The Legacy of Florence Nightingales

FLORENCE NIGHTINGALE AND IMPACT OF HEALTHCARE ENVIRONMENTS RESEARCH
The Legacy of Florence Nightingale’s

Environmental Theory:
Nursing Research Focusing on the
Impact of Healthcare Environments
Terri Zborowsky, PhD, EDAC
ABSTRACT
OBJECTIVE: The purpose of this paper is to explore nursing research RESULTS: Descriptive statistics reveal that topics and settings most fre-
that is focused on the impact of healthcare environments and that has quently cited are in keeping with the current healthcare foci of patient
resonance with the aspects of Florence Nightingale’s environmental care quality and safety in acute and intensive care environments.
theory. Research designs and methods most frequently cited are in keeping with
the early progression of a knowledge area.
BACKGROUND: Nurses have a unique ability to apply their observational
skills to understand the role of the designed environment to enable heal- CONCLUSIONS: A few assertions can be made as a result of this study.
ing in their patients. This affords nurses the opportunity to engage in First, education is important to continue the knowledge development in
research studies that have immediate impact on the act of nursing. this area. Second, multiple method research studies should continue
to be considered as important to healthcare research. Finally, bedside
METHODS: Descriptive statistics were performed on 67 healthcare nurses are in the best position possible to begin to help us all, through
design-related research articles from 25 nursing journals to discover the research, understand how the design environment impacts patients dur-
topical areas of interest of nursing research today. Data were also ana- ing the act of nursing.
lyzed to reveal the research designs, research methods, and research
settings. These data are part of an ongoing study. KEYWORDS: Evidence-based design, literature review, nursing
AUTHOR AFFILIATIONS: Terri Zborowsky is a Research Associate at The ACKNOWLEDGMENTS: Part of the funding for the article review process was
Center for Health Design; a Principal at Zborowsky Healthcare Design Consult- provided by The Center for Health Design.
ing; and Research Chair at the Nursing Institute for Healthcare Design.
PREFERRED CITATION: Zborowsky, T. (2014). The legacy of Florence Night-
CORRESPONDING AUTHOR: Terri Zborowsky, Terri.zborowsky@gmail.com; ingale’s environmental theory: Nursing research focusing on the impact of
(651) 724-0081. healthcare environments. Health Environments Research & Design Journal,
7(4), 19–34.
© 2014 VENDOME GROUP LLC HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 19
RESEARCH SUMMER 2014 • VOL. 7 NO. 4, pp. 19–34
F
lorence Nightingale was one of the first nurses to document the impact
of the built environment on patients. In addition to writing about sanita-
tion, infection rates, and ventilation, Nightingale understood that envi-
ronmental aspects such as color, noise, and light, along with the nurse’s presence,
significantly contributed to health outcomes. Dossey (2005) has summarized
Nightingale’s comments on the defects of hospital construction that compro-
mised health, including:
• Arrangement of the bed along the dead wall and more than two rows of
beds between the opposite windows.
• Defective means of natural ventilation and warming; windows only on
one side, or a closed corridor connecting the wards.
• Defective height of wards and excessive width of wards between the
opposite windows.
• Defective ward furniture.
• Defective hospital kitchens and laundries.
• Defective condition of water closets.
• Defects of sewerage.
• Use of absorbent materials for walls and ceilings, and poor washing of
hospital floors.
• Selection of bad sites and bad local climates for hospitals and erecting of
hospitals in towns.
• Defective accommodation for nursing and discipline.
It is clear that Nightingale was well aware of the impact the built environment
had on patients—she knew this from direct observation. In fact, all of her asser-
tions were from her acute observations of patient or community outcomes and
their surroundings. Nightingale’s environmental theory can be viewed as a sys-
tems model that focuses on the “client” in the center, surrounded by aspects of
the environment all in balance. If one element is out of balance, then the client
is stressed, and it is up to the nurse to do what is needed to bring back balance to
the client’s surrounding environment to relieve the stress (Lobo, 2011).
Nurses have been the primary caregivers of the sick, infirmed, and the injured.
While doctors and allied practitioners assist in patient diagnosis and treatment,
nurses have always been at the bedside of the patient, delivering the care pre-
scribed, whether the care is provided in an infirmary, hospital, or in the patient’s
home. Since Nightingales’ documentation of her “bedside’ experiences, the role
of the nurse has evolved and changed. Nursing has evolved from a vocation to
a professional career. Nurses today can be educated in a variety of specialties.
Nurse practitioners diagnose and treat their own patients. Nurses play an import-
ant role in healthcare leadership as Chief Nursing Officers or Chief Executive
Officers, often putting in place the policies needed to provide quality patient
care. Other nurses specialize in research, both in academia as well as in clinical
settings. Yet today nurses remain the most likely of healthcare professionals to be
20 WWW.HERDJOURNAL.COM © 2014 VENDOME GROUP LLC

at the patient’s side delivering the care needed. It is in the very act of nursing that
an intimate relationship is created, one that puts the nurse in a unique position.
Similar to Nightingale, nurses today see the influence of the surrounding envi-
ronment on the patient’s ability to heal. This makes nurses uniquely able to apply
their observation skills to understanding the role of the designed environment
to enable healing in their patients. These types of observations afford nurses the
opportunity to contribute greatly to this growing body of knowledge.
The purpose of this article is to explore the role that nurses have played in the
development of research studies that resonate with aspects of Nightingale’s envi-
ronmental theory. The particular aspects of interest are those from the built
or ambient environment, termed the “designed environment” for this article.
Nightingale (1860) listed these aspects as:
• Noise
• Light
• Air
• Ventilation
• Cleanliness
• Variety
This article uses data from an ongoing study to explore these and other vari-
ables of interest in current nursing research journals. To provide context for
this research, a brief review of nurses in healthcare design and related literature
is included. This article also includes recommendations to advance a research
agenda for bedside nurses.
Overview
Few government healthcare reports have garnered public attention like the Insti-
tute of Medicine’s To Err Is Human: Building a Safer Healthcare System (2000).
The report was a comprehensive look at medical errors and the quality of health-
care in the U.S. and as a result disclosed the failure of this healthcare system
to protect the very people it should, its patients. The disclosures in the report
shocked many in the public realm, but to those who worked in the system, many
of them nurses, it served as an acknowledgement of issues of which they were
already aware. However, nurses understood assigning blame on human error
alone was not going to solve the larger systemic issues healthcare organizations
faced (Tri-Council of Nurses, 2000). As with most dark clouds, however, there
was a silver lining. The report sparked a series of follow-up reports that explored
the problems underlying the dismal statistics and provided solutions. For nurses
this meant discussions would focus on understanding how their work environ-
ment, as part of the larger system, affected the quality of patient care.
In both the original To Err Is Human report and the subsequent report, Cross-
ing the Quality Chasm: A New Health System for the 21st Century (Institute of
Medicine, 2001), the overall concept of nurses’ work environment was discussed
as it related directly to patient safety and quality care. However, not until the
2004 report, Keeping Patients Safe: Transforming the Work Environment of Nurses
(Institute of Medicine, 2004) were the various parts unravelled and the physi-
cal aspects of nurses work environment discussed in depth. Chapter 6, “Work
and Workspace Design to Prevent and Mitigate Errors” dealt specifically with
the “evidence on the design of nurses’ work hours, work processes, and work-
spaces, primarily as they relate to patient safety, but also with respect to efficien-
cy” (IOM, 2004, p. 227). After a thorough review of nursing work issues such
as medication errors, fatigue, hand washing, distractions, supply management,
acuity adaptable patient rooms among other issues, several recommendations
were made, including:
• Nursing leadership should be provided with resources that enable them
to design the nursing work environment and care processes to reduce
errors, and should concentrate on errors associated with:
— Surveillance of patient health status.
— Patient transfers and other patient hand-offs.
— Complex patient care processes.
— Non-value added activities performed by nurses, such as locating and
obtaining supplies, looking for personnel, completing redundant and
unnecessary documentation, and compensating for poor communi-
cation systems.
• Hand washing and medication administration should be addressed
(IOM, 2004, p. 13).
Chapter 6 and the recommendations revealed an important fact: Physical aspects

of nurses’ work environment significantly impact their ability to perform their
job and, as a result, impact patient care outcomes. Keeping Patients Safe revealed
how using quality improvement tools such as Lean or Six Sigma could help rede-
sign these work environments to decrease the chances of error and increase value
added time for the nurse. Nurses’ time is better spent at the bedside, providing
the care and education needed to improve patient outcomes.
Sadly, 10 years later, many of the same problems remain. Nurses face an increas-
ingly complex patient population with diminishing resources available to them.
When building projects are underway and the opportunity exists to engage
nurses in the design and planning of these work environments, rarely is this
opportunity to make the changes so badly needed utilized. As Gregory (2009)
noted in her editorial, “Nobody Asked Me: Why Nurses Should Take an Inter-
est in Workplace Design,” nurses have not been asked to be at the table during
the design process. As a result of the disconnect she witnessed, Gregory helped
launch the Nursing Institute for Healthcare Design (NIHD) with the vision
to help educate and empower nurses to bring their “bedside” knowledge to the
table when the opportunity to design their workspaces occurs. “We challenge
nurses to learn about what other nurses are doing to influence hospital design,
to research design trends, and to speak up, using their experience and prob-
lem-solving skills to improve their work surroundings” (Gregory, 2009, p. 11).

Within healthcare systems, nurses remain strong advocates for their patients and
family members; they remain at their bedside providing the care that is needed,
and they remain ever vigilant, observing and documenting what they see, hear,
and feel. In 2010, the Robert Wood Johnson Foundation (RWJF) published
“Addressing the Quality and Safety Gap—Part III: The Impact of the Built
Environment on Patient Outcomes and the Role of Nurses in Designing Health
Care Facilities” (Robert Wood Johnson Foundation, 2010). It noted, “[N]urses
at all levels and in every setting have a critical role to play on multidisciplinary
teams charged with assessing, planning, and designing new and replacement
facilities” (p. 1). The report goes on to discuss the role of research findings, spe-
cifically evidence-based design (EBD), to provide the framework from which to
make design decisions during the design process. This is particularly true when
considering the importance of integrating architecture, information technology,
clinical processes, and workplace culture. What this document did so well was
to highlight how nurses can explore the aspects of the designed environment
that affect the quality of patient care and safety. As noted by Kerm Henriksen,
PhD, the human factors advisor for patient safety at the Agency for Healthcare
Research and Quality, “Nursing is the backbone for what goes on in hospitals.
Nurses have a lot of practical knowledge and can help identify design threats to
patient safety and quality of care” (RWJF, 2010, p. 2).
Figure 1. Aligning Infrastructure, Leadership, and Processes: A Multidisciplinary Model.
Transformational
Leadership and
Culture
Re
r ch
se
s ea
Strategic Goals:
ar c
Re
Improved Patient,
Staff, and Resource
Outcomes
Infrastructure:
Building, Reengineered
Technology, Clinical and
Furniture, Research Administrative
Equipment Processes
Source: Adapted from Evidence-Based Design: Application in the Military Health System,
E. Malone, J. R. Mann-Dooks, & J. Strauss (Noblis, 2007, p. 12). Used with permission.
Malone, Mann-Dooks, and Strauss (2010) presented a framework for under-

standing how healthcare leaders can solve clinical problems utilizing research in
the process. Malone, herself a nurse and former CEO and commander emeritus
of DeWitt Army Community Hospital at Fort Belvoir, noted that coordination
in this area is often missing. “[W]e have these wonderful stovepipes of innova-
tion but very little integration because architects, IT experts, and clinicians tend
to work in separate silos.” (Malone, Mann-Dooks, & Strauss, 2010, p. 3). Their
model provides a conceptual framework to examine the interplay among phys-
ical, technological, and human factors, as well as the need for more multidisci-
plinary research.
Finally, Lamb and Zimring (2010) offered some pedagogical solutions. Together,
with a group of educators from around the country, they identified interprofes-
sional competencies for systems integrators—leaders capable of bringing togeth-
er experts from different disciplines, including nursing. “The real challenge is to
integrate knowledge from different professional disciplines to create better and
safer health care environments.” (Lamb & Zimring, 2010, p. 8). Six domains were
identified for teaching:
1. Science of healthcare design—applying and extending evidence-based
research;
2. Healthcare systems and environments—describing and influencing the
context in which services are planned, delivered, and evaluated;
3. Patient- and family-centered care—engaging patients in their own care
and mobilizing and leveraging support systems;
4. Teamwork—facilitating collaboration and communication among dif-
ferent stakeholders;
5. Professional cultures—identifying and capitalizing on expertise of
designers, architects, engineers, clinicians, and so on; and
6. Innovation—thinking creatively to solve problems.
In March 2014, RWJF published “Ten Years After Keeping Patients Safe: Have
Nurses’ Work Environments Been Transformed?” This paper revisited some of
the recommendations in the Institute of Medicine’s report for averting harm,
highlighting both progress and persistent gaps in transforming nurses’ work
environments, and showcased research, policies, and tools with the potential
to advance this transformation. This RWJF document fell short, however, in
addressing the role of the built environment in helping to overcome the quality
gap. The discussion about improving nurse work environments should be focused
on people, process, and place as interrelated concepts. Kreitzer and Zborowsky
(2009) used these concepts to explore the creation of “Optimal Healing Environ-
ments.” Examining the relationship between people and process is not enough;
the designed environment must be included in the discussion. Previous litera-
ture reviews in this field of knowledge have stressed the impact that the designed
environment has on staff efficacy, satisfaction, and safety, as well as patient out-
comes, including physiological, behavioral, and psychological (Rubin, Owens,
& Golden, 1998; Ulrich, Zimring, Quan, Joseph, & Choudhary, 2004; Ulrich

et al., 2008). It is time to look more closely at the legacy of Nightingale and the
role nurses have played in conducting nursing research, studies that reveal the
impact of the designed environment on their patients and on the act of nursing.
Nurse Research on the Impact of Healthcare Environments

Outside of Florence Nightingale’s work, there is little documentation of the role
nurse researchers might play in this knowledge domain, although it is clear that
nurses have been publishing research on the impact of the design environment
on nurses’ ability to conduct their work safely and efficiently, as well as on patient
outcomes. In the past, nurses may not have had the design vocabulary to explain
their studies within the healthcare design domain. These two knowledge areas,
healthcare and health design, had not frequently crossed paths. It was not until
the Institute of Medicine’s initial healthcare quality report (1999) that nursing
researchers and others started to rigorously explore all aspects of healthcare—
people, process, and place—for help in understanding how to fix the quality gap.
Bedside nurses were on the frontlines of the discussion. Not just observers of
this phenomena, they were actors as well. They were, in essence, studying their
own experiences—how the designed environment impacted their patients and
enabled them to provide the very best care. Nurses feel the effects of a lack of
proper air temperature. They see the work-arounds created because of poor spa-
tial adjacencies and they understand how it feels to make patient decisions while
standing in a corridor that might have decibel level peaks similar to a freeway.
Many nurses observed these effects, but it was only through conducting research
that they were able to explore how to make needed change.
Nursing journals have been around since the early 20th century. The American
Journal of Nursing, first published in 1900, is still in print. These journals have
served to document the research and opinions of nurses through the years. At
some point, articles began to examine the role of the designed environment in
care delivery. Many articles published in this genre through the years appear to
be quality improvement strategies. So what can we learn from further exam-
ination of these studies? What might this research offer to us as practitioners
of nursing and/or design? What might the research tell us about Nightingale’s
environmental theory—is it relevant today? The rest of this article will explore
answers to these questions. Using a literature review approach, it will identify
how variables in Nightingale’s environmental theory are explained or explored
in studies published in nursing journals. The literature review below examines
selected nursing journals. It is part of a larger study to be published at a later date.
Literature Review: Nurses in Healthcare Design and Related Literature

As part of an effort partially funded by The Center for Health Design (CHD),
and in collaboration with the Nursing Institute for Healthcare Design (NIHD),
a search was conducted in PubMED for journals with the word “nurse” or “nurs-
ing” in the title. Forty-three journals were found; 25 were reviewed in this phase
of the study (see Table 1).
Once the journals were identified, each journal’s table of contents was reviewed
for research article titles that indicated one or more of the variables studied was
an aspect of Nightingale’s environmental theory articulated in Notes on Nursing:
What It Is, What It Is Not (Nightingale, 1860), such as air temperature, sound, or
light. Key search terms included “air,” “temperature,” “light,” “noise,” “sound,”
“art,” “furniture,” “equipment,” “space design,” “layout design,” “interior design”
“nature,” and “gardens.” Some of these terms are extensions of Nightingales’
original environmental attributes; for example, Nightingale’s term “variety”
was understood as a design element that could be extended to art, furniture, or
interior design. There were a total of 67 articles found that met the criteria for
inclusion. Descriptive statistics were used to indicate the frequency that articles
appeared in these journals with relevant research studies or articles focused on
environmental variables.
Tables of contents for each of the selected journals were reviewed for 6 years,
between the years 2007 and 2013, ending with the last issue published in 2013.
The 6-year mark was merely a stopping point for data analysis. Ultimately the
intent is to review all of the journal issues. The journals under review for this
Table 1. Nursing Journals Reviewed with Number of Articles with Qualifying Terms
Journal No. of Articles with Qualifying Terms
American Journal of Critical Care . . . . . . . . . . . . . . . . . . . . . . . 2

Applied Nursing Research . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Cancer Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Critical Care Clinic Nursing of North America . . . . . . . . . . . . . . . . . . 1
Critical Care Nursing Quarterly . . . . . . . . . . . . . . . . . . . . . . . 7
Holistic Nursing Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Intensive and Critical Care Nursing . . . . . . . . . . . . . . . . . . . . . 6
International Journal of Nursing Studies . . . . . . . . . . . . . . . . . . . . 4
Journal of Advanced Nursing . . . . . . . . . . . . . . . . . . . . . . . . . 4
Journal of Clinical Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Journal of Gerontological Nursing . . . . . . . . . . . . . . . . . . . . . . 5
Journal of Holistic Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Journal of Nursing Administration . . . . . . . . . . . . . . . . . . . . . . . 1
Journal of Nursing Care Quality . . . . . . . . . . . . . . . . . . . . . . . 9
Journal of Nursing Management . . . . . . . . . . . . . . . . . . . . . . . . 2
Journal of Pediatric Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Journal of PeriAnesthesia Nursing . . . . . . . . . . . . . . . . . . . . . . . 1
Journal of Perinatal & Neonatal Nursing . . . . . . . . . . . . . . . . . . . . 3
Nursing Outlook . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Nursing Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Nursing Research and Practice . . . . . . . . . . . . . . . . . . . . . . . . 1
Nursing Standard . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Research in Gerontological Nursing . . . . . . . . . . . . . . . . . . . . . . 2
Research in Nursing & Health . . . . . . . . . . . . . . . . . . . . . . . . . 3
Western Journal of Nursing Research . . . . . . . . . . . . . . . . . . . . . 1
TOTAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

article represent only a portion of the journals that met the search criteria, others
are still under review.
The Journal of Nursing Care Quarterly and Critical Care Nursing Quarterly had
the most articles that met the search criteria (9 and 7, respectively), followed by
Intensive and Critical Care Nursing (6) and the Journal of Gerontological Nursing
(5). It is interesting to note that the journals with the most articles in this knowl-
edge area focus on patient care quality, critical care, and gerontological nursing.
The data appear to align with closing the patient care quality gap, as well as the
environmental theories that assume the more vulnerable the patients the more
their environment impacts them (Lawton & Nahemow, 1973).
Descriptive statistics were also used to identify the frequency of each of the vari-
ables of interest in each study. Figure 2 illustrates the results on the frequency
of dependent variables. Sleep (n = 6) was the most frequently cited dependent
variable, while noise (n = 4) and medication errors (n = 4) tied for second. The
dependent variables of interest are linked with patient experience. The percep-
tion of noise during the night is a highly regarded marker of the Hospital Con-
sumer Assessment of Healthcare Providers and Systems (HCAHPS) scoring of
patient satisfaction.
Figure 3 illustrates the results on the frequency of independent variables. The

term “environmental feature” occurred most frequently (n = 20). This term was
used to describe a multitude of features of the designed and ambient environ-
ment and was defined numerous ways. The next most frequently cited indepen-
dent variables were sound and light studied together (n = 6), then sound (n = 5)
and light (n = 2) studied separately. It is worth noting that “noise” and “sound”
are not equivalent terms but fall into a similar category of study in this context.
Sound and light appear to be important measures of patient and resident well
being. Again, these data validate Lawton & Nahemow’s (1973) environmen-
tal theory, the more vulnerable the person, either in premature babies or in the
elderly, the more likely impacted by the environment.
Research design and methods were analyzed next. The most frequently used
research design was case study (n = 40) followed by literature reviews (n = 13)
(see Figure 4). Experimental designs (n = 7) and quasi-experimental studies (n
= 3) lagged behind. Two studies fell outside the empirical realm: one that had a
phenomenological approach and one that was ethnographic in nature. The
research designs utilized for the selected articles seem indicative of the new
nature of this field of knowledge.
It also should be noted that none of the research designs reviewed in this study
appeared to be replicated studies, which are important to validate exploratory
case studies and advance the knowledge in a discipline. Figure 5 is a graph-
ic illustration of the the progression of “evidence” in evidence-based medicine
(EBM). EBM has been used as model to promote EBD (Hamilton, 2006).
Of the research methods used, “multiple methods,” the use of two or more
research methods used to look at the same research question, was used most
Figure 2. Frequency of dependent variables.
Ambient environment
Children’s communication
Circadian patterns in infants
Critical care unit design
Depression
Experience — Nurses
Experience of living at home for people…
Fall detection & fall risk
Falls
Global function in people w. Alzheimers
High-quality care & high nursing job…
Infection control
Length of stay; patient outcomes
Medication delivery & staff frustration
Medication errors
Noise
Nursing satisfaction
Nursing workload
Pain relief
Parent & nursing fatigue
Patient outcomes
Patient care quality
Patient dependency, nursing activity,…
Patient experience
Patient experience—Pediatrics
Patient falls
Patient memories
Patient outcomes
Patient outcomes; staff work environment
Patient safety
Patient’s ability to hear, understand, …
Physical demands & staff satisfaction…
Physiological & biobehavioral responses of…
Physiological responses & thermal comfort
Quality of life
Quality patient care; nursing job satisfaction
Resident falls
Room layout
Safe patient handling
Safety
Seating pressure
Sleep
Sleep—Parents
Staff health hazards
Staff well-being & performance
Stress
Successful bath
Time spent doing tasks
Ventilator weaning outcomes
Wayfinding
0 1 2 3 4 5 6 7

Figure 3. Frequency of independent variables.
Air temperature & handling

Ambient environment—Music
Art
Chair surface material
eICU control center design
Environmental features
Equipment
Equipment & ambient noise
Equipment—Beds
Floor sensors
Garden walking
Grab bar location in the bathroom
Light
Medication room design
Medication storage cabinet location
Mirrors
Motion detection system
Nursing tasks
Single-room, acuity-adaptable patient room
Sound
Sound & light
Sound, light & temperature
Unit & patient room layout
Unit design layout
View of nature
0 5 10 15 20 25
Figure 4. Frequency of research design.
45
40
35
30
25
20
15
10
0
Case Literature Ethnographic Experimental Grounded Quasi-
Study Review Theory Experimental
Figure 5. Quality of Evidence Pyramid.
Figure 7: Source:
ModifiedAdapted fromQuality
Figure: Evidence-Based Clinical
of Evidence Practical Resources. © Copyright 2006–2014. Trustees
Pyramid
of Dartmouth
(c) Copyright CollegeTrustees
2006 - 2014. and Yale University.
of DartmouthAll Rights Reserved.
College and Produced by Jan Glover,
Yale University. Dave Reserved.
All Rights Izzo, Karen
Odato, and Lei Wang. Used with permission.
Produced by Jan Glover, Dave Izzo, Karen Odato, and Lei Wang.
frequently (n = 24). Often quantitative methods, used to assess the magnititude

and frequency of variables, and qualitative methods, used to explore meaning
and understanding of concepts, are used together. Literature reviews (n = 12) and
questionnaires (n = 8) followed (see Figure 6). The category of multiple methods
can be broken down further (see Table 2).
Finally, this descriptive analysis concludes with the settings in which the research
took place (see Figure 7). Overwhelmingly, acute care (n = 26) and intensive care
unit (n = 11) settings were utilized for the research studies reviewed, followed
by “other” (n = 8). The other category included settings such as lab simulation
and home- or community-based settings. Only one study reviewed for this arti-
cle represented an outpatient setting. It will be interesting to see how the current
socio-political climate impacts the research settings of interest in the next few years
in the U.S. Perhaps the focus will be on outpatient settings or even the promotion
of homecare. (Remember that in Nightingale’s era, hospitals were reserved for the
very ill, the poor, or those deemed mental ill; everyone else was treated at home.)
Limitations
There are several limitations to this study. First, the journals represented here do
not represent all of the nursing journals that have published research studies on
this topic, but were the first journals on which the author has completed a 6-year

Figure 6. Frequency of research methods.
25
20
15
10
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review. The trends and analyses described here are based on a limited number
of articles from a selected set of journals. It is not a comprehensive review, and
the study is ongoing as of this writing. Second, it should not be assumed that
the research studies were all authored by nurses or by nurses alone. This study
represents articles published in nursing journals and selected for inclusion based
on relevance to the topic area. None of the authors’ credentials were considered
for selection criteria so it is unknown how many were actually nurses. Finally,
it should be acknowledged there may be other journals which do not contain
the word “Nursing” in the title that publish articles by nurses and others on
Table 2. Breakdown of Multiple Research Methods

Research Method No. of Occurrences
Ambient Environment Measurement (includes light,

sound and temperature measurement) . . . . . . . . . . . . . . . . . . . . . 6
Behavioral Observation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Bio-Behavioral Measurement (activity monitoring) . . . . . . . . . . . . . . . 2
Content Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Data Mining . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Interviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Physiological Measurement (includes vital signs monitoring) . . . . . . . . . . 6
Questionnaires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Figure 7. Frequency of research site.
30
25
20
15
10
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this topic area. This phase of the literature review only considered journals with
“nurses” or “nursing” in the title.
Conclusions
Despite the limitations, these findings are significant as a view into nursing
research, much of it conducted during caregiving activities, on the impact of
the designed environment on patients. The findings revealed that the journals
publishing these studies, as well as the variables being studied, were in keeping
with the Institue of Medicine’s aims to explore what impacts patient care quali-
ty and patient safety. The data also revealed that nurses are aware of the role the
designed environment plays in patient outcomes, and while the exact aspects of
the design environment may not yet be completely isolated, they are exploring
research questions with this in mind. It is also interesting to note that some of
the significant findings aligned with Nightingale’s environmental theory attri-
butes (Nightingale, 1860). Sound and noise ranked high among the dependent
variables and sleep among independent variables (the result of sound and noise).
As stated by Nightingale, “Unnecessary noise is the most cruel absence of care
which can be inflicted either on sick or well” (Nightingale, 1860, p. 27). In this
context, Nightingale’s environmental theory appears to still have merit today
in the selection of research variables for study at the bedside. It is humbling to

consider the medical and nursing advances made to date and yet we still do not
have solutions to the problems that plagued Nightingale and others more than
150 years ago.
Research design and research methods utilized in these studies reflect the early
stages of evidence developed in this knowledge area and reveal the complex
nature of bedside research. The use of multiple or mixed methods to study
healthcare research questions is supported (Meissner, Creswell, Klassen, Clark
& Smith, 2010). It is important in this early stage of knowledge development to
examine cause and effect as well as meaning in research studies of this nature.
A few assertions can be made as a result of this study. First, education is impor-
tant to continue the knowledge development in this area. Second, multiple meth-
od research studies should continue to be considered as important to healthcare
research. Finally, bedside nurses are in the best position to, through observation
and research, understand how the design environment impacts their patient dur-
ing the act of nursing. Nightingale would be proud.
Implications for Practice

• Educate nurses, doctors, designers, engineers, facility managers—anyone
who is involved with providing care in a healthcare setting—about the
impact the built environment has on the care delivered.
• Educate the educators who teach these professionals about action based
research—what it means to conduct research at the bedside.
• Conduct research on the impact of the built environment paying particu-
lar attention to settings that serve the most vulnerable populations.
• Use multiple method research designs when possible, because we are still
in the early stages of knowledge progression and we need to gather as
many data as possible when conducting research.
• Mine additional non-design professional journals for environmental
design findings.
• Replicate studies, since this is the optimal way to enhance knowledge in
a profession.
• Because nurses have a unique ability to understand the impact the design
environment has on their patients, it is important to support and/or fund
bedside nursing research.
• Disseminate the findings of studies and evidence-based projects so that
the information can be used to guide decisions in future projects.
References
Creswell, J. W., Klassen, C., Clark, V. L., & Smith, K. C. (2011). Best practices for mixed meth-
ods research in the health sciences. Office of Behavioral and Social Sciences Research.
Bethesda, MD: National Institutes of Health. Retrieved from http://obssr.od.nih.gov/
mixed_methods_research
Dossey, B. M., Selanders, L. C., Beck, D. M., & Attewell, A. (2005). Florence Nightingale today:
Healing, leadership, global action. Silver Spring, MD: American Nurses Association.
Gregory, D. (2009). Nobody asked me: Why nurses should take an interest in workplace design.
American Journal of Nursing, 109(12), 11.
Hamilton, D. K. (2003). Four levels of evidence-based practice. Healthcare Design. Retrieved from
http://www.healthcaredesignmagazine.com/article/four-levels-evidence-based-practice
Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC:
National Academies Press. Retrieved from http://www.iom.edu/Reports/1999/to-err-is-
human-building-a-safer-health-system.aspx
Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st
century. Washington, DC: National Academies Press. Retrieved from http://www.iom.edu/
Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.
aspx
Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment of
nurses. Washington, DC: National Academies Press. Retrieved from http://www.iom.edu/
Reports/2003/Keeping-Patients-Safe-Transforming-the-Work-Environment-of-Nurses.aspx
Kreitzer, M. J., & Zborowsky, T. (2009). Creating optimal healing environments. In M. Snyder &
R. Lindquist (Eds.), Complementary & alternative therapies in nursing (6th ed.) (pp. 321–330).
New York, NY: Springer Publishing Company.
Lawton, M. P., & Nahemow, L. (1973). Ecology and the aging process. In C. Eisdorfer & M. P.
Lawton (Eds.), The psychology of adult development and aging (pp. 619–674). Washington,
DC: American Psychological Association.
Lobo, M. L. (2011). Environmental model: Florence Nightingale. In J. B. George (Ed.), Nursing
theories: The base for professional nursing practice (6th ed.) (pp. 47–62), Upper Saddle River,
NJ: Prentice Hall.
Malone, E., Mann-Dooks, J. R., & Strauss, J. (2007). Evidence based design: Application in
the MHS. HFPA Planning & Programming Division & TRICARE Management Activity, Falls
Church, VA. Retrieved from http://facilities.health.mil/repository/getFile/7
Nightingale, F. (1860). Notes on nursing: What it is, what it is not. London, England: Harrison
and Sons.
Robert Wood Johnson Foundation. (2010, November). Addressing the quality and safety gap—
part III: The impact of the built environment on patient outcomes and the role of nurses
in designing health care facilities. Retrieved from http://www.rwjf.org/content/dam/farm/
reports/issue_briefs/2010/rwjf68886
Robert Wood Johnson Foundation. (2014). Ten years after keeping patients safe: Have nurses’
work environments been transformed? Retrieved from http://www.rwjf.org/en/research-publi-
cations/find-rwjf-research/2009/01/charting-nursings-future-archives/ten-years-after-keep-
ing-patients-safe--have-nurse-work-environme.html
Rubin, H. R., Owens, A. J., & Golden, G. (1998). Status report: An investigation to determine
whether the built environment affects patients’ medical outcomes. Concord, CA: The Center
for Health Design.
Tri-Council for Nurses. (2000). Response to the Institute of Medicine’s report “To err is human:
Building a safer health system.” Washington, DC: American Association of Colleges of Nurs-
ing. Retrieved from http://www.aacn.nche.edu/publications/position/tri-council-sept-2000
Ulrich, R., Zimring, C., Quan, X., Joseph, A., & Choudhary, R. (2004). Role of the physical envi-
ronment in the hospital of the 21st century. Concord, CA: The Center for Health Design.
Ulrich, R. S., Zimring, C., Zhu, X., DuBose, J. R., Seo, H. B., & Choi, Y. S., … Joseph, A. (2008). A
review of the research literature on evidence-based healthcare design. Health Environments
Research & Design Journal, 1(3), 61–125.

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FLORENCE NIGHTINGALE AND IMPACT OF HEALTHCARE ENVIRONMENTS RESEARCH

The Legacy of Florence Nightingale’s

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Chapter 6 and the recommendations revealed an important fact: Physical aspects

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Figure 1. Aligning Infrastructure, Leadership, and Processes: A Multidisciplinary Model.

Malone, Mann-Dooks, and Strauss (2010) presented a framework for under-

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Nurse Research on the Impact of Healthcare Environments

Literature Review: Nurses in Healthcare Design and Related Literature

American Journal of Critical Care . . . . . . . . . . . . . . . . . . . . . . . 2

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Figure 3 illustrates the results on the frequency of independent variables. The

Figure 2. Frequency of dependent variables.

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Figure 3. Frequency of independent variables.

Air temperature & handling

Figure 4. Frequency of research design.

Figure 5. Quality of Evidence Pyramid.

frequently (n = 24). Often quantitative methods, used to assess the magnititude

30 WWW.HERDJOURNAL.COM © 2014 VENDOME GROUP LLC

Figure 6. Frequency of research methods.

Table 2. Breakdown of Multiple Research Methods

Ambient Environment Measurement (includes light,

Figure 7. Frequency of research site.

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Implications for Practice

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