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Florence Nightingale’s Environmental Theory Positively Influences the Role of a
Registered Nurse
Bao Nguyen
Western University of Health Sciences
GN 6165: Evidenced Based Practice/Theory
Dr. Marci Luxenburg Horowitz and Renata Jones
November 30, 2020
It is safe to say that no nurse could deny the contribution of Florence Nightingale in the
development, reformation, and transformation of nursing practice. Florence Nightingale is
widely known as the pioneer that shed lights into the field of nursing, which many can visualize
the picture of her holding a lamp and works her way through darkness. Throughout the years of
working for the British army in the Crimean War, she developed and coiled many important
nursing concepts that modern nursing still utilizes (Wills, 2018). One of her well known and
most recognizable works is the Nightingale environmental theory (Kamau et al, 2015). The
theory emphasizes essential components of the environment and its impacts on a patient’s
healing process, which makes it unique from other nursing theories (Mughal & Ali, 2017). The
purpose of this paper is to introduce, analyze, and critically critique the theory’s influences in
modern nursing and its application in clinical practices.
Review of Literature
Florence Nightingale environmental theory focuses on the external factors that have
direct influence on the patient. Early in her work at the army hospital, she realized the cause of
the soldiers’ death was not from the primary injury, but rather by the conditions in the hospitals
itself. She noted that lack of cleanliness, wholesome food, pure air and water were the main
cause of mortality. Based on these observations, Nightingale believed that cleanliness, pure air,
pure water, light, and well drainage to be the five crucial components for a healthful house
(Wills, 2018). In addition, she believed that a healthful house prevented illnesses and promoted
wellness of an individual. Nightingale also emphasized on the impact of sounds that could
negatively disturb the patient and suggested that nurses must keep the patient’s environment with
minimum extraneous noises. She considered a healthy environment was the key for a patient to
achieve best healing (Mughal & Ali, 2017). Furthermore, she indicated the concept of holistic
nursing care that focused on the well-being of a patient as a whole, which included
physiological, psychological, and spiritual. Nightingale created theoretical frameworks for many
studies on the impact a healthy environment and provided foundation for nursing practice
(Awalkhan & Muhammad, 2016).
It is not feasible to carry out a research on a grand theory, therefore, many researchers
have focused on the usefulness of the theory in modern nursing practice and its application in
clinicals. According to Awalkhan & Muhammad (2016), the symptoms and suffering from a
disease is unavoidable; however, the exacerbation of symptoms was mostly related to the level of
care that patients received. Nurses cannot change the disease process, rather, they can intervene
and manipulate the environment to keep patients at their best form for nature to act upon. This
requires the nurse to be proactively involve in maintaining and manipulating the environment to
fit patients’ needs in order for them to regain stability (Mughal & Ali, 2017). Opposingly,
Kauma et al (2015) pointed out a limitation in Nightingale grand theory; though these concepts
were effective in promoting physical’s health restoration, they lack considerations on the
patient’s psychological health. Nevertheless, Nightingale’s theoretical concepts remain effective
and still being applied to modern nursing practices, even though it was developed more than a
century ago (Awalkhan & Muhammad, 2016).
Application to Nursing Practices
The patient’s health is comprised of many determinant factors such as physiological,
social, psychological, spiritual, and cultural (Kauma et al, 2015). However, the nurse’s scope of
practice is not to interfere these aspects, but to manipulate the surrounding to accomplish best
patient satisfaction (Awalkhan & Muhammad, 2016). This can be achieved by incorporating
basic environmental concepts into the care plan. According to one study done on a patient with
post-colostomy complications, she was able to recovery faster and showed significant
improvements after the nurse provided well wound hygiene and nutritious food (Awalkhan &
Muhammad, 2016). Nursing students, especially those with minimum knowledge about the field,
could utilize these techniques to assist the patient healing process since they are not trained to do
advanced skills. In addition, nurses must keep in mind that cleanliness is the utmost importance
when performing care. Patient will be psychologically heightened when they observe or knowing
that they are getting proper cares (Mughal & Ali, 2017). Nurses could also educate patients to
maintain cleanliness by simply washing their hands regularly. It is undeniable that washing
hands is one of the most effective ways to prevent the spread of diseases, for instance COVID-19
(Juthamanee, 2020).
Registered nurse should also consider other aspect of the environmental theory such as
pure air. A research on tuberculosis drug-resistance demonstrated that the patient showed
improvement in overall health when fresh, negative-pressure air flown room was provided
(Kamau et al, 2015). Consistently, another study illustrated that closed room setting exacerbated
the condition or symptoms of those with asthma and other pulmonary diseases (Mughal & Ali,
2017). By incorporating the concept of fresh air into practice, nurses could enhance the patient’s
comfort and prevent avoidable sequelae. In addition to providing quality care, a nurse
successfully illustrates the integration of evidence-based practice when applying these theoretical
concepts. This theory provides the essential foundations for a registered nurse to develop the
tools and skills necessary for improving patient’s healing process and well-being (Wills, 2018).
Sounds and noises were also mentioned as a determinant factor that directly affect a
patient’s healing process. Nightingale stressed that extraneous noises should be kept at the
minimum and patient should not be disturbed by the noises made by nurses. Salzmann‐Erikson et
al (2016) illustrated that adaptation of the environment as a sleep-promoting nursing strategy to
keep noises at the minimum directly promoted patient’s sleep and in turn increased patient’s
wellbeing. The researcher further expressed that noises such as electronic alarms negatively
affected the heart rhythm and cerebral cortex activity. It is great to realize that nurses have
already implemented these techniques into the nursing practice. Nevertheless, it is beneficial for
developing nurses to acquire this knowledge and to be able to apply it into their future practice as
a registered nurse.
External stimuli such as sounds and noises may negatively impact the patient sleeps;
however, soothing and self-affirmative sounds inversely benefit the patient’s mood and
wellbeing. According to a study on oncology patients receiving chemotherapy, nature and selfaffirmative sounds during treatment significantly reduced chemotherapy-related symptoms
which included pain, drowsiness, depression, and anxiety (Yildirim et al, 2017). It is worthwhile
to recognize that sounds could also be therapeutically used to enhance patient’s feelings and
mental state in appropriate settings. Having this in mind, registered nurses could manipulate to
use sounds as a nonpharmacological adjuvant to help patient with their coping skills. He or she
could further attempt to eliminate as much sounds as possible in order to provide the patient best
sleeping environment. While it may not be important for registered nurses to use sounds in
assisting patient to cope with their illnesses, it is imperative for them to acknowledge that noises
negatively impact the patient’s sleep and rest that they must try to avoid making whenever
Another component of the environmental theory that Nightingale also highlighted was
proper nutrition. According to Vowden & Vowden (2017), adequate nutrition is one of many
important factors that nurses must be closely monitored in order to support proper wound
healing. Consistently, a research study on diabetic foot ulcer also indicated that balanced and
proper nutrition as well as nutrition education significantly increased wound healing speed and
reduced wound size in the first week (Basiri et al, 2020). This is a very valuable piece of
evidence that nurses can easily apply into daily practice in order to promote patient wellness.
However, morbidity state will likely contribute to the patient’s decreased appetite (Maier et al,
2016); therefore, it is the nurse’s responsibility to encourage and reassure that the patient is
getting sufficient nutrition. In coherent with the previous study, another research found that
longer wound healing time was directly associated with malnutrition. Not only that, inadequate
intake of essential nutrition that required for wound healing increased wound severity; it could
ultimately lead to complication such as infection and amputation as the last resort intervention
(Maier et al, 2016). Overall, registered nurses must ensure that patients are supplied with
balanced and proper nutrition that is required for wound healing. Furthermore, nurses should be
aware of which nutrition is appropriate for the patient based on his or her pathophysiological
state of the disease.
Water is surely one of the most important substances on earth and perform many essential
functions in the body. Therefore, it is no surprised that Florence Nightingale included pure water
as a crucial component for patient healing. Water-borne diseases such as cholera, dysentery, and
typhoid were closely observed by Florence Nightingale, but still causing many deaths until today
(Lee et al, 2013). Nurses must be able to acknowledge these water-borne diseases, the
importance of pure water, and be able to apply Nightingale’s environment theory into daily
practices in order to prevent infections from contaminated water. According to a meta-analysis,
improved water quality and sanitation greatly reduced the morbidity in children water-borne
infection and mortality up to 50% (Esrey et al, 1991). Consistently, Shrestha et al (2020) also
illustrated that nutritional deficiency and diarrhea positively associated with total coliforms in
drinking water source. Coliforms are groups of bacteria that can be found in the animal or
human’s intestine and feces; drinking water is tested for the number of coliforms as an indicator
for cleanliness and safety (Shrestha et al, 2020). These pieces of evidence are in congruent with
Nightingale’s environmental theory on pure water. Since water is colorless and tasteless, nurses
must be mindful when providing water to the patients. Ensuring the water is clean and pure will
greatly reduce the risk of acquiring an infection that may be detrimental to the patient current
condition. In addition, the patient’s body will devote its energy for reconstruction and healing if
unnecessary complications could be avoided. Bedside nurses are the ones who will directly come
in contact with the patients and the water he or she provided, it is imperative for nurses to
incorporate this theoretical concept of pure water into daily practice to further enhance the
patient’s condition and healing process.
Modern nursing is greatly influenced by Florence Nightingale, and her works and
contributions served as essential framework and foundation for nursing science (Wills, 2018).
Nightingale environmental theoretical concepts were not only applicable in building in a
healthful home, they effectively improved the patient’s healing process when intergraded in the
healthcare settings (Kamau et al, 2015). Researches illustrated that patient’s healing process,
well-being, and psychological status significantly improved upon modifications of the
environment. It is critical and imperative for nurses to utilize and implement these concepts into
daily nursing practice. Environmental theory positively influences the role of a nurse by creating
essential fundamental, ethical, and evidence-based nursing practice.
Awalkhan, A., & Muhammad, D. (2016). Application of Nightingale Nursing Theory to care of
patient with colostomy. European Journal of Clinical and Biomedical Science, 2(16), 97101. http://doi: 10.11648/j.ejcbs.20160206.17
Juthamanee, S. (2020). ‘Wash your hand!’: the old message from Florence Nightingale to
battle COVID-19. Belitung Nursing Journal, 6(2), 62.
Kamau, S. M., Rotich, R. J., Cheruiyot, B. C., & Ng’eno, L. C. (2015). Applying Florence
Nightingale’s model of nursing and the environment on multiple drug resistant
tuberculosis infected patients in the Kenyan setting. Open Access Library Journal, 2(08),
1. http://doi 10.4236/oalib.1101796
Mughal, F. B., & Ali, B. H. (2017). Enhancing patient well-being: Applying
environmental theory in nursing practice. Annals of Nursing and Practice, 4(3), 1085.
Wills, E. M. (2018). Theoretical basis for nursing. Wolters Kluwer.
Lee, G., Clark, A. M., & Thompson, D. R. (2013). F lorence N ightingale–never more relevant
than today. Journal of advanced nursing, 69(2), 245-246.
Salzmann‐Erikson, M., Lagerqvist, L., & Pousette, S. (2016). Keep calm and have a good night:
nurses’ strategies to promote inpatients’ sleep in the hospital environment. Scandinavian
journal of caring sciences, 30(2), 356-364.
Yildirim, M., Gulsoy, H., Batmaz, M., Ozgat, C., Yesilbursali, G., Aydin, R., & Ekiz, S. (2017).
Symptom Management. Clinical journal of oncology nursing, 21(1).
Maier, H. M., Ernst, J. I., Arjmandi, B., Kim, J. S., & Spicer, M. T. (2017). Deficiencies in
nutritional intake in patients with diabetic foot ulcers. Journal of Nutritional
Therapeutics, 5(4), 85-92.
Basiri, R., Spicer, M. T., Levenson, C. W., Ormsbee, M. J., Ledermann, T., & Arjmandi, B. H.
(2020). Nutritional supplementation concurrent with nutrition education accelerates the
wound healing process in patients with diabetic foot ulcers. Biomedicines, 8(8), 263.
Esrey, S. A., Potash, J. B., Roberts, L., & Shiff, C. (1991). Effects of improved water supply and
sanitation on ascariasis, diarrhoea, dracunculiasis, hookworm infection, schistosomiasis,
and trachoma. Bulletin of the World Health organization, 69(5), 609.
Shrestha, A., Six, J., Dahal, D., Marks, S., & Meierhofer, R. (2020). Association of nutrition,
water, sanitation and hygiene practices with children’s nutritional status, intestinal
parasitic infections and diarrhoea in rural Nepal: a cross-sectional study. BMC public
health, 20(1), 1-21.
Vowden, K., & Vowden, P. (2017). Wound dressings: principles and practice. Surgery
(Oxford), 35(9), 489-494.
Annotated Bibliography
Mughal, F. B., & Ali, B. H. (2017). Enhancing patient well-being: Applying
environmental theory in nursing practice. Annals of Nursing and Practice, 4(3), 1085.
The purpose of this case study was to testify Florence Nightingale’s environmental theory
and if there was any delay in patient’s recovery process when one failed to apply the
concepts of this theory into clinical practice. In context of the research, a 71-year-old
female patient was admitted to the post anesthesia care unit after her laparotomy and
anastomosis procedure. She had history of asthma, diabetes, and hypertension. Despite
the nurse’s efforts to intervene and assist the patient to heal and rest, she showed no sign
of recovery but constantly experienced an increased in blood pressure, pulse, and
respiration rate (Mughal & Ali, 2017).
The authors of this article did not possess a title of an RN or any nursing accreditation;
however, these two authors were represented by two nursing schools so there is a high
chance that they were nursing students. In addition, the fact that this article was not
written in the United States nor studied a case within the American territory made it
difficult to assess its usefulness for the American epidemiology. Furthermore, only one
test subject was presented in the study negatively affected the reliability of the results.
However, the article thoroughly described the scenario and provided readers many
essential information to make the case suitable to study. In addition, the authors also
comprehensively defined and explained Florence Nightingale’s environmental theory.
Even though the authors did integrate prior knowledge of a grand theory and apply it into
a realistic case study, they failed to fully synthesize a thesis statement or a hypothesis that
encompass their expectations and the anticipated results. Nevertheless, the results of the
case study did not validate Nightingale’s theory; however, it did prove that the patient
were unable to gain maximal recovery when the nurse failed to incorporate theoretical
concepts into practice. This study will still be helpful in determining if Nightingale’s
theory is applicable in today practice at a different approach. The article could be served
as a secondary source of literature to support the validity of Florence Nightingale’s
environmental theory.
Awalkhan, A., & Muhammad, D. (2016). Application of Nightingale Nursing theory to care of
patient with colostomy. European Journal of Clinical and Biomedical Science, 2(16), 97
101. doi: 10.11648/j.ejcbs.20160206.17
The study discussed the application of Nightingale environmental theory in colostomy
care and its usefulness in hospital settings. The study presented Mrs. X in post-op
colostomy for intestinal obstruction with unknown etiology. The patient appeared pale
with septic wound and colostomy site was cover by a plastic bag. She experienced fever,
hypertension, and tachycardia. She was only 38kg. The nurse used nursing process to
assess the situation and provide appropriate interventions. After the proper care was
given, Mrs. X showed signs of improvement on the skin around the stoma, weight, sleep,
and overall health (Awalkhan & Muhammad, 2016).
The study successfully incorporated Florence Nightingale’s environmental theory into
clinical practices along with nursing process. Readers can clearly see the positive impact
that the environment have on the patient’s healing process. Not only that, it also halted
the exacerbation of post-operation infection that Mrs. X was experiencing. However,
Mrs. X was the only test subject in this study and the results were solely based on her. In
addition, using her name anonymously raises a question if this patient is real or is she a
fictional and fabricated character? These instances lower the reliability and credibility of
the study. Nevertheless, the study did prove that optimal environment was another way to
boost up her healing process. It also validated Florence Nightingale’s grand theory and its
application in clinical settings. Furthermore, the study confirmed the theory’s usefulness
in modern nursing care and the fundamental of nursing practices even though it was
established more than a century ago.
Kamau, S. M., Rotich, R. J., Cheruiyot, B. C., & Ng’eno, L. C. (2015). Applying Florence
Nightingale’s model of nursing and the environment on multiple drug resistant
tuberculosis infected patients in the Kenyan setting. Open Access Library
Journal, 2(08),1. http://doi 10.4236/oalib.1101796
The paper started with an introduction to Florence Nightingale’s theory as well as
multiple drug resistant tuberculosis; then it discussed on the application of this theory in
practice. A case study presented a 61-year-old female that was brought to the Casualty
department after being found with acute confusion, malnutrition, wasted, dehydration,
and UTI. The patient also reported fever, night sweats, thirsty but unable to eat, along
with weight loss and productive cough. Her subjective data matched the assessed
objective data; she was diagnosed with TB. The plan of care includes hygiene wound
care, consulted medications and diets, and provided a room with natural light plus
systemic ventilation. The fever subsided after 3 weeks, the patient was able to eat, and
her weight increased. Due to the extensive treatment period of Tb, the paper was
submitted before the end results could be collected; however, several improvements were
noted (Kamau, 2015).
Due to the lack of final results, it is difficult to evaluate the effectiveness of Nightingale’s
grand theory in this case. There was also no direct evidence to support that the patient’s
improvement was the result of ‘right’ environment as described by Nightingale, nor
because of the right medication that she was getting. Nevertheless, the nurse manipulated
the environment and mediated the right care for the patient to be in the best condition for
nature to act upon. A patient’s ability to heal is largely facilitated by nurses’ power to
conduct an environment that is suitable for a patient’s current state of disease.
Furthermore, Nightingale was not only famous for her environment theory, but she was
also a pioneer in keeping statistic and documentations of the patient’s health status. By
keeping chart and using statistics, a nurse could prevent further complications and
sequela from developing (Kamau, 2015). Based on this, the nurse’s plan of care
incorporated charting and observing showed a successful integration of Nightingale’s
early work into modern nursing, which is now considered as evidence-based practice.

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