CHAPTER VII

ENVIRONMENTAL THEORY

"I think one's feelings waste themselves in words; they ought all to be distilled into actions which bring
results."

Getting to Know the Theorist

Florence Nightingale, the matriarch of modern nursing, was born in Florence, Italy, on May 12, 1820. As
she grew up, her father provided her with a reputable education, which was uncommon for a Victorian
woman (women in those times were often not educated as well as men). According to her biographer,
Sir Thomas Cook, Nightingale was a linguist; had a vast knowledge of science, mathematics, literature,
and the arts; was well read in philosophy, history, politics and economics; and was well-informed about
the workings of government and political science. She wanted to do more with her life than become an
inactive wife of an aristocrat. Florence had a firm faith in God (she was a Unitarian Christian), and for a
time believed she had a religious calling.

First Nurse Educator

While Nightingale was struggling with decisions about her life, the seeds of modern nursing were being
planted in Germany. Germany was the place of the first nursing school. In 1936, Pastor Theodor
Fleidner, a protestant pastor in Kaiserswerth, Germany, opened a hospital in a "vacant textile factory
with one patient, one nurse, and a cook' (Hegge, 1990). When Fleidner recognized there was no staff for
the hospital, he decided to design a school of nursing. Nightingale went to Kaiserswerth and stayed for
14 days in 1850 after a trip to Egypt. She applied for admission to the school with a 12-page,
handwritten "curriculum" showing her interest of becoming a nurse and entered the nursing program
July 6, 1851, as the 134th nursing student to attend the Fleidner School of Nursing. She left Kaiserswerth
on October 7, 1851, and was considered to be educated as a nurse. During the three months of studying
with the sisters of Kaiserswerth, she developed skills in both nursing care and management which she
took back to England. When Nightingale went back to England, she used the knowledge from
Kaiserswerth to prove her cause as a reformer for the well-being of the citizens.

The Lady with the Lamp (Crimean War)

With her lamp, Nightingale traversed the night during the Crimean War — the battle of English versus
Turkish — to look for the wounded soldiers and to heal them with her consoling hands. Nightingale
went to the front of the Crimean war at the request of her friend, Sir Sidney Herbert, Secretary at War at
Great Britain. She arrived in Scutari on November 5, 1854, accompanied by 38 nurses. Nightingale's 19th
month stay at military was hard for many to accept. The hospital barracks were infested with fleas and
rats, and sewage flowed under the wards. She used her superb statistical and managerial skills to make
drastic changes in the mortality rate of soldiers and victims of war. The mortality rate at the hospital was
42.7 percent of those treated; a mortality rate which was higher from disease than from war injuries
(Cohen, 1984). Six months after, the mortality rate at the hospital went down to 2.2 percent. She
achieved this drop in mortality by attending to the environment of the soldiers. Nightingale became a
heroine in Great Britain as a result of her work in the Crimean War. Her depiction of the very poor
sanitary conditions in the hospital wards at Scutari is overwhelming. She fought the bureaucracy for
food, bandages, fresh bedding, and cleaning supplies for the soldiers. At times she bought supplies with
her finances. She showed concern for the comfort of the English soldier - well, injured, or sick, including
supporting the establishment of a laundry, library, assistance with letter writing, a banking system so
the soldiers could save their pay, and a hospital for the families who go with the soldiers to war. Also,
she provided comfort and security to the seriously sick and dying. Her skills in decision-making were
often better than those of many officers in the army. She spent the years after the Crimea establishing
schools of nursing and influencing public policy by lobbying her acquaintances about several of her
concerns.

Nurse Statistician

Nightingale was truly a skilled nurse; she was an expert statistician who used statistics to present her
case for hospital reform. She was viewed as a pioneer in the graphic display of statistics and was
selected a fellow of the Royal Statistical Society in 1858. In 1874 an honorary membership In the
American Statistical Association was bestowed on her. Given her dependence on observable data to
support her position, it can be said that Nightingale was the first nurse researcher. Besides that, she was
also an excellent writer. Her writings, Notes on Matters Affecting the Health, Efficiency and Hospital
Administration of the British Army, Notes on Hospitals, and Report on Measures Adopted for Sanitary
Improvements in India from June 1869 to June 1870, showed her ongoing concerns about these issues,
particularly for the military. Also, her most frequently cited work, Notes on Nursing, was written not as a
nursing text but to "give hints for thoughts of women who have personal charge of the health of others"
(Nightingale, 1859).

Awards and Later Life

In her lifetime, Nightingale's work was recognized through the numerous awards she gained from Great
Britain and many other countries. Notably, she was the first woman to be granted the Order of Merit
(OM) and the Royal Red Cross (RRC) by no less than Queen Victoria of Great Britain. During her time, she
was the second most famous British person, after the Queen herself. Recipients of the awards are
entitled to use the post-nominal letters (OM, RRC) on their names. She was able to work into her
eighties and died in her sleep on August 13, 1910 at the ripe age of 90. She is honored each year in a
commemorative service at St. Margaret's Church, East Wellow, Great Britain, where she is buried. The
news of her death spread across the world, and she instantly became a celebrated and legendary
person: "Florence Nightingale, the famous nurse of the Crimean war, and the only woman who ever
received the Order of Merit, died yesterday afternoon at her London home. Although she had been an
invalid for a long time, rarely leaving her room, where she passed the time in a half-recumbent position,
and was under the constant care of a physician, her death was somewhat unexpected. A week ago she
was quite sick, but then improved, and on Friday was cheerful. During that night alarming symptoms
developed, arm she gradually sank until 2 o'clock Saturday afternoon, when the eno came." (The New
York Times, 1910)

Her birthday marks the International Nurses Day celebration each year.

Theoretical Sources of Nightingale's Theory

A lot of factors influenced the improvement of Nightingale's Theory for Nursing. Individual, societal, and
professional values were all essential to the development of her work. She combined her individual
resources with societal and professional resources to create a great impact of change.
Education

Nightingale's education from her father was an unusual one for a Victorian woman. Her mastery in
subjects such as mathematics and philosophy from her intellectual father provided her with the
knowledge and conceptual thought that was exceptional for women of her time. Her Aunt Mai, a
devoted relative, described her as being a highly intellectual being; this was a description not used to
described Victorian women, but one absolutely accepted for Nightingale. It remains unknown whether
or not Nightingale was a genius who developed her prominence through her formal education.
However, she would have likely been a political or civil society leader if she been born in modern times.

Literature

The noble family of Nightingale provided her with access to persons of power and influence. Many were
family friends such as Stanley Herbert, who remained important to Nightingale all through her life. In
Charles Dicken's novel, The Adventures of Martin Chuzzlewit, he portrays Sairey Gamp, a drunken,
inexpert, and horrible nurse which provided society with an image of the terrors of the Victorian
untrained nursing. Nightingale's influence with Dickens unquestionably served as a factor in her
definitions of nursing and healthcare and provided her with a discussion to convey her views about
social and healthcare issues.

Intellectuals

Political leaders, intellectuals, and social reformers like John Stuart Mill, Benjamin Jowett, Edwin
Chadwick, and Harriet Marineu influenced Nightingale's theoretical and rational thinking, which is
manifested in her theory for nursing. Most likely, these dialogues inspired her to change the things she
viewed as unacceptable in the society.

Religious Beliefs

Lastly, Nightingale's faith and religion were very significant for her nursing theory. She believed that
action for the benefit of others is a primary way of serving God which is a basis for defining her nursing
work as a religious calling. In addition, her Unitarian faith strongly supports the education of a person as
a means of developing their divine potential and serving them toward perfection in their lives and
service to God. Her faith provided her with personal strength throughout her life and provided her with
the conviction that education was a significant factor in establishing the profession of nursing.

Use of Empirical Evidence

Through Nightingale's notable contributions regarding health and sanitary conditions in the Crimean
War and in England, she was honored as an excellent scientist and researcher. Her proficiency as a
statistician is alsc manifested on the reports that she generated throughout her lifetime on the different
subjects of healthcare, nursing and social reform. The efficacy of her hospital nursing system and
organization during the Crimean War is perhaps her finest known work. Her unique written report of her
experiences and collected data in Notes on Matters Affecting the Health, Efficiency, and Hospital
Administration of the British Army was submitted to the British Royal Sanitary Commission. This
commission had been organized in response to Nightingale's charges of deprived sanitary conditions.
This report provided a strong argument in favor of her proposed reforms in the Crimean hospital
barracks. According to Cohen, she made-up the polar-area diagram (a type of statistical diagram) to
noticeably represent the point of useless death in the British military hospitals in the Crimea. Cohen
noted the work of Nightingale as both a researcher and a statistician by stating that "she helped to
pioneer the revolutionary notion that social phenomena could be objectively measure and subjected to
mathematical analysis."

Palmer identifies Nightingale's research skills as including recording, communicating, ordering, coding,
conceptualizing, inferring, analyzing, and synthesizing. The observation of social phenomena at both an
individual and systems level was particularly important to Nightingale and serves as the basis of her
writings. She highlighted the simultaneous use of observation and the performance of tasks in the
education of nurses.

Metaparadigm in Nursing

Nursing

Nightingale had always considered that nursing is very essential for everybody's well being. One of her
masterpieces, Notes on Nursing, provided essential principles for rendering and implementing an
efficient and effective nursing care. Moreover, she instilled an ideal attitude of thinking and acting like a
real nurse.

Person

Nightingale viewed the essence of a person as a patient. She believed that nurses should perfcirm tasks
to and for the patient as well as control the patient's environment to facilitate easy recovery.
Predominantly, she explained a passive patient in this relationship. However, when there are definite
references to the patient performing self-care when possible, the nurse is particularly instructed to ask
the patient about his or her preference. However, Nightingale gives emphasis to the nurse who is in
control of the patient's environment.

Health

Nightingale's statement regarding health is "being well and using overy power that the person has to the
fullest extent." In addition, she defined disease as "a reparative process that nature instituted from a
want of nttention". She believed that prevention of disease through environmental control will greatly
uplift the maintenance of health. Furthermore, she Illustrated modern public health nursing and the
more modern concept of health promotion. She compared these concepts of nursing as different from
caring a sick patient to living better and increasing recovery.

Environment

Nightingale's statements about conditions in the community are also upplicable to her theory. She
believed that the sick, poor people would benefit from environmental improvements that addressed
their physical and mental aspects. She stressed that nurses could have a special role in iplifting the social
status of the poor by improving their living situations. I urthermore, her concept of environment was
described by Fitzpatrick and Whall as "those elements external to and which affect the health of the sick
,Iod healthy person" and includes "everything from the patient's food ano flowers to the patient's verbal
and non-verbal interactions with the patient."

Theoretical Assertion
Nightingale believed that disease was a reparative process; disease was nature's effort to remedy a
process of poisoning or decay, or a reaction against the conditions in which a person was placed.
Nightingale did not provide a definition of nature. In her writings, she often capitalized the word nature
in her writings, thereby suggesting that it was synonymous with God. Her Unitarian religious beliefs
would support this view of God as nature.

However, when she used the word nature without capitalization, it is unclear whether or not the
intended meaning is different and perhaps synonymous with an organic pathological process.
Nightingale believed that nursing's role was to prevent an interruption of the reparative process and to
provide optimal conditions for its enhancement.

Nightingale was totally committed to nursing education (traiisning). Although she wrote Notes on
Nursing for all women, her py treate was that women were to be specifically trained to provide care for
thehealth sick person and that nurses providing preventive healthcare (public nursing) required even
more training. Nightingale also felt that nurses needed to be excellent at the observation of their
patients and the environment; this was an ongoing activity for trained nurses. In addition, she believed
that nurses needed to use common sense in their nursing practice, coupled with their observation,
perseverance and ingenuity. Finally, Nightingale believed that persons desired good health and that they
would cooperate with the nurse and nature to allow the reparative process to occur or alter their
environment to prevent disease.

Although Nightingale has often been maligned or ridiculed for not embracing the germ theory, she very
clearly understood the concept of contagion and contamination through organic materials from the
patient and/or the environment. Many of her observations are consistent with the concepts of infection
and the germ theory; for example, she embraced the concept of vaccination against various diseases.
ightingale also strongly believed that appropriate manipulations of the environment would prevent
disease; this concept underlies modern sanitation activities. Nightingale did not explicitly discuss the
caring behaviors of nurses. She wrote very little about interpersonal relationships except as they
influenced the patient's reparative process. She did describe the phenomenon of being called to nursing
and the need for commitment to nursing work. From the perspectives of Victorian England and her
religious beliefs, these descriptions may describe a caring component of her nursing theory. Finally,
Nightingale believed that nurses should be moral agents. She addressed their professional relationship
with their patients; she instructed them on the principle of confidentiality and advocated for care to the
poor to improve -their health and social situation. In addition, she commented on patient decision
making (a relevant modern ethical concept). Nightingale called for concise and clear decision making
regarding the patient, noting that indecision or changing the mind is more harmful to the patient that
the patient having to make a decision.

Acceptance by the Nursing Community

Practice The environmental aspects of Nightingale's theory (ventilation, warmth, quiet, diet, and
cleanliness) remains a significant component of current nursing care until today. These concepts, even
from the 21st, showed significance as the global society encounters new issues of disease control. Like
for instance, sanitation and water treatment somehow controlled sources of diseases and sicknesses. In
addition, environmental concerns are also utilized by modern architecture. For instance the term "sick
building syndrome", nurses need to ask whether buildings and constructions meet Nightingale's
principle of good ventilation and lighting. Moreover the disposal of waste, such as chemicals and other
toxic also pose challenges to healthcare professionals to reconsider the concept of a healthy
environment. In places such as clinics and hospitals, the control for room temperature for an individual
patient is also considered. Also, that same environment, though it contains technology that helps for
recovery, may create uncomfortable noise that would affect the healing process. Nurses are looking at
these problems by doing different studies and researches as they continue to affect the healthcare
system.

Education In the academe, Nightingale's principles of nursing training developed a universal pattern for
early nurse training schools beginning with St. Thomas Hospital and King's College Hospital in London.
Using the Nightingale model of nursing training, three experimental schools were established in the
United States in 1873 (Bellevue Hospital in New York, New Haven Hospital in Connecticut and
Massachusetts Hospital in Boston. The influence of this training system and many of its principles are
still apparent in today's nursing programs. Nightingale firmly considered that better practice could result
only from better education. She believed that the measurement of the art of nursing could not be
accomplished through licensing examinations, but she used testing methods, including case studies for
nursing trainees at St. Thomas Hospital.

Research Nightingale's expertise in scientific inquiry and statistics continues to assist and define nursing
research. She was remarkably efficient and resourceful in her capability to gather and analyze data. Also,
her ability to graphically represent data was first identified in the polar diagrams. Her empirical
approach to deal with problems of healthcare delivery is also evident in her various writings. In addition,
her concepts have also served as the basis for current researches which adds to modern nursing science
and practice in different countries. Lastly, she also used brief case studies, possible patterns, to
demonstrate various concepts she discussed in Notes on Nursing.