Florence Nightingale is the founder of modern nursing and was known as “Lady with the Lamp”. She is one of the most well-known nursing theorists (currentnursing.com, 2012). Nightingale’s theory has been used for over a hundred years and still critical to the nursing profession today (Selanders ; Crane, 2012). Her theory is mainly based on environmental factors, such as light, cleanliness, clean air and ventilation, warmth, diet and noise (Claywell, 2014). Nightingale (1969) emphasized almost more than anything else that without clean, pure, warm air, a patient will likely never get better. She also emphasized that if the nurses could only do one thing, they should forget everything else and ‘keep the air he (the patient) breathes as pure the external air, without chilling him’ (Nightingale, 1969). The environment theory was formed when Nightingale found that the health institution had poor sanitation, health workers had a little education and training and were frequently incompetent and unreliable in attending to the needs of the patients. She stated in her nursing notes that nursing “is an act of utilizing the environment of the patient to assist him in his recovery” (Nightingale, 1860).
There are seven assumptions made in the Environment Theory which focuses on taking care of the patient’s environment in order to reach health goals and cure illness. These assumptions are: 1) naturals laws, 2) mankind can achieve perfection, 3) nursing is a calling, 4) nursing is an art and a science, 5) nursing is achieved through environmental alteration, 6) nursing requires a specific educational base, and 7) nursing is distinct and separate from medicine. A nurse’s role in a patient’s recovery is to alter the environment in order to gradually create the optimal conditions for the patient’s body to heal itself. For example in some cases, it would mean minimal noise and in other cases could mean a specific diet. All of these areas can be manipulated to help the patient meet his or health goals and get healthy.
Nursing is a distinct field and is not like medicine. It is a science and also an art. As Nightingale served as a nurse during the Crimean War, she observed that there is correlation between the patients who died and their environmental conditions. As a result of these observation, the Environment Theory of nursing was born. In her book, “Notes on Nursing, she explained about this theory: What it is, What it is Not. In Nightingale’s days, hospitals were regarded as places to die, and not places to receive healing (Rechel, Wright, Edwards, Dowdeswell & McKee, 2009). In view of this, she strived to obtain a higher standard, starting in the Crimean War and continuing on after returning home. Under hardwork and leadership of Nightingale during the war, the death rate of patients fell from 42% to 2.2% (Samadi, 2014). Nightingale instituted her environmental theory beginning in the Crimean war by providing ‘an enormous supply of clean shirts, plenty of soap and such necessities as plates, knives and forks, cup and glasses to the hospital ward (Fee & Garofalo, 2010).
Florence Nightingale, through the Environmental Theory defined Nursing as ‘the act of utilizing the environment of the patient to assist him in his recovery”. In clinical setting, it involves the nurse’s initiative to configure environmental settings appropriate for the gradual restoration of the patient’s health, and that external factors associated with the patient’s surroundings affect life or biologic and physiologic processes, and his development. As she stated that “What nursing has to do, is to put the patient in the best condition for nature to act upon him” (Nightingale, 1859/1992). A person or human beings is a member of nature whose natural defenses are influenced by a healthy or unhealthy environment (Medeiros, 2015).
In nursing, such concern about the environment has existed since the foundation of professional nursing in the second half of the nineteenth century. It can be found on the present days, in a humanized care, based on environmental control around the patient, which is seen as a being that is part of relationships and interactions with the environment in which this one can be found. Nurses are responsible to modify patient’s environment as a basic component of nursing care. Nightingale emphasizes on the manipulation of physical environment as a basic component of nursing care. Health is not only to be well, but to be able to use well every power we have to use (Butts and Rich, 2015). Disease is a process given by nature to clean the body from impurity which has entered the body because one or more of the body’s natural needs is not fulfilled (Rahim, 2013).Thus, in this paper, I will examine Florence Nightingale’s environment theory and how it should be apply to nursing profession in clinical setting to restore health and healing for the patient by give example of case scenario.
The clinical scenario that I still recall was the day when I faced the patient with respiratory problem. Mr. R, 62 years old from Kampung X was admitted for the second time in Hospital H with the diagnosis of exacerbation of Chronic Obstructive Pulmonary Disease (COPD). His wife with three sons accompanied him to the ward. He was admitted with the complaint of severe shortness of breath, cough and high grade fever. For the past fifteen years, the patient was suffering from COPD. Although the patient was not smoking in the hospital, he used to smoke three packs of cigarette daily for the past twenty years. Chest X- ray revealed irregular densities noted on the left apex of is left lung suggesting chronic inflammatory process. Patients weight also decrease in previous months. Mr. R was sitting in high Fowler’s position, breathing with 3litre oxygen through nasal prongs. When I entered in to his room (sharing room with 8 patients), I greet him and started the conversation about his condition that day. At once I felt that he was not feeling comfortable to talk because of dyspnea. He told me that he had increased amount of yellow thick sputum while coughing. He also complaint that his appetite was decreasing because of cough and shortness of breath (SOB). He had sleep disturbance which is during sleeping, he used more pillows because difficult to breath, even he needs to sleep on the chair instead of bed to avoid SOB. This eventually resulted in increased headache in the morning. Moreover, he had increased feeling of fatigue and lack of energy. For daily activities daily living, he even dependent on his family. In surrounding of the room, I noticed that the room’s windows were closed. He told me he never open the windows as he was afraid that the outside dust will exacerbate and worsening his condition. Further, I observed that his food was placed on bedside and used meal tray were also kept there. The washroom door inside the room was slightly open. Under his bed, I saw a bag with full of soiled linens. There’s also small dustbin placed besides his bed which was filled with used tissues. All these things were making the room untidy. His vital signs were stable, oxygen saturation with 3L oxygen through nasal prong was 98%. During my initial visit, at once I removed the used meal tray and soiled lines from his room. At the end of my shift, I was shocked when suddenly the patient’s attendant came out from the room shouting that the patient is complaining of SOB and chest tightness. Immediately, I checked his oxygen saturation and the reading was below the normal range which is 84%. Simultaneously, nebulizer was administered and the doctor was informed. Gradually, his condition become worsen which is critical and he was transfers to intensive care unit at that evening.
APPLICATION OF NIGHTINGALES ENVIRONMENT THEORY IN CLINICAL SETTING
Florence Nightingale didn’t use the environmental theory of nursing to create definitions of who was a patient or a human beings. She didn’t even attempt to define what “good health” would actually be. She simply believe that nurses could make environmental modifications to help eliminate the promotion of internal disease. From this statement, it can be conclude that Nightingale believe that people who did not take care of their personal environments properly would be more susceptible to disease.
When I assessed the case scenario, keeping in mind of Nightingale’s environmental theory, I came to know that few aspects of physical environment was ignored which pushed the patient to critical situation. Mr. R was diagnosed as COPD. COPD is a progressive lung disease that makes a person feels increasingly difficult to breathe. The condition mostly occurs in people aged 40 years and above and is mainly caused by smoking and smog in the atmosphere. Common symptoms are breathlessness, excessive phlegm production, as well as chronic cough (WHO, 2015).
Over the years, there have been many educational initialize around COPD, yet there are still many undiagnosed COPD cases in Malaysia. It is estimated that 500,000 Malaysians have COPD (The Malaysia Times, 2014) and many of them are suffering in silence. Patients often misread their increased breathlessness and coughing as symptoms of asthma or even as ‘smokers cough’, others may mistakenly assume the symptoms as signs of ageing. Many cases also go unnoticed as COPD can develop for years without any noticeable signs of shortness of breath. The lack of awareness of the disease contributes to late diagnosis of COPD. There is need to continue awareness and educational programs to increase early detection and better management of COPD. Thus, nurse should manipulate the surrounding to promote sufferer recovery and should be skillful, vigilant and confidential, also their practice should be evidence base.
When I reflect back to the scenario, I realized that if I had modified the patient’s environment during my first interaction, his condition might not have deteriorated. Nightingale (1860) as cited by Rahim (2013) emphasized that, ‘the most important practical lesson that can be given to nurses is to teach them what to observe-how to observe; which are the evidence of neglect and of what kind of neglect. From Nightingale’s different aspects of environment, Mr. R’s ventilation, food and room cleanliness was adversely affected. Nightingale (1969) as cited by Rahim (2013) that when one or more aspects of the environment are out of balance, the patient uses his increased energy to balance it; however, this extra effort drains his energy which put delays in his healing.
One of the important concepts of Nightingale theory is cleanliness of room and walls. She pointed out, “greater part of nursing consists in preserving cleanliness”. Moreover, Nightingale linked the ventilation with cleanliness. She emphasized, “Without cleanliness, you cannot have all the effect of ventilation; without ventilation, you can have no thorough cleanliness”. Unclean room was another important factor which has affected the patient’s health. In current scenario, Mr. R was suffering from COPD and had severe cough, so in that situation dust acts as allergen which has exacerbated the patient’s condition. His room also was crowded and windows were closed so there was no proper ventilation which made the patient sick. Mr. R did not open the windows because he thought that dust from outside will affect negative on his health, however, he was not aware of inside dust. At that time, I could have opened the windows for certain period of time and then closed it. As Nightingale (1860) stated that ventilation of the sick room means open the windows with the alternative intervals and closed them after intervals of time so that room should be adequately fresh aired. Besides, I could have limited the attendants and gave teaching to patient and his family members regarding importance of proper ventilation. Nightingale (1969) as cited by Parker & Smith (2010) believed that the person who repeatedly breathed his or her own air would become sick or remain sick. Nightingale also addressed that proper arrangement of sunlight in the room is beneficial for both health and recovery. Moreover, a small dustbin was placed beside patient’s bed which was full of garbage. That was also source of infection and irritant for the patient. I could have given awareness on important of environmental hygiene to patient and especially the family members because patient was dependent to them.
Another concern of my patient was his limited food intake. Mr. R was unable to take his food due to dyspnea. According to Nightingale cited in George, (2002), ‘Chronically ill patients may be starved to death because their incapacitation can make them unable to feed themselves and attention is not given to what will enhance their ability to eat”. I feel that if I had given attention to patient’s diet then he might have eaten some food. Nightingale also emphasized, “let the food come at the right time, and be taken away, eaten or uneaten, at the right time” (Nightingale, 1969). Nightingale also instructed nurses that, “have a rule of thought about your patient’s diet; consider, remember how much he has had, and how much he ought to have today” (Nightingale, 1969). May be if I had considered Mr. R’s food preferences then it might have worked as Nightingale emphasized that the patient desire a different pattern of taking foods like eating breakfast food at lunch time. Though I noticed that patient’s meal tray was having more than half food left, I thought that when patient feel he is better he will take it.
Mr. R came from heritage background who just had a primary education. Another important aspects is that he do not have access to primary health care center which deprived them from environment health care awareness. In my patient scenario, patient’s family background including his sons who were not educated because their social environment does not permit them to give important to education. When I requested family members to limit attendants, they started arguments. They were thinking if they remain with patient then it will help patient to improve his health. They did not understand that COPD patients should be avoid crowd because it precipitates his condition. It is estimated that 500,000 Malaysians have COPD and many of them are suffering in silence. Patients often misread their increased breathlessness and coughing as symptoms of asthma or even as ‘smokers cough’, others may mistakenly assume the symptoms as signs of ageing (The Malaysian Times, 2014). Many cases also go unnoticed as COPD can develop for years without any noticeable signs of shortness of breath. The lack of awareness of the disease contributes to late diagnosis of COPD.
Nightingale’s environmental theory assist health care professional to provide unique contribution in caring for their patients. Her theory of care which more than a century old is appropriate for application to the care of patients diagnosed COPD. Florence Nightingale’s environmental theory of nursing has one core principle: that nursing is the act of utilizing the environment of the patient I order to assist that patient in their recovery. By configuring the environment of a patient so that it best meets their needs at that moment, it would assist in the healing process. Nightingale believed that there were many natural elements that could help a patient begin to have their health restore. Nursing, she proposed, was more than just emotionally caring for a patient, following doctor’s order, or meeting physical needs. By adding light, warmth, fresh air, quietness and cleanliness to the environment in a proper order, then along with meeting nutritional needs, a patient could unmake what God had made disease to be.
The environment is capable of preventing or contributing to disease or death. The environment paradigm in Nightingale’s Model is understandably the most important aspect. Her observation taught her that unsanitary environments contribute greatly to ill health, and that the environment can be altered in order to improve conditions for a patient and allow healing to occur. Thus, it is our responsibility as a nurse for maintaining an environment that is adequate to sustain the health of the patient. By having environmental control around the patient and the relationships and influences of the nurse, the health and disease states of a patient can be enhanced.
Florence Nightingale’s emphasized on manipulation of physical environment as a basic component of nursing care. Nightingale identified 13 canons of environment and gave a detailed description of each aspect. Her major canons include: ventilation, light, noise, cleanliness of room/walls, bed and bedding, personal cleanliness and taking food. According to Nightingale, if nurses modify patients environment according to her 13 canons, she can help patient to restore his usual health or bring patient in recovery. Hence, Nightingale provided a basis for providing holistic care to the patients and it is still applicable today. It is recommended that awareness regarding basic environmental hygiene should be given at community and hospital level.
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