I have been a school nurse for almost 30 years. During this time I have worked in several different school buildings, some very nice and some not so nice. In one of the schools where I was once assigned, in the small nurses' office, there was a lone broken window with a slab of metal and wood covering it to keep out the drafts. At the top of the slab of metal and wood was a small vent window with a handle that could be accessed using a large pole with a hook at the end of it. It was the only slice of daylight that entered the office and with the pole I could pull the small, hinged window open and access some fresh air.
Outside of my nurses’ office was an outer area with two cots and two small bathrooms. There were no windows in either the outer area or the bathrooms, and at times it would get very stinky in that area where students would be trying to rest when they were feeling ill or waiting for a parent to come pick them up. Being a nurse and a mother, I was very particular about opening windows from time to time to “change out the air” and “get rid of all the cooties,” even on the coldest of days. The small vent in my office was utilized at least once a day to do just that, and more if a sick child had just left or the air freshener didn’t quite cut it at eliminating any foul odors in the area.
I worked in this “cave” for well over a year until the school invested some money in new windows for the school building. I was so excited when I opened my office door one morning to find a brand new, large vertical window that let in plenty of sunlight and exposed a view of a lovely flowering tree outside. I was beyond delighted until I noticed that this was a fixed window that did not have a vent to open to allow fresh air in. I immediately went to my principal to politely ask why I was not given a window that could open. I stressed the importance of having at least a modicum of fresh air in the office to help get rid of germs and allow for comfort of the students in my care. She was remarkably quite amenable to my suggestions and asked that I draft a letter to the district operations department stating my case for installing a replacement window with a vent.
My letter discussed Florence Nightingale’s Environmental Theories regarding the need for fresh, circulating air. I offered vignettes of Ms. Nightingale’s accomplishments during the Crimean War as she boldly advocated for supplies for her nursing team to care for ailing soldiers and the results of her concern for sanitation, hygiene, clean water and fresh air. Well, I can never be sure if it was my words or just the fact that the “powers that be” didn’t know what to do with all this information, but the following Monday I arrived at work to find that a new window had been installed in my office complete with a vent at the top to allow the fresh air in! I felt victorious, knowing that my persistence paid off, just as it did for Florence and her nursing team.
The Impact of Florence Nightingale’s Environmental Theories on the Current Pandemic
Florence Nightingale is considered the first nursing theorist. She believed that environment had a strong influence on patient outcomes and that people are essentially “in connection” with their environments. Proper nursing care according to Nightingale was to put the patients in the “best conditions for nature to act upon them.” Paramount to these conditions were fresh air, sunlight, warmth and cleanliness.
In 1859, Florence Nightingale was the first to conceptualize nursing’s work into a theoretical framework. Although Nightingale’s Environmental Theory was presented over 160 years ago, many elements of her assumptions are still practiced today. Nightingale challenged nurses to create environments where the health of populations was a realistic expectation. She was also the first to propose that nursing required specific education and training.
Nurses play a crucial role in applying their research and data through evidence-based practice to influence the design process in hospitals and healthcare settings that promote positive patient outcomes. As nurses, we apply evidence-based design practices through case studies on reducing infection rates, particularly during the current Covid-19 Pandemic.
In the Spring of 2009, the Swine Flu swept through the country causing some excitement as school nurses scrambled to find N95 masks and other PPE and closely monitored emerging cases within school buildings. I had just completed my Master’s thesis on “Pandemic Preparedness in Schools” just one year prior and I was aware of what could happen should the virus spread and mutate into something more deadly. There were many students as well as staff who were sickened with the virus and there were temporary closings of some schools for a few days or up to a week to allow for social distancing and stopping the spread of infection. Luckily, Summer break was on the horizon allowing for the social distancing needed. Later there was Ebola and then Zika Virus, both of which gave pause to again plan for isolation and mitigation strategies should these diseases become serious global threats. What I had learned from writing my paper on pandemics was that it was only a matter of when and not if something close to the unusually deadly 1918 influenza pandemic, (where it was estimated that about one-third of the world’s population became infected), could happen again.
Fast forward to February 2020. Covid-19 crept into the country, seemingly slowly, yet all at once. Cruise ships. Nursing Homes. West Coast. East Coast. Europe. The entire world. Shutdowns. Lockdowns. Toilet paper shortages. Supply hoarding. Essential workers. And so it went on. We needed to find ways to Flatten the Curve, Stop the Spread. And how do we do this? Florence Nightingale knew. Care for the sick while establishing mitigation strategies such as thorough handwashing, personal protective gear, quarantines and isolation of infected persons.
School nurses have worked tirelessly over the past year preparing and allowing for the safe return of students to school. We have collaborated with facilities management to provide adequate ventilation systems including HEPA filters in every classroom and office area. Medical waiting rooms have been established with an emphasis on social distancing and proper isolation procedures for sick students. PPE for nurses, such as gloves, gowns, face shields, surgical and N95 masks have been procured and hand washing stations have been installed at key places throughout buildings.
School nurses have assumed roles as teachers and counselors, reassuring staff and students and providing up-to-date knowledge and information about current national and local protocols and procedures, mitigation strategies, contact tracing, travel guidance and Covid testing sites. Nurses have acted as Covid-19 test site coordinators in schools by implementing weekly in-house PCR testing for staff and running weekly Pool Testing for students to provide district-wide surveillance of Covid-19 infection rates among student populations. We have advocated for and provided information regarding Covid-19 vaccines for our staff and helped them to weigh the safety and efficacy of the vaccines vs side effects by keeping our knowledge current through many professional development offerings and other training. Overall, school nurses have served as key players as part of a multidisciplinary team approach to design safe and healthy school environments for our staff and students during this pandemic.
In 1860, Florence Nightingale published “Notes on Nursing: What it Is and What it Is Not.” She discussed her environmental theory, citing a multi-faceted approach to healing stressing the importance of fresh air, natural light, clean water and sanitation, a healthy, varied diet along with environmental stimuli such as colorful flowers and plants to keep the mind stimulated. Her theories aim to provide the best possible chance of recovery for patients. Nightingale believed in treating the whole person, taking into consideration not just the body, but the mind and spirit as well.
It is my belief that Ms. Nightingale, our first mentor and founder of nursing practice would be impressed with how the nurses of our generation have stepped up and shown their worth by being fearless warriors in the fight against Covid-19. She would marvel at stories of nurses acting not only as the trained medical professionals that they are, but also as teachers, counselors, listening ears, hand-holders, family caretakers, and overall guardian angels in this time of a global health crisis.
Gonzalo, Angelo. "Florence Nightingale: Environmental Theory." www.nurselabs.com
Nightingale, Florence. "Notes on Nursing: What It Is and What It Is Not."