A Little Paper on Nursing Theory and Application

Carpediem1012, BSN, RN

As a student nurse, I am just beginning to establish my personal philosophy of nursing. During my study of nursing theory, I will be able to integrate broad concepts from a variety of theories to identify what my future practice might comprise. I selected Florence Nightingale's Environmental Model to explore here as I anticipate it will be useful to my practice. Nightingale was a pioneer in the development of modern nursing. It was her attention to the fundamental human needs in her model that I admire and hope to incorporate in my care.

Nightingale's Environmental Model

Florence Nightingale is considered to be the founder of modern nursing. She was born on May 12, 1820 to a wealthy family in Victorian England. During her lifetime of more than 90 years, she dedicated her work to reforming nursing care and social policy. As a child and a young woman, Nightingale's father encouraged her keen interest in education. She studied a classical education of math, philosophy, languages and religion not afforded many women of the time. Nightingale's mother, however, did not support the idea that women should pursue anything further than being a good hostess and a well-placed marriage. Nightingale was not allowed to nurse the sick, as nursing was seen to be an inferior position beneath her station in life. Lack of support from her mother did not discourage Nightingale. By the age of 31, she enrolled in the Kasierworth Institute in Germany where she began her formal nursing education.

During the Crimean War of 1854-1856, Nightingale, accompanied by 34 nurses of her choice worked on the frontlines nursing wounded soldiers. It was here that her nursing model first took shape. She noted that doctors were spreading disease amongst the wounded on which they worked. The simple act of hand washing, in addition to improved sanitation, that she promoted, decreased mortality significantly (George 2011 p. 48). Based on her experiences in Crimea, Nightingale began to observe and statistically record patient outcomes related to care. Following the war, Nightingale returned to England to found the Nightingale School of Nursing. She began to write prolifically on her philosophy of nursing. In 1859, she published her most famous volume, "Notes on Nursing What it is, and What it is Not". She intended to educate women in general, whom she stated would be care givers at various times during their lives. Ironically, she wrote a work that would stimulate the development of the nursing profession and continue to influence nursing care to the present day. She did not write a theory as such, but instead based her writings and teaching around her more conceptual environmental model consisting of thirteen canons.

Nightingale's thirteen canons were based on adapting the environment to place the patient in the best position to allow nature to heal him. They include the canon "Health of Houses", which concentrates on the five essentials of pure air, pure water, efficient drainage, cleanliness, and light, "without these, no house can be healthy" (Nightingale 1946/1859 p. 15). Further canons address noise, nutrition, and hygiene. Mental health and well being are addressed in her Canon titled, freedom from "Chattering Hopes and Advices" (Nightingale 1946/1859 p.54). To Nightingale, "healing was a holistic perspective and process of bringing together all aspects of oneself-body, mind, and spirit-to achieve and maintain integration and balance" (Dossey, Selanders, Beck, Attewell 2005, p.7).

Nightingale's model was "a landmark in the development of nursing science and provided the foundation for the metaparadigm concepts of the discipline of nursing" (Masters 2012 p. 28). These four concepts include the patient, the environment, health and the nurse. The metaparadigm evolved subsequently to Nightingale's time as a broad framework used to compare nursing theory phenomena. Nightingale spoke indirectly on each of the concepts. She focused more closely on the person as the patient and recipient of care, and of the environment, which could act on the patient in a positive or negative way. Although she did not specifically define health, she believed in promoting wellness, as well as caring for illness. She stated, "nature alone cures" (Nightingale 1946/1859 p. 7) and promoted sanitation and hygiene as the way to further wellness. As for the concept of nursing, Nightingale viewed the purpose of the nurse as an instrument to "put the patient in the best possible condition for nature to act on him" (Nightingale 1946/1859 p. 6).

Many of Nightingale's principles are still in use today. Considering the time in which she wrote, when sanitation was far from adequate, and germ theory had yet to be embraced, it is remarkable how insightful her observations and teachings were. Nightingale's environmental model has been criticized by some theorists as lacking the aspect of psychological care that modern nursing attempts to afford patients, and yet much of her writings are permeated by her strong spiritual beliefs and respect for her patient's mental well being (Alligood 2002 p. 78). It is Nightingale's environmental model that has been instrumental in the development of many modern nursing theories as evidenced by the direct influence she has made on later theorists (George 2011 p. 61).

Incorporating the Environmental Model into Practice

As a student nurse, I can imagine Nightingale's environmental model to be very valuable to my practice. I have an interest in one day working with individuals and the community as whole from the inner city. I am not yet capable of performing many procedures of the licensed, registered nurse. I can work within my scope, however, to understand how the environment of the patient is best manipulated to further health and promote healing.

The inner city would have had similarities to Victorian England in terms of poverty, lack of sanitation, and proper nutrition within the community. If I were to apply Nightingale's environmental model to the case of a patient who came to a clinic where I was a student nurse, I would work first to ensure the clinic space was set up in a culturally sensitive and respectful manner. I would be sure the patient felt comfortable by ensuring privacy and by keeping the exam room quiet. I would have a small, colourful vase of flowers on a side table and pictures of peaceful scenery on the walls. I would ask if he/she were hungry and if I could provide a nutritious snack during our visit.

As we moved on to their health history, I would be continually vigilant to watch for signs that the patient may be uncomfortable or uneasy and would adapt the clinical environment as needed. After establishing a nursing diagnosis, I would provide care, as needed, but also help the patient to obtain resources needed for support. Time would be spent discussing home life and resources currently being accessed. Determinants of health such as education, housing, nutrition, finances, and family dynamics would be assessed. As stated by Nightingale, "chattering hopes" (Nightingale 1946/1859 p.54) of promised recovery would be avoided, and instead an attempt made to empower the patient. When discharged, the patient would have a plan in place with resources to access their essential needs. If a safe house were required, we would contact an appropriate space and provide a means of transportation. If nutritious food was needed, I would arrange for Meals on Wheels or provide contact with the local food bank. The possibility of attending cooking classes at the facility would be approached, both to further knowledge of food preparation, but also to foster social opportunities. Resources for education or employment as required would be explored. By teaching the patient to manage their own environment by use of these resources, and with continued support, they would then have more control over their own optimal wellness.

Nightingale defined the nurse as instrumental to optimizing the environment to the benefit of the patient. "All nursing must take place in the context of society and nursing as a whole" (Selanders, 1993 p. 22). Following Nightingale's concept of environmental reform (Masters 2012 p. 32), I would look to the broader implications of the community influence on my patient. I would advocate for social programs to promote wellness both for the individual and the community using Nightingale's integralist approach.

Conclusion

The environmental model by Nightingale is an elegant, yet simple model with applications very relevant to current nursing practice. As a student, I was first drawn to this model for its simplicity and practical approach. What makes the model so brilliant, though, is that when it was written, it was revolutionary. Sanitation was lacking. Education of nurses was poor. Women were not often encouraged or allowed education, let alone to influence policy. Despite this, Nightingale saw a need for change and determined to address it. Nightingale approached her work in a systematic, scientific way. She then utilized this information to provide care not only to the individual, but to the community, as well. By advocating for social reform, she knew she would best effect change for all. Nightingale has inspired me to incorporate her model into my own practice. I believe by following her model of providing basic environmental needs, and also looking at the broader issues for each patient, I will be a better nurse.

References

Alligood, Martha Raile. (2002). Nursing Theorists and Their Work. St. Louis, Missouri: Mosby.
Dossey, Barbara Montgomery, Selanders, Louise C., Beck, Deva-Marie, Attewell, Alex. (2005). Florence Nightingale Today: Healing Leadership Global Action. Silver Spring, Maryland: American Nurses Association.
George, Julia B. (2011). Nursing Theories: The Base For Professional Practice. Fullerton, California: Pearson Education.
Masters, Kathleen. (2012). Nursing Theories: A Framework for Professional Practice. Sudbury, Massachusetts: Jones and Bartlett Learning.
Nightingale, Florence. (1946/1859). Notes on Nursing: What it is, and What it is Not. Philadelphia, Pennsylvania: Edward Stern and Company, Inc.
Selander, Louise C. (1993). Florence Nightingale: An Environmental Adaptation Theory. Newbury, California: Sage Publications Inc.

A Little Paper on Nursing Theory and Application

Nightingale's Environmental Model

Incorporating the Environmental Model into Practice

About Carpediem1012, BSN, RN

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