FLORENCE NIGHTINGALE’S

ENVIRONMENTAL ADAPTATION MODEL

FLORENCE NIGHTINGALE’S

ENVIRONMENTAL ADAPTATION MODEL

KENN S. NUYDA, RN

The Florence Nightingale Pledge

The Florence Nightingale Pledge

I solemnly pledge myself before God and in the presence of this assembly, to pass my life in purity and to practice my profession faithfully.

I will abstain from whatever is deleterious and mischievous, and will not take or knowingly administer any harmful drug.

I will do all in my power to maintain and elevate the standard of my profession, and will hold in confidence all personal matters committed to my keeping and all family affairs coming to my knowledge in the practice of my calling.

With loyalty will I endeavor to aid the physician, in his work, and devote myself to the welfare of those committed to my care.

Who is Florence Nightingale?Who is Florence Nightingale?

Born: May 12, 1820 Villa Colombaia,

Florence, Italy Parents:

– William Edward Nightingale

– Frances Nightingale née Smith

• rich, upper-class well-connected English family (Victorian family)

Residence of NightingaleResidence of Nightingale

Embley Park, now a school, was the family home of Florence Nightingale

Parents were landowners, “class citizens”

Sister: Parthenope Tutored by father in:

mathematics, languages, religion and philosophy

Participated in social gatherings at Victoria’s social events during her adolescence

Exposed during her childhood to the “poor” and the “sick”

Visited various hospitals to see the occupations of women there

What influenced Nightingale to pursue Nursing?What influenced Nightingale to pursue Nursing?

Personal experiences

Societal involvement of her family

Professional values

– Education– Social status– Personal

experience– Religion

L U V L I F E???L U V L I F E???

Courted by politician and poet Richard Monckton Milnes, 1st Baron Houghton, but she rejected him

“Marriage” would interfere with her ability to follow her calling to nursing

Rome 1847 – met Sidney Herbert

Secretary of War Crimean War Herbert was already

married, but he and Nightingale were immediately attracted to each other and they became lifelong close friends

Knowledgeable in the works of her government

1837 - Had a strong belief in GOD and she had a “religious calling”– “God spoke to me

and called me to his service”

1851 – completed her training in nursing at KAISERWERTH, GERMANY, stayed there for 3 months

Herbert was instrumental in facilitating her pioneering work in Crimea and in the field of nursing, and she became a key advisor to him in his political career.

1850 she visited the Lutheran religious community at Kaiserswerth-am-Rhein where she observed Pastor Theodor Fliedner and the deaconesses working for the sick and the deprived.

She regarded the experience as a turning point in her life, and issued her findings anonymously in 1851; The Institution of Kaiserswerth on the Rhine, for the Practical Training of Deaconesses, etc. was her first published work

1851 - rejected Milnes' marriage proposal against her mother's wishes

Visited various hospital facilities, reformatories, charitable institutions after her training

August 22, 1853 – became the superintendent of the HOSPITAL FOR INVALID GENTLEWOMEN (London)

CRIMEAN WAR

• October 21, 1854 – under the authorization of Sidney Herbert Nightingale and 38 newly recruited nurses were sent to Crimea (Turkey)

• She and her nurses found wounded soldiers being badly cared for by overworked medical staff in the face of official indifference

• Medicines were in short supply

• Hygiene neglected and infections most common

Criteria for Being A Nurse

• Young• Middle class women• Basic general education to nursing

care• Needs to address the

environmental pxs

• 4077 soldiers died • Cleaned the

hospital and equipment

• Reorganized patient care

• typhus, typhoid, cholera and dysentery

• d/t overcrowding and the hospital's defective sewers and lack of ventilation

• March 1855 – 6 months after she arrived in Scutari: flushed out the sewers and improved ventilation, death rates were reduced

LADY WITH A LAMP

• She is a ‘ministering angel’ without any exaggeration in these hospitals, and as her slender form glides quietly along each corridor, every poor fellow's face softens with gratitude at the sight of her.

• When all the medical officers have retired for the night and silence and darkness have settled down upon those miles of prostrate sick, she may be observed alone, with a little lamp in her hand, making her solitary rounds.

• Immortalized by the poem of Henry Wardsworth Longfellow on “Santa Filomena”

• Lo! in that hour of miseryA lady with a lamp I seePass through the glimmering gloom,And flit from room to room.

Returning Home

• August 7, 1857 • Given honor by

Queen Victoria• Awarded with

funds which she used in establishing institution for nurses – St. Thomas’ Hospital and King’s College Hospital in London

• Was stricken by a fever, probably due to a chronic form of Brucellosis ("Crimean fever") that she contracted during the Crimean war

• Home confined

• Played the central role in the establishment of the Royal Commission on the Health of the Army, of which Sidney Herbert became chairman.

• Notes on Matters Affecting the Health, Efficiency, and Hospital Administration of the British Army Founded Chiefly on the Experience of the Late War

• Notes on Hospitals• Reports on Measures

Adopted for Sanitary Improvements in India from June 1869 – June 1870

• Wrote 15000 – 20000 letters to friends, acquaintances, allies and opponents conveying her beliefs, observations and desire for social changes in health care and society

• August 13, 1910 – death of Florence Nightingale at her own home

The grave of Florence Nightingale in the churchyard of St. Margaret's Church, East

Wellow

• Blessed with determined motivation, Nightingale was a stern, starchy but gifted organizer. Her success in elevating nursing owed much to her insistence in her 'Notes on Nursing' (1859) on the requirement for nurse recruits to receive a thorough training in nursing theory and practice. She was a great advocate in the power of facts, calling statistics 'the most important science in the world'. Florence believed nursing involved dedication, devotion and discipline, but it was also to be a skilled profession. 

Statue of Florence Nightingale. The statue is in Waterloo

Place, London SW1.

NIGHTINGALE’S APPROACH TO NURSING

• Focused on the Environment

• Environment = all the ext’l conditions and influences affecting the life and dev’t of an organism and capable of preventing, suppressing or contributing to disease, accidents or death. (Murray and Zentner)

COMPONENTS OF ENVIRONMENT

• VENTILATION

• WARMTH

• LIGHT

• DIET

• CLEANLINESS

• NOISE

• She integrated the physical, emotional and social aspects of the environment, that they are interrelated with each other in the role of attaining health of man.

• But her NOTES ON NURSING gave emphasis on the PHYSICAL aspect of the env’t

5 ESSENTIAL COMPONENTS OF ENVIRONMENTAL HEALTH

1) Pure air

2) Pure water

3) Efficient drainage

4) Cleanliness

5) Light“ Badly constructed houses do for the healthy

what badly constructed hospitals do for the sick. Once insure that the air is stagnant and sickness is certain to follow.”

PROPER VENTILATION and WARMING

• Greatest concern of Nightingale

• “Keep the air he breathes as pure as the external air, without chilling him.”

• Asked the caregiver to consider the source of air in the pt’s room

• If he keeps on breathing his/her own air he would become sick

• Concerned pretty well in “noxious air” or EFFLUVIA (foul odor from excrement)

• Urinals, bedpans, utensils• Criticized “fumigations” – coz it just treats

the offensive smell, not the source• Room Temperature – not too warm or too

cold

LIGHT

• Direct sunlight• “light has quite as real and tangible

effects upon the human body… who has not observed the purifying effect of light, and especially of direct sunlight, upon the air of the room?”

• Move and expose cts to sunlight• Decreases confusion and psychoses

CLEANLINESS

• Dirty environment (floors, carpets, walls and linens) is a source of infection through the organic matter in it

• Nurse, patient & environment• Proper handling and disposal of body

secretions and sewage • Daily bathing of the pt was advocated• Clothes of the pt must be clean• Handwashing = pt and the nurse

• Believed that many diseases were caused by breaks in the skin

• Unwashed skin poisoned the pt• Bathing:

– Just as it is necessary to renew the air round a sick person frequently, to carry off morbid effluvia from the lungs and skin, by maintaining free ventilation, so is it necessary to keep pores of the skin free from all obstructing excretions.”

BED AND BEDDINGS

• Bed should be placed at the lightest part of the room and pt must be able to see the window

• Nurse must maintain its cleanliness, dryness and neatness at all times

VARIETY

• Affects the recovery of the pt• Change in color and form – plants

and flowers• 10 – 12 paintings be rotated each

day, week or month• Advocated reading, needlework,

writing and cleaning to relieve boredom

WARMTH

• Measure the pt’s temperature by palpating the extremities to assess heat loss

• Nurse must manipulate the env’t to maintain both ventilation and patient warmth by using good fire, opening windows and properly positioning the pt in the room

NOISE/QUIETNESS

• Noise must be avoided ‘coz it could harm the patient

• Example: – Jarring noises– Pt should be waked intentionally or

accidentally during the 1st part of sleep– Whispering and long conversations about pts

are thoughtless and cruel

* Nurses must stop these noises

DIET

• Assess dietary intake, meal schedule and effect on the pt

• There must be variety of foods served to the pt

• Noted:– Individualization of foods per person– Frequent small feedings were beneficial to

clients– Patterns of eating (breakfast) at lunch

– Chronically ill may be starved to death because of their incapacitation can make them unable to feed themselves

– No business should be done while patient is eating to avoid distractions

CHATTERING HOPES AND ADVICES

• Means what is said to the patient• To cheer the sick by making light of their

illness• False hopes are depressing to the clients

making him more fatigued• Nurse must heed what is being said by the

visitors• Sick persons must hear good news that

would make them healthier

SOCIAL CONSIDERATIONS

• She observed that generations of families lived and died in poverty

• Wrote letters and sent them to improve the undesirable living conditions

• Started the political activism by nurses

• Pet visits may bring comfort to the patient

• Protect the patient from upsetting news, visitors who affect the recovery

I. NURSINGI. NURSING

• Believed that every woman, at one Believed that every woman, at one time in her life, would be a nurse in time in her life, would be a nurse in the sense that nursing is having the the sense that nursing is having the responsibility for someone else’s responsibility for someone else’s healthhealth

• Provided guidelines to women in the Provided guidelines to women in the care of their loved ones at home and care of their loved ones at home and to give advise on how to “think like a to give advise on how to “think like a nurse” – NOTES ON NURSING (1859)nurse” – NOTES ON NURSING (1859)

• ““What nursing has to do… is to put What nursing has to do… is to put the best condition for nature to act the best condition for nature to act upon him”upon him”

• Viewed Viewed medicine and surgerymedicine and surgery as as removing obstructions to health to removing obstructions to health to allow nature to return the person allow nature to return the person to healthto health

• ““Nursing ought to signify the proper use Nursing ought to signify the proper use of fresh air, light, warmth, cleanliness, of fresh air, light, warmth, cleanliness, quiet and the proper selection and quiet and the proper selection and administration of diet – all at the least administration of diet – all at the least expense of vital power to the patient.”expense of vital power to the patient.”

• ““The art of nursing as practiced, seems The art of nursing as practiced, seems to be expressly constituted to unmake to be expressly constituted to unmake what God has made disease to be, a what God has made disease to be, a reparative process.”reparative process.”

Trained NursesTrained Nurses

• Apply scientific principlesApply scientific principles• Observe and report pt’s statusObserve and report pt’s status• Performing interventions Performing interventions

II. PERSONSII. PERSONS

• PERSON = PATIENTPERSON = PATIENT• In relationship with the environment In relationship with the environment

and the impact of the environment upon and the impact of the environment upon themthem

• N performs tasks to and for the ptN performs tasks to and for the pt• N must manipulate the environment for N must manipulate the environment for

the ptthe pt• Patient’s self – care should be Patient’s self – care should be

encouragedencouraged

• Ask the client about his/her Ask the client about his/her preferences (individualization)preferences (individualization)

• Must have respect for persons of Must have respect for persons of any background, be non-any background, be non-judgmental about social worth judgmental about social worth

III. HEALTHIII. HEALTH

• Health Health – “being well and using – “being well and using every power (resource) that the every power (resource) that the person has to the fullest extent in person has to the fullest extent in living his/her life”living his/her life”

• DiseaseDisease – “reparative process that – “reparative process that nature instituted when a person nature instituted when a person did not attend to health concerns”did not attend to health concerns”

• ““nature alone cures”nature alone cures”• Nursing should provide care to the Nursing should provide care to the

healthy as well as the illhealthy as well as the ill• Discussed health promotion as an Discussed health promotion as an

activity in which a nurse should activity in which a nurse should engageengage

MAINTENANCE OF HEALTHMAINTENANCE OF HEALTH

• PreventionPrevention• Environmental controlEnvironmental control• Social responsibility Social responsibility

• PromotionPromotion• PHNPHN• Modern concept of health promotion Modern concept of health promotion

(BHWs)(BHWs)

IV. ENVIRONMENTIV. ENVIRONMENT

• ““elements external to and which affect elements external to and which affect the health of the sick and healthy the health of the sick and healthy person”person”

• ““everything from the patient’s food and everything from the patient’s food and flowers to the patient’s verbal and non-flowers to the patient’s verbal and non-verbal interactions”verbal interactions”

• Nurses must create and maintain a Nurses must create and maintain a therapeutic env’t to enhance pt’s therapeutic env’t to enhance pt’s comfort and recoverycomfort and recovery

RURAL HYGIENERURAL HYGIENE

• Describe specific environmental problems Describe specific environmental problems and their resultsand their results

• Practical solutions to these problems for Practical solutions to these problems for households and communitieshouseholds and communities

• Believed that “sick poor people” would Believed that “sick poor people” would benefit from environmental improvementsbenefit from environmental improvements

• Nurses are instrumental in changing the Nurses are instrumental in changing the social status of the poor by improving social status of the poor by improving their physical and psychological living their physical and psychological living conditionsconditions

CLIENT

NURSE

Nurse Observer Practitioner

Noise

Air

H of houses

Variety

Light

Bedding

Cleanliness

Chattering Hopes

Nutrition

Ventilation

THEORETICAL THEORETICAL ASSERTIONSASSERTIONS

• Believed that disease was a Believed that disease was a reparative processreparative process

• Disease was nature’s effort to Disease was nature’s effort to remedy a process of poisoning remedy a process of poisoning

• Or decay or a reaction against the Or decay or a reaction against the conditions in which a person was conditions in which a person was placedplaced

• Believed that nursing's role was to Believed that nursing's role was to prevent an interruption of the prevent an interruption of the reparative process and to provide reparative process and to provide optimal conditions for its optimal conditions for its enhancementenhancement

• She was totally committed to nursing She was totally committed to nursing education – NOTES ON NURSINGeducation – NOTES ON NURSING• womenwomen

• She also felt the She also felt the need that nurses need that nurses must be excellent must be excellent observersobservers

• Must make use of Must make use of their common sensetheir common sense

• Must be perseveringMust be persevering• Must have ingenuity Must have ingenuity

• She believed that She believed that people who desires people who desires good health must good health must cooperate with the cooperate with the nurse and nature to nurse and nature to allow the reparative allow the reparative process process

• They should also They should also alter their alter their environment to environment to prevent the diseaseprevent the disease

COMMITMENTSCOMMITMENTS

• Observing patients at Observing patients at nightnight

• Sitting with them Sitting with them during the dying during the dying processprocess

• Standing beside them Standing beside them during surgeryduring surgery

• Writing letters for Writing letters for themthem

• Providing reading Providing reading materials during materials during recuperationrecuperation

• Wrote letters to their Wrote letters to their families following deathfamilies following death

• Nurses must be moral Nurses must be moral agentsagents

• Must have professional Must have professional relationship with the relationship with the patientspatients

• Maintain confidentialityMaintain confidentiality• Nurses must have Nurses must have

clear, concise decision clear, concise decision makingmaking

PETTY MANAGEMENTPETTY MANAGEMENT

• Nurse is in control of the Nurse is in control of the environment both physically and environment both physically and administrativelyadministratively

• To protect the patient from both To protect the patient from both physical and psychological harm physical and psychological harm

ACCEPTANCE BY THE ACCEPTANCE BY THE NURSING COMMUNITYNURSING COMMUNITY

1. 1. Practice Practice • Remains to be integral in nursing careRemains to be integral in nursing care• Modern sanitation and water txModern sanitation and water tx• Environmental concernsEnvironmental concerns• Controlled room temperature and noise to Controlled room temperature and noise to

client’s roomclient’s room• Suffrage movement – FEMINIST THEORY Suffrage movement – FEMINIST THEORY

dev’t – influenced the upper class women dev’t – influenced the upper class women of the society to be useful/contributory of the society to be useful/contributory members of the communitymembers of the community

2. Education2. Education

• Scientific principle instructions Scientific principle instructions and practical mastery of skillsand practical mastery of skills

• St. Thomas’ Hospital and Kings’ College St. Thomas’ Hospital and Kings’ College Hospital in LondonHospital in London

• US – based hospitalsUS – based hospitals• Bellevue Hospital, NYBellevue Hospital, NY• New Haven Hospital, ConnecticutNew Haven Hospital, Connecticut• Massachusetts Hospital, BostonMassachusetts Hospital, Boston

• The art of nursing could not be The art of nursing could not be measured by licensing examinationsmeasured by licensing examinations

• Instead, use case studiesInstead, use case studies• Good education = good practiceGood education = good practice• ““Training is to teach a nurse to know Training is to teach a nurse to know

her business… Training is to enable her business… Training is to enable the nurse to act for the best… like an the nurse to act for the best… like an intelligent and responsible being.intelligent and responsible being.

3. Research3. Research

• Nightingale’s theory defines the Nightingale’s theory defines the scientific inquiry used in nursing scientific inquiry used in nursing researchresearch

• Gathering and analyzing the dataGathering and analyzing the data• Graphic illustrationsGraphic illustrations• Lack the complexity and testability Lack the complexity and testability

found in modern nursing theoriesfound in modern nursing theories

• Considered to be a grand theory Considered to be a grand theory (explains the totality of behavior, (explains the totality of behavior, vague, w/o specific definitions of vague, w/o specific definitions of terms and concepts and w/o full terms and concepts and w/o full dev’t of relationships b/w conceptsdev’t of relationships b/w concepts

• Also classified as lower level Also classified as lower level theorytheory

CHARACTERISTICS OF CHARACTERISTICS OF NIGHTINGALE’S THEORYNIGHTINGALE’S THEORY

1. Simplicity1. Simplicity• 3 major relationships (Env’t – pt, N – 3 major relationships (Env’t – pt, N –

env’t, N – pt)env’t, N – pt)• Environment is the main factor Environment is the main factor

creating illness (harm and benefits)creating illness (harm and benefits)• Environmental manipulation and Environmental manipulation and

elimination of contagionelimination of contagion• NPR was not well-defined NPR was not well-defined

2. Generality2. Generality

* still applicable today (N – P – E)* still applicable today (N – P – E)

* applied in all hospital settings * applied in all hospital settings (ICU, wards), home, community(ICU, wards), home, community

3. Empirical Precision 3. Empirical Precision

* Nurses must practice based on * Nurses must practice based on their observations and experiencestheir observations and experiences

* May be used to formulate * May be used to formulate another nursing theoryanother nursing theory

1. Florence Nightingale’s major 1. Florence Nightingale’s major writing on nursing is: writing on nursing is:

A. Managing the Environment A. Managing the Environment 

B. Nature of Nursing B. Nature of Nursing 

C. Notes on Nursing C. Notes on Nursing 

D. Theory of NursingD. Theory of Nursing

2. 2. In using Florence Nightingale’s theory in In using Florence Nightingale’s theory in the assessment phase of the nursing the assessment phase of the nursing process, data to be collected would process, data to be collected would include:include:

A. The patient’s ability to be mobileA. The patient’s ability to be mobile

B. Skin turgor B. Skin turgor 

C. Family relationships C. Family relationships 

D. Light and ventilation in the roomD. Light and ventilation in the room

3. Nightingale’s canon that relates 3. Nightingale’s canon that relates most closely to continuity of care most closely to continuity of care is: is:

A. Chattering hopes and advices A. Chattering hopes and advices 

B. Cleanliness B. Cleanliness 

C. Health of houses C. Health of houses 

D. Petty managementD. Petty management

4. Florence Nightingale’s practice of 4. Florence Nightingale’s practice of nursing was based on the belief that: nursing was based on the belief that:

A. Germs cause disease A. Germs cause disease 

B. Proper nutrition is primary to healing B. Proper nutrition is primary to healing 

C. Suffering humans can heal C. Suffering humans can heal themselves themselves 

D. Whispering and quiet movements D. Whispering and quiet movements enhance sleepenhance sleep

F I NF I N

~GRACIAS~~GRACIAS~