RAHMAN INSTITUTE OF NURSING AND PARAMEDICAL

SCIENCES, GUWAHATI

ASSIGNMENT
ON
CONCEPT OF EVIDENCE BASED PRACTICE

SUBJECT: NURSING RESEARCH AND STATISTICS

Submitted to: Submitted by:

Mrs. Marami Baishya Malsawmpuii
Asst. Professor M.Sc (N) 1stYear
Department of OBG Roll No - 1

Date of Submission: _________________

 CONTENT

 Introduction

 Biography of Nightingale

 Healthful Environment

 Assumptions of Nightingale’s Theory

 Nightingale’s Nursing theory

 Conceptual framework of Nightingale’s Environmental Theory

 Nightingale’s Environmental theory’s Model

 Nightingale’s Model and the characteristics of Theory

 Nightingale’s theory and Metaparadigm in Nursing

 Application of Nightingale’s theory in the nursing process

 Application of Nightingale’s theory in practice and education

 Strengths of Nightingale’s theory

 Weakness of Nightingale’s theory:

 Limitation

 Critique

 Conclusion

 Research Review

 Bibliography
NIGHTINGALE’S ENVIRONMENTAL THEORY

Introduction

Florence Nightingale’s Environmental Theory defined Nursing as “the act of utilizing the
environment of the patient to assist him in his recovery.”

It involved the nurse’s initiative to configure environmental setting appropriate for the gradual
restoration of the patient’s health and that external factors associated with the patient’s
surrounding affect life or biology and physiologic processes, and his development. She identified
FIVE environmental factor- Fresh air, pure water, efficient drainage, cleanlinessor sanitation and
light to direct sunlight.

Biography of Nightingale

 Born- 12 May 1820 in Florence, Italy.

 Founder of modern nursing, the first nursing theorist.
 Pioneer of the formal nursing concept.
 In 1844, Nightingale enrolled as a nursing student at the Lutheran Hospital of Pastor
Fliedner in Kaiserwerth, Germany.
 In the early 1850s, Nightingale returned to London, where she took a nursing job in
Amiddlesex Hospital. Hospital authorities were impressed by her work and gave
promotion to the post of superintendant within one year.
 In 1860 she established ST. Thomas’ Hospital and the Nightingale Training School for
nurses.
 In 1854, the minister of war appointed her as Nursing Superintendent on War torn
environment.
 Her experience in treating sick/injured soldiers in the Crimean war strongly influenced
her philosophy of nursing.
 Patient’s needs should be prioritized according to Maslow’s Hierarchy.
  With her lamp, Nightingale traverse the night during the Crimean War. Nightingale
became a heroine in Great Britain as a result of her work in the war with the title “The
Lady with the lamp.”
 In 1860 Nightingale published Notes on Nursing.
 She explained her environmental theory in her famous book Notes on Nursing: what it is,
what it is not.
 She was the first to propose nursing required specific education and training.
 She was a statistician, using bar and pie charts, highlighting key points.
 International Nurses Day, May 12 is observed in respect to her contribution to Nursing
profession.
 She died in her sleep at the age of 90 on August 13, 1910 in London.

Assumptions of Nightingale’s Theory

The assumptions of Florence Nightingale in her Environmental Theory are as follows:

 Florence Nightingale believed that five points were essential in achieving a healthful
house: “pure air, pure water, efficient drainage, cleanliness, and light.”

 A healthy environment is essential for healing. She stated that “nature alone cures.”

 Nurses must make accurate observations of their patients and report the state of the
patient to the physician in an orderly manner.

 Nursing is an art, whereas medicine is a science. Nurses are to be loyal to the medical
plan but not servile.

Nightingale’s Nursing theory

 Nightingale’s nursing theory the first published nursing theory in 1860.

 Persons are in relation with the environment. Stresses the healing properties of the
physical environment (fresh air, light, warmth, and cleanliness).
 Nursing puts patients in the “best conditions” for nature to act upon them.
  Health is “the positive of which the pathology is the negative”. “Nature alone cures”.
 When aspects of the environment are out of balance, the client must use energy to counter
these environmental stresses.
 Stresses drain the client of the energy needed for healing viewed disease as a reparative
process.
 The health of the home/community is critical components in an individual’s health

Conceptual Framework of Nightingale’s Environmental Theory

 1. Ventilation and warmth 2. Health of houses

3. Petty management 4. Noise

5. Variety 6. Food intake

7. Food 8. Bed and bedding

9. Light 10. Cleanliness of rooms/walls

11. Personal Cleanliness 12. Chattering hopes and advances

13. Observation of the sick

FIG.1: Nigtingale’s conceptual framework

1. VENTILATION AND WARMTH: 
 Keeping patient’s room warm 
 Keeping patient’s room well ventilated and free of odors. 
 Keep the air within as pure as the air external air/without noxious smells.

2. HEALTH OF HOUSES:
 This canon includes five essentials of- Pure air, Pure water, Efficient drainage,
Cleanliness, Light
 Examples include: removing garbage or standing water
 Ensuring clean air and water and free from odour and that there is plenty of light.

3. PETTY MANAGEMENT:
 Continuity of the care, when the nurse is absent
 Documentation of the plan of care and all evaluation will ensure others give the
same care to the client in your absence.

4. NOISE:
 Avoidance of sudden/startling noises.
 Keeping noise in general to a minimum.
 Refrain from whispering outside the door.

5. VARIETY:
 Provide variety in the patient’s room to help him/her avoid boredom and
depression.
 This is accomplished by cards, flowers, pictures, books or puzzles (presently
known as diversional therapy)
 Encourage significant others to engage with the client.

6. FOOD INTAKE:
 Assess the diet of the client.
  Documentation of amount of foods and liquids ingested at every meal.

7. FOOD:
 Instructions include trying to include patient’s food preferences.
 Attempt to ensure that the client always has some food or drink available that
he/she enjoys.

8. BED AND BEDDING:

 Comfort measures related to keeping the bed dry, wrinkle-free and at the lowest
height to ensure the client’s comfort.

9. LIGHT:
 Assess the room for adequate light.
 Sunlight works best.
 Develop and implement adequate light without placing the client in direct light.

10. CLEANLINESS OF ROOMS/WALLS:

 Assess the room for dampness, darkness and dust or mildew.
 Keeping the environment clean (free from dust, dirt, mildew and dampness)

11. PERSONAL CLEANLINESS:

 Keeping the patient clean and dry at all times
 Frequent assessment of client’s skin is needed to maintain adequate moisture.

12. CHATTERING HOPES AND ADVICES:

 Avoidance of talking without reason or giving advice that is without fact.
 Continue to talk to the client as a person. And to stimulate the client’s mind
 Avoid personal talks.

13. OBSERVATION OF THE SICK:
  Making and documenting observations.
 Continue to observe the client’s surrounding environment.

Nightingale’s Environmental Theory Model

Figure2: Nightingale’s Environmental Theory Model

1. Physical environment
 Physical environment consists of physical elements where the patient is being
treated and affects all other aspects of the environment. E.g. cleanliness,
ventilation, air, light, noise, water, bedding drainage, diet.
 Cleanliness of environment relates directly to disease prevention and patient
mortality.
 Aspects of the physical environment influence the social and psychological
environments of the person.
2. Psychological environment
 It can be affected by a negative physical environment which then causes stress
and affect to the patient’s emotional state.
  It requires various activities to keep the patient’s mind active (i.e. manual work,
appealing Food, a pleasing environment).
 Communication should be therapeutic, soothing and unhurried.
 Patient should not be encouraged by false hopes and advice about their illness.
3. Social environment
 Social environment involves collecting data about illness and disease prevention.
 It includes components of the physical environment i.e. clean air, clean water, and
proper drainage etc.
 It consists of a person’s home or hospital room, as well as the total community
thataffects the patient’s specific environment.
 Observation of the social environment especially as related to specific data
collection related to illness which is essential to preventing disease.

NIGHTINGALE’S MODEL AND THE CHARACTERISTIC OF THEORY

 Theories can Interrelate Concepts – When nursing situations are viewed from a
Nightingale’s prospective, using her environment model, new insights into the
phenomena of interest to nursing can be identified. Examining environmental aspects,
such as light, noise, or warmth can provide new insights into human responses to health
and illness, which means that health and illness are not only influenced by the
pathophysiology but also psychological environment.
 Theories must be Logical in Nature – Florence Nightingale’s environmental model is
logical. There is nothing illogical in her discussions of the physical or psychological
environment. She built her conclusion from observations; she made her case, draw her
conclusions, and then acted. She believed that she has used logic to correct her
conclusion.
 Theories must be Relatively Simple yet Generalizable – Nightingale’s writings are simple,
as in the articulation of her environmental model. The beauty of her model is its
generalizability, including its continued applicability today. Her model can be applied at
the most complex hospital, intensive care unit, the home, at work site, or the community
at large.
 Theories can be based for Hypothesis – Nightingale has stimulated the development of
nursing science with her work. The research related to the impacts of the environments
on client health has been influenced by Nightingale.
  Theories Constitute to and Assist in Increasing – Nightingale’s theory seems to have
more relevance to practitioners today than ever before. More and more data are becoming
available to indicate the critical nature of the environment on the health and well-being of
the individual.
 Theories can be used by Practitioner to Guide and Improve their Practice –
Nightingale’s theory has found applicability to the nurse practitioner. Reading her work
raises a consciousness on the nurse about how the environment influences client
outcomes.
 Theories must be Consistent with Validated Theories – Nightingale’s theory works well
with ecological, system, adaptations and interpersonal theories. While direct testing of
Nightingale’s theory was not done, she stimulated the development of nursing science
with her work. Nightingale’s theory is a lower level theory, but it sets the state for further
work in the development of nursing theories.

Nightingale’s theory and Metaparadigm in Nursing

Figure3: Metaparadigm in Nursing

 1. Nursing
 Nursing is different from medicine and the goal of nursing is to place the patient in
bestpossible condition for nature to act.
 Nursing is the activities that promote the health which occur in any care giving
situation. They can be done by anyone.
 Nursing provide fresh air, light, warmth, cleanliness, quiet and proper diet.
 Facilitates a patient reparative process by ensuring the best possible environment.
2. Environment
 Environment is the foundational component of Nightingale’s theory.
 The external conditions and forces that affect one’s life and development includes
everything from a person’s food to a nurse’s verbal and nonverbal interactions
with the patient poor or difficult environments led to poor health and disease.
 “Environment could be altered to improve conditions so that the natural laws
would allow healing to occur.”
3. Person
 Person referred to by Nightingale as “the patient”.
 A human being acted upon by a nurse, or affected by the environment has
reparative powers to deal with disease. Recovery is in the patient’s power as long
as a safe environment exists.
 People are multidimensional, composed of biological, psychological, social and
spiritual components.
4. Health
 Health maintained by using a person’s healing powers to their fullest extent
 It maintained by controlling the environmental factors so as to prevent disease.
 Disease is viewed as a reparative process instituted by nature.
 Health and disease are the focus of the nurse.
 Health is “not only to be well, but to be able to use well every power we have”

Application of Nightingale’s theory in the nursing process

 Figure4: Nursing diagnosis

Situation 1: Mrs. Anderson, a public health nurse has just visited Mrs. Rose, an 80 year old
arthritis patient who lived alone in a small rural community. Since Mrs. Rose had difficulty in
ambulating, her neighbours visited her often to assist her in any way they could. One of these
neighbours requested Mrs. Anderson’s visit to assess the situation.

Assessment:

On entering Mrs. Rose’s home, Mrs. Anderson was made aware of –

 The lack of fresh air.

 The darkness in the environment caused by old dusty drapes covering the windows and a
draught in the bedroom.
 She found Mrs. Rose sitting in an old chair that provided little or no view of the world
around her.

Intervention:

After her visit, Mrs. Anderson contacted Mrs. Rose’s neighbours to set up a plan to improve her
environment -

 The drapes were to be removed and replaced by simple curtains that would let the
morning sun enter the home.
 The windows were to be opened in keeping the weather during specific periods of the
day, with care given to reduce drafts.
 Mrs. Rose favourite chair was to be placed in such a way that she could look out the
window to watch the neighbours coming and going.

Situation 2: Miss. Samjhana Dahal, age 48 years, has admitted in female medical ward of
GandakiMedical College & Teaching Hospital, Pokhara for a diagnosis of fever. She had
complaints of fever with headache, chills, rigor malaise and anorexia. She was in hospital for 5
days. Her laboratory report shows plenty of WBCs in urine RE and waiting for blood and urine
culture report, chest X- ray shown normal.

Assessment

1. Physical environment

 Presence of enough window & proper ventilation.

 Presence of fowl smelly dumping site outside the window
 Having proper light but no direct sun light to the bed.
 Well facility for hot water twice a day but without purification.
 Ward toilet drainage system is good but presence of food particles and dust in the
pan and around the pan.
 Room environment is clean and ward is swiped frequently.
 Presence of water leakage around the sink.
 Having only one piece of biscuits with milk, one full cup of dal and 1 glass of
plain water during 6 hours period.
 Bed is clean and tidy but presence of food particles and cover of medicines,
pieces of papers and dust inside the locker.
 Cool room temperature.
 Patient covered with 2 blankets but still feeling cold.
 Hospital is located centrally near to the main city so there is noise of horn,
loudspeakers.
2. Psychological environment

 Patient has never been admitted in hospital before.

 Feeling uncomfortable and unable to sleep well.
 Patient felt noise because of presence of nursing station near to the patient bed.
 She is very active women and feels her time is wasted since the admission.

3. Social Environment
  Patient told that her home environment is clean.
 They use to drink boiling water.
 Her room is small but with enough ventilation and sunlight.

Nursing Diagnosis

 Imbalanced nutrition less than body requirement R/T inadequate intake of food as
evidenced by patient complain of anorexia.
 Impaired comfort measures R/T strange, noisy, and cold environment as evidenced by
sudden change in the patient’s environment.
 Risk for infection R/T unsafe drinking water, dust from locker, dirt from sink and outside
of the room as evidenced by poor environment sanitation.
 Risk for injury R/T wet floor as evidenced by presence of leaking of water around the
sink.

Nursing Goal
 The client’s nutrition level will be maintained as evidence by constant weight till
hospitalization.
 The client will feel comfortable as evidence by absence of noise near to the nursing
station and increase room temperature.
 The client will be free from infection during hospital stay as evidence by normal
WBC’srange, no diarrhea and vomiting.
 The client will be free from injury as evidence by not slip on the floor.

Intervention
 Provide purified & boiling water for drinking according to patient demand.
 Clean the locker routinely and keep all medicines in small paper box or medicine bag.
 Inform to the in-charge for maintenance of sink, waste disposal.
 Keep the surrounding clean.
 Provide adequate diet by encouraging small frequent and nutritious feeding.
 Maintain temperature by proper dress up and provide extra blanket.
 Dispose waste properly.
 Keep the patient in calm and comfortable position and avoid unnecessary stimulation,
noise.
 Provide sufficient support and advice related to disease process, diet therapy.
Evaluation
 She told that she is getting boiled and purified water.
 She said that she has no vomiting and loose motion.
 She has gained a weight and no feeling of weakness and increased appetite.
 Locker is cleaned and no presence of dust around the sink.
 Bed seems to be cleaned, absence of dust, piece of papers, medicines.
 Absence of crowd near to the nursing station so she felt comfortable and felt asleep.
 She said that she is not feeling cold.
 Her laboratory test result shows normal WBCs and no evidence of fever so no risk for
infection.

Applications of Nightingale’s Theory in Practice and Education

In Practice
 “Patients are to be put in the best condition for nature to act on them; it is the
responsibility of nurses to reduce noise, to relieve patient’s anxieties, and to help them
sleep”.
 As per most of the nursing theories, environmental adaptation remains the basis of
holistic nursing care.

In Education
 The idea that nursing required specific education was revolutionary in 19th century.
Nightingale’s nursing education emphasized the need to blend a mixture of
theoretical and clinical experiences.
 Schools of nursing were established on her model throughout the world.
 They emphasized the moral qualities of nursing and introduced humanitarian, patient-
centered values that are still relevant today.

Strengths of Nightingale’s theory

 Nightingale’s theory has broad applicability to the practitioner. Her model can be applied
in most complex hospital intensive care environment, the home, a work site, or the
community at large.
 Her theory is logical in nature.
 Her writings are simple, easy to understand.
 It increases the general body of knowledge.
Weakness of Nightingale’s theory:
 In Nightingale’s Environmental Theory, there is scant information on the psychosocial
environment compared to the physical environment. The application of her concepts in
the twentieth century is in question.

Limitation
 Professional distance – The close nurse-patient relationship that Nightingale theory
stresses helps create a nurturing, emotionally supportive environment, but it also risks
violating the boundaries of professional distance that health professionals are expected to
maintain.
 Patient Incapacitation – Nightingale’s theory conceives the patient as a central agent of
his own healing. This might be effective, but is limited in cases in which the patient is
incapacitated or otherwise incapable of working towards his own healing.
 Emphasis on Environmental Measures – The theory emphasized on environmental
measures. Clean air and water, drainage, light and warmth, may be effective to an extend
but is inherently limited.

Critique
 Clarity and Simplicity: The concepts in the environmental adaptation model areas very
clear and followed a logical sequence.
 Generality: This theory is having a wide horizon of application. Some of the concepts can
be easily adapt into the every spheres of nursing practice ranges from hospital to a vast
community. Nevertheless, ventilation is not always been bliss for the patients, the
contaminated air can infect an open wound or a burned skin.
 Empirical Precision: Nightingale theory lacks the complexity and test ability of the
modern nursing theories.

Summary
Research questions that can lead to hypothesis need to be tested within clinical nursing, For
instance, what effect does the hospital environment have on the pace of the healing process? Do
the nurses have the authority to impact on the patient’s environment adequately? Do sudden,
frequent environmental changes affect patient’s perception of their reparative process? These are
only few of the many possible questions that can be used to guide research. The answers to these
questions could be used to develop guidelines for nursing education and practice.

Conclusion
Florence Nightingale developed the first model of nursing care that is grounded in the belief that
alteration of the environment will prevent disease. Nightingale is considered the first nursing
theorist. Her Environmental theory, which was incorporated the restoration of the usual health
status of the nurse’s clients into the delivery of health care – it is still practiced today.

Related Research Review

1.Title: Florence Nightingale’s Theory and her contributions to holistic critical thinking in
nursing.
Author: Fernando Riegel, Maria da Graca Oliveira Crossetti, Jussara Gue Martini, Andrea
Aparecida Goncalves Nes
Date of Published: 3 May, 2021
Objective: To reflect on Florence Nightingale’s legacy and describe her contributions to critical
holistic thinking in nursing.
Methods: This is a theoretical reflection, for which scientific productions on Florence
Nightingale’s environmental theory, as published in national and international journals, were
based.
Results: Florence Nightingale’s philosophy and teachings emphasize that the nurse must use her
brain, heart and hands to create healing environments to care for the patient’s body, mind and
spirit. Nursing, since the time of Nightingale, has been building the holistic paradigm, in all
schools of thought, with a view to a humanistic approach to the human being in their indivisible
relationship with the environment.
Final considerations: Florence’s contributions to holistic critical thinking in nursing are evident,
constituting nurses’ differential in clinical practice.

2.Title: War against the Covid-19 pandemic: Reflection in light of Florence Nightingale’s
nursing theory.

Author: Andreia Guedes Oliva Fernandes, Tatila de Cassia Raminelli da Silva

Date of Published: 21 December, 2020. National Library of Medicine (NIH).

Objective: To reflect on the relationship and importance of the environmental theory regarding
practices for promotion, prevention and treatment of COVID-19.

Methods: A theoretical-reflexive study about COVID-19 pandemic in light of the environmental

theory proposed by Florence Nightingale.

Results: It is observed that the application of the theoretical foundations proposed by the
environmental theory is related to the current practices used in the fight against the COVID-19
pandemic.

Final considerations: It is believed that the theoretical basis is foundational for the critical-
reflexive training of the nursing professional, for the consolidation of Nursing as a science;
therefore, it could provide a foundation in nowadays battle against the pandemic.

Bibliography

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Edition. Bangalore: EMMESS Medical Publishers;2019

2. Navdeep BK, Rawat HC. Textbook of Advanced Nursing Practice. New Delhi: Jaypee

Brother Medical Publication; 2015

3. Sharma K. Nursing Research & Statistics. Third Edition. New Delhi : Elsevier ; 2018

4. Fernandes GA, Talita RS. War against the COVID-19 pandemic: Reflection in light of

COVID-19. December, 2020. Available from: http://pubmed.ncbi.nlm.nih.gov/3338172/

5. Riegel F, Crossetti MG, Martini J, Andrea G. Florence Nightingale’s theory and her

contributions to holistic critical thinking in nursing. May, 2021. Available from:

http://pubmed.ncbi.nlm.nih.gov/33950