Implementation of Nightingale's Environmental Theory


The current work gives a short description of Nightingale’s environmental theory and the concept of environment introduced in the 19th century that has been successfully implemented ever since. This theory is based on the understanding that the surroundings have a significant impact on the physical and psychological conditions of healthy and ill individuals. The surroundings can be determined as air, water, cleanliness, drainage, lighting, noise, etc. The environmental concept undermines the fact that both the external and internal factors should be taken into account during the treatment of a person.

Description of a model case, a related case, and an illegitimate case described the application of the chosen concept with different extents of effectiveness. Much attention is paid to the possibility of measuring the environmental concept by assessing the quality of care and the patient’s condition before and after the intervention. The final part of the paper describes the application of the environmental concept to the children exposed to HIV at birth. This can be performed at their homes and health care providing institutions. Further investigation of this possibility will enable change in the nursing guidelines, amends in the existing practices, and more effective allocation of resources.

Keywords: Nightingale’s environmental theory, environmental concept, HIV.

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Nowadays, there exists a great variety of nursing theories and concepts, which make the treatment of patients more effective and efficient. However, not all of them are universal and can be applied to a great variety of situations. The current work will focus on the description and analysis of one of the universal theories. It was developed more than a century ago by Florence Nightingale. Currently, it forms the background for nursing practices in different locations all over the world and is applied for healing numerous complicated physical and psychological diseases. The emphasis will be put on the description of the environmental concept that makes the stress on the significant role of surroundings in the health conditions of ill and healthy individuals.

Much attention would be paid to providing the definition of the environmental concept and its integral parts and showing its application in a model case, a related case, and an illegitimate case in real-life situations. Moreover, real-life examples and studies will prove its relevance. The final part of the paper will introduce the recommendations on the application of the described concept for the improvement of the condition of children exposed to HIV. The description of the Nightingale’s environmental theory with an emphasis on the environmental concept, its analysis, and application, provides a clear understanding and the ability of effective and efficient application for the great variety of health reasons.

Selection of a Nursing Theory

This work will provide a description of the theory that forms the background for modern nursing practices. It was developed by Florence Nightingale in the 19th century and still remains relevant. Nightingale’s environmental theory is based on the understanding that the patient’s health conditions depend greatly on the outer environment. Nightingale’s theory is used the four major concepts: environment, person, health, and nursing (Pirani, 2015). One of these concepts will be discussed below. Nightingale’s environmental theory includes the following cannons, which should be strictly fulfilled for granting effective treatment:

  • ventilation and warmth of a patient’s room;
  • the purity of air, water, drainage, cleanliness, and light;
  • petty management (absence of a nurse);
  • using variety to avoid depression and boredom;
  • the strict control of the intake of food and drink;
  • the food should correspond to the personal preferences of a patient;
  • keeping the bed dry and wrinkle-free;
  • adequate lighting in a room;
  • cleanliness of walls and rooms;
  • cleanliness of a patient’s body;
  • avoidance of nonessential conversations;
  • observation and documentation of observations (Masters, 2011).

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Additional emphasis should be made on the necessity of noise elimination because this factor was recognized as “the cruelest abuse of care which can be inflicted on either the sick or well” (Ryherd, Ackerman, Zimring, Okcu, & Waye, 2012, p. 301). It can be concluded that Nightingale’s environmental theory undermines the complex approach to patients' healing based on the great variety of interventions into the surrounding environment.

The major contribution of this theory to the modern practice is the instruction of relevance of the outer environment and its significant influence on the patient’s condition: “has focused primarily on the environment, interpreted as all external conditions and influences that affect the life and development of an organism, that are able to prevent, suppress or contribute to disease and death” (Medeiros, Enders, & Lira, 2015, p. 519). Thus, nurses need to provide suitable conditions for the physical and mental restoration of a patient by saving their energy.

Florence Nightingale brought understanding that “nurse is expected to care for the spiritual needs of the patients in spiritual distress” (Masters, 2011, p. 50). This statement is based on the belief that each patient has different spiritual distinct characteristics and holistic dimensions, which should be addressed differently.

The last but not least contribution of this theory to the modern nursing practice is that it brings the idea that “nurses should be involved in health promotion and health teaching with the sick and with those who were well” (Masters, 2011, p.50). Consequently, nurses became viewed not only as health care providers but also as educators, because the healthy way of living means avoiding or treating various diseases. Moreover, their knowledge becomes more relevant to healthy people.

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Selection and Description of the Concept

This work provides a description of the basic concept of Nightingale’s environmental theory under the name of environmental hygiene, i.e. the control of various physical components of the life of patients. It is reflected in the realization of the canons described above. The environment in this concept is understood as a combination of external and internal conditions (Masters, 2011). The external conditions are ventilation, temperature, and bedding (Masters, 2011). The internal conditions are medication, water, and food (Masters, 2011). The treatment is directed towards a certain person – “a recipient of nursing care” (Masters, 2011, p. 49).

In this particular case, nursing is understood as alteration or management of the environment for the implementation of “the natural laws of health” (Masters, 2011, p. 49). It is notable that Florence Nightingale had a specific understanding of health. It is reflected not only in being and feeling well but also in the ability “to use well every power we have to use” (Masters, 2011, p. 49).

Analysis of the Concept

As it was mentioned above, the environment is defined as a combination of such factors as ventilation, light, warmth, cleanliness, noise, and diet (Masters, 2011). At the same time, Jarrin (2012) provides a different understanding of the environment and environmental health. As it is presented in her article “The Integrality of Situated Caring in Nursing and the Environment” (2012), the environment includes internal and external environments that cannot be separated from each other. They are represented by “physical, emotional, mental, and spiritual” dimensions (Jarrin, 2012, p.5).

It is notable that both definitions share such similarity as making an emphasis on the external conditions surrounding the patient. This provides an understanding that the patient’s condition depends greatly on the surrounding in which the person lives, i.e. a healthy or ill state is considered to be direct results of environmental impacts. Thus, deficiencies in the major factors (fresh air, pure water, cleanliness, drainage, and light) lead to a health deficit. Thus, much attention should be paid to the assurance of fulfillment of these components.

At the same time, this theory also makes an emphasis on the psychological comfort and absence of any pressure on the individual for the promotion of convalescence. Consequently, Florence Nightingale realized this and introduced the understanding that a person should be considered a multidimensional being whose condition depends on physical, psychological, and spiritual components (i.e. valuing the individual). Nurses should integrate these components into the surrounding environment for the provision of effective treatment.


This work provides descriptions of a model case, a related case, and an illegitimate case for a better understanding of the concept.

The first case will be represented by a real-life example that will contain all the critical attributes of the environmental concept. The patient is a 50-year-old woman, who suffers from an inability to eat, significant weight loss, and productive cough. The health care providers observed poor hygiene and a restless condition. She suffers from tuberculosis. The patient was put in a well-ventilated dry room with good natural light, isolated from outer stresses. Much attention was paid to healthy nutrition, cleanliness, and proper medication. After a month of treatment, the patient gained weight. Health care providers observed the mitigation of her anorexia. These positive results of treatment are based on the effective use of Nightingale’s environmental theory.

The related case will represent a scenario that is similar to the environmental concept of Nightingale’s theory but does not share all attributes. The young men who lived near a nightclub suffered from a mental disorder reflected in the fear of society and intended isolation from other individuals. He was prescribed to use psychotherapy and avoid any stressful situations and noise by changing the place of living. After a one year course, the isolation became less sharp and the patient could freely interact with other people. The improvement of the patient’s condition was largely caused by effective psychotherapy. The noise avoidance also brought a positive effect, however, it was not the main contributing factor.

The illegitimate case will represent the inappropriate use of the concept. The patient suffered from a severe cough and high temperature caused by the flue. The health care provider decided to apply Nightingale’s environmental theory and ventilate the room and avoid any questions for the clarification of the patient’s condition. The condition of the patient became worse. The inappropriate treatment by use Nightingale’s theory leads to inflammation of the lungs

The Measurement of the Concept

The measurement of the described environmental concept can be performed by using several methodologies. The first one is reflected in the assessment of the quality of care. It is based on understanding the realization of Nightingale’s theory is based on the realization of the assurance that the surrounding does not harm the physical and psychological state. Thus, it is proposed to measure the effectiveness of the concept by using the Nursing Care Performance Framework that is based on the analysis of the extent of achievement of the following functions: “acquiring, deploying and maintaining nursing resources, transforming nursing resources into nursing services, and producing changes in patients’ conditions” (Dubois, D’Amour, Pomey, Girard, & Brault, 2013, p. 1).

This method is considered to be relevant and effective because it enables assessing various aspects of the work of health care providers and determining the existing gaps for their timely rectification. Its successful application was shown in the example of the analysis of the performance of 25 nurses in one of the public hospitals in Ribeiro?o Preto (Gabriel, Melo, Rocha, Bernandes, Miguelaci, & Silva, 2011). The use of special indicators was considered to be essential for the evaluation of the work of health care providers (for example, patients bed rests “were considered by 100% of the nurses as highly relevant to evaluate the quality of the nursing care” (Gabriel et al., 2011, p.1252).

One more methodology that can be used for the measurement of the environmental concept is the comparison of the indicators of the patient's’ condition prior to and after the intervention. Its successful application was described in the example of drug-resistant tuberculosis-infected patients in Kenya (Kamau, Rotich, Cheruiyot, & Ng’eno, 2015). The observation of the patient’s condition before the realization of a concept showed that the person “has been admitted for acute confusion, dehydration, wasted, urinary tract infection, malnutrition, and wound care” (Kamau et al., 2015, p. 8).

The female has a restless appearance and poor hygiene (Kamau et al., 2015). The three-month treatment reflected in the use of appropriate medication, assurance of proper air ventilation, clean water, and high vitamin food, cleanliness, natural light and rest lead to the gaining of the weight and improvement of anorexia (Kamau et al., 2015).

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Concept Application

This work will also describe the application of the environmental concept of Nightingale’s theory for the children exposed to HIV at birth. The negative impact of this epidemic can become sharper because of unhealthy housing conditions, like “precarious access to water, sanitation and hygiene practices” (De Lima & Galvao, 2011, p.1). The unfavorable surrounding conditions can stipulate the causation of allergies, asthma, dengue fever, a parasitic worm, etc. (De Lima, Pedrosa, Aguiar, & Galvao, 2013). Thus, health care intervention should be directed on the improvement of the surrounding by describing the necessity of cleanliness, proper ventilation, lighting, and nutrition, and avoidance of psychological stresses.

All these actions can lead to a realistic outcome reflected in the lowering of the number of health issues among children exposed to HIV mentioned above. This possible outcome can be used for the guidance of the health care providers in locations with high rates of HIV infections, especially among the young population. These guidelines could help to mitigate the issue and save people’s lives. At the same time, the practices which form the background of the environmental concept may be used for improving the nursing care of children who already receive treatment for various diseases in health care providing institutions by making it more effective and efficient.

The significant positive effect that can be obtained by applying the environmental concept of healing to these children, using it for reconsideration of the current treatment policies, and making a greater emphasis on the creation of an environment that promotes healing. This can be realized through the allocation of the human resources, i.e. increasing the number of nurses who would assure the necessary level of cleanliness, ventilation, lighting, nutrition, and avoidance of external irritants.

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In conclusion, the current work provides a description and explanation of Nightingale’s environmental theory developed in the 19th century. This theory is based on the understanding that the health conditions of both ill and healthy patients depend greatly on the surrounding factors, like air and cleanliness. The environmental concept emphasized that these factors are both internal and external, i.e. some of them influence the psychological state of an individual (like noise), while the other affects the physical state (like the air temperature). It is notable that the described theory has several contributions to modern nursing practice.

The first major one is that it emphasizes the great role of the environment in the treatment of patients in health care providing institutions. The physical and psychological characteristics of patients should be addressed by using different measures. Moreover, nurses started to be perceived as educators who can teach how to improve the conditions of both ill and healthy individuals. The effectiveness of the concept and the theory is evidenced by continuous research and investigations.

In the current work, it was evidenced by the study that described the improvement of the physical conditions of the patient who suffered from tuberculosis. Nowadays, it can also be effectively used for other interventions, like healing children exposed to HIV at birth. Their condition can be improved by changing the surrounding environment, i.e. better ventilation, nutrition, level of cleanness, etc. These procedures can be realized in the homes of these children and in health care providing institutions.

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