her call for fresh air runs up against industrialization, and fresh air is not always good for every patient, since natural air carries impurities that can infect open wounds and drainage, as in burns. With light, today's sunlight is harmful because of ozone-layer destruction, so constant direct exposure can hurt more than help. A healthy environment does heal, as Nightingale stated, but the harder question now is how the environment stays healthy amid technology and industrialization. The theory needs development to fit those changes, but it remains a superb starting point that catalyzed nursing's progress.

Assumptions

• Five points are essential to a healthful house: "pure air, pure water, efficient drainage, cleanliness, and light."
• A healthy environment is essential for healing; "nature alone cures."
• Nurses must observe their patients accurately and report the patient's state to the physician in an orderly way.
• Nursing is an art, medicine a science. Nurses are loyal to the medical plan but not servile.

Strengths

Nightingale's writing is cultured, logical, and elegant. The theory has broad reach: it applies in complex intensive care environments, the home, a worksite, or the community, and it raises the nurse's awareness of how the environment shapes client outcomes.

Weaknesses

There is scant attention to the psychosocial environment compared with the physical one, and applying the concepts in the modern era is, in places, in question.

Conclusion

The Environmental Theory is a patient-care theory focused on altering the patient's environment to change their health, with care of the patient counting for more than the nursing process or the nurse-patient relationship. The model must be adapted to each patient. Environmental factors affect different patients differently by situation and illness, so the nurse addresses them case by case to best care for the individual.