NIGHTINGALE INSTITUTE OF NURSING,

NOIDA

SEMINAR
ON

NIGHTINGALE’S THEORY

(SUBJECT: ADVANCED NURSING PRACTICE)

SUBMITTED TO SUBMITTED BY

MS. ANN GLADIS Ms. DHAIRYA ARORA

ASSISTANT PROFESSOR M.Sc. (N) 1st YEAR

NIN, NOIDA NIN, NOIDA

FLORENCE NIGHTINGALE’S ENVIRONMENTAL THEORY
OF NURSING
BACKGROUND OF THE THEORIST
The goal of nursing is “to put the patient in the best condition for nature to act upon him”.
– Florence Nightingale.

Nightingale was born on 12th may 1820 in Florence, Italy, privately educated by father
inclined to care for sick. She attended nursing programs in Kaiser Werth, Germany in 1850 and
1851. She worked as the Nursing superintendent at the Institution for care of sick gentlewomen
in distressed circumstances, where she instituted many changes to improve patient care. Called
to Turkey, during Crimean war. Her work proved successful in decreasing the mortality rate in
the war. She is known as ‘The Lady With The Lamp’ and considered as the first nursing
theorist.
She began the Nightingale school of nursing at St. Thomas hospital, King’s College in
London, Founder of modern nursing and the first nursing theorist. She wrote Books: Notes on
Nursing(1859), What it is, what it is not (1860), Notes on hospitals (1863) ,Sick-Nursing and
Health-Nursing (1893) . She stated in her nursing notes that nursing “is an act of utilizing the
environment of the patient to assist him in his recovery.” Her contribution during Crimean war is
well-known. She was a statistician, using bar and pie charts, highlighting key points. Her
birthday,12th May, is observed in respect to her contributions in nursing & is celebrated as
International Nurse’s Day.
She died on 13th August 1910 in London.
INTRODUCTION
The foundation of Nightingale’s theory is the environment- all the external conditions
and forces that influence the life and development of an organism. According to her, external
influences and conditions can prevent, suppress, or contribute to disease or death. Her goal was
to help the patient retain his own vitality by meeting his basic needs through control of the
environment.
EVOLUTION OF NIGHTINGALE’S THEORY
Early in her work at the army hospital Scutari, Nightingale noted that the majority of the
soldier’s deaths was caused by transport to the hospital and conditions in the hospital itself.
Nightingale found that open sewers and lack of cleanliness, pure water, fresh air and wholesome
food were more often the cause of soldier’s death than their wounds; she implemented changes
to address these problems.
Nightingale instituted a system of care that reportedly cut causalities from 48% to 2% within 2
years. She adapted a statistical reporting method known as polar area diagram or Cock’s comb
model, to analyze the data she rigorously collected.
TYPES OF ENVIRONMENT
There are three types of environments:
• Physical Environment -consists of physical elements where the patient is being treated. It
affects all other aspects of the environment. Cleanliness of environment relates directly to
disease prevention and patient mortality. Aspects of the physical environment influence the
social and psychological environments of the person
 • Psychological environment- can be affected by a negative physical environment which then
causes stress. It requires various activities to keep the mind active. It involves communication
with the person, about the person, and about other people.
• Social environment -It includes components of the physical environment - clean air, clean
water, proper drainage. It consists of a person’s home or hospital room, as well as the total
community.
NIGHTINGALE’S THIRTEEN CANONS
There are 13 canons:
1. Ventilation And Warmth: Keeping patient, patient’s room warm Keeping patient’s
room well ventilated and free of odors. Keep the air within as pure as the air external
air/without noxious smells.
2. Health Of Houses: This canon includes five essentials of- Pure air, Pure water, Efficient
drainage, Cleanliness, Light Examples include: removing garbage or standing water
ensuring clean air and water and free from odour and that there is plenty of light.
3. Petty Management: Continuity of the care, when the nurse is absent Documentation of
the plan of care and all evaluation will ensure others give the same care to the client in
your absence.
4. Noise: Avoidance of sudden/startling noises. Keeping noise in general to a minimum.
Refrain from whispering outside the door.
5. Variety: Provide variety in the patient’s room to help him/her avoid boredom and
depression. This is accomplished by cards, flowers, pictures, books or puzzles (presently
known as diversional therapy) Encourage significant others to engage with the client.
6. Food Intake: Assess the diet of the client. Documentation of amount of foods and
liquids ingested at every meal.
7. Food: Instructions include trying to include patient’s food preferences. Attempt to
ensure that the client always has some food or drink available that he/she enjoys.
8. Bed And Bedding: Comfort measures related to keeping the bed dry, wrinkle-free and
at the lowest height to ensure the client’s comfort.
9. Light: Assess the room for adequate light. Sunlight works best. Develop and
implement adequate light without placing the client in direct light.
10. Cleanliness Of Rooms/Walls: Assess the room for dampness, darkness and dust or
mildew. Keeping the environment clean (free from dust, dirt, mildew and dampness.
11. Personal Cleanliness: Keeping the patient clean and dry at all times Frequent
assessment of client’s skin is needed to maintain adequate moisture.
12. Chattering Hopes And Advices: Avoidance of talking without reason or giving advice
that is without fact. Continue to talk to the client as a person. And to stimulate the
client’s mind Avoid personal talks.
13. Observation Of The Sick: Making and documenting observations. Continue to observe
the client’s surrounding environment.
METAPARADIGMS OF NURSING ACCORDING TO NIGHTINGALE:
There are four metaparadigms:
 Person - Recipient of nursing care. People are multidimensional, composed of
biological, psychological, social and spiritual components. Environment Environment
can be external as well as internal. Poor or difficult environments led to poor health and
disease. Environment could be altered to improve conditions so that the natural laws
would allow healing to occur.
 Health - For nightingale, health is “not only to be well, but to be able to use well every
power we have”. Disease is considered as dys-ease or the absence of comfort. [Six D’s
of Dys-ease are: Dirt, Drink (need clean drinking water), Diet, Damp, Draughts and
Drains (need proper drainage and sewer systems)]
 Environment – Nightingale stated that "Poor or difficult environments led to poor health
and disease". "Environment could be altered to improve conditions so that the natural
laws would allow healing to occur."
  Nursing - Nursing to nightingale was above all, “Service to God in the relief of man” To
alter or manage the environment to implement the natural laws of health. Nursing is
different from, medicine and the goal of nursing is to place the patient in the best possible
condition for nature to act. Nursing is the activities that promote health (as outlined in
canons) which occur in any caregiving situation.

NIGHTINGALE’S ENVIRONMENTAL MODEL

ANALYSIS OF NIGHTINGALE’S ENVIRONMENTAL MODEL OF NURSING

1. Assumptions: Philosophical assumptions: Nursing is a calling. Nursing is both art and
science. People can control the outcomes of their lives to pursue perfect health. Nursing
requires a specific educational base. Nursing is distinct and separate from medicine.
Additional assumptions: Maintaining a clean room, bedding and clothing aids in patient
recovery. Noise can be harmful to patients. Managing the environment improves the health of
the patient.
2. Propositions: The person is desirous of health, so that the nurse, nature and the person will
co-operate; so that all reparative process occur. The nurse’s role is to prevent the reparative
process from being interrupted and to provide conditions to optimize the reparative process.
Brief Critique -The model is a simple one, characterized by only three major relationships:
1) Environment to patient
2) Nurse to environment
3) Nurse to patient
Nightingale’s model was developed inductively major concepts are clearly defined, and
the relationships among the concepts flow logically. She focused more on physical factors than
on psychological needs of patient. Although, some of the Nightingale’s rationales have been
modified or disproved by advances in medicine and science, many of the concepts in her theory
have not only endured but have been used to provide guidelines for nurses for more than 150
years. In particular, her model remains relevant to illness prevention and health promotion.
NIGHTINGALE’S ENVIRONMENTAL MODEL AS A FRAMEWORK FOR NURSING
PRACTICE
Nightingale expected nurses to use their skills of observation in caring the patients.
Nursing observations and documentation should focus on the assessment of the patient in
relation the 13 canons identified by Nightingale when nursing care is provided that is framed by
Nightingale’s environment model.
RELEVANCE OF THEORY IN NURSING PRACTICE, EDUCATION AND
RESEARCH NURSING PRACTICE
Nursing Practice
1.Disease control
2. Sanitation and water treatment
3. Utilized by modern architecture in the prevention of "sick building syndrome" applying the
principles of ventilation and good lighting.
4. Waste disposal
5. Control of room temperature
6. Noise management.
Education
1. Principles of nursing training. Better practice result from better education.
2. Skills measurement through licensing by the use of testing methods, the case studies.
Research
1. Use of graphical representations like the bar, pie diagrams.
2. Notes on nursing.
THE NURSING PROCESS AND NIGHTINGALE’S ENVIRONMENTAL MODEL
Application Of Nightingale's Theory In Nursing Process
Assessment The following information should be adequate:
• Adequacy of ventilation
• Cleanliness of environment
• Presence of draft
• Sudden noises
• Amount of sunlight and artificial light  
• Variety of dietary offerings
• Odors present in throughout ward
• Methods of disposal of human waste and sputum
• Opportunity to communicate with others
• Insufficient warmth
• company from family and other patient
• Insufficient knowledge regarding disease
Nursing Diagnosis • Non-stimulating environment
Implementation
• Provide adequate ventilation by opening doors and windows.
• Keep the surrounding environment clean (linen, bed, utensils)
• Keep the patient in warm and comfortable room, avoid unnecessary noise.
• Increase stimulus through a greater exposure to sunlight and fresh air.
• Provide nutritious diet and encourage for liquid diet frequently.
• Proper disposal of sputum, human excreta and other waste to remove odors.
• Proper dress-up, maintain room temperature and wear warm clothes.
• Isolate the patient from the children from the other patients but keep in touch and interaction
with limited visitors.
• Keep in stimulating environment such as listening to radio, reading magazines and newspapers.
• Provide sufficient advice, information about disease, it’s prognosis, course of treatment to the
patient and family members.
Evaluation
• It is based on observation on the effect of a changing environment on the health of a person
specially focus on the vital signs and adequate knowledge about disease condition.
Example :
• Assessment: Nancy Smith, a 10 yrs old was injured in an accident related to farm machinery.
She had head injury then she was admitted to PICU. Because of PICU environment, she had
interrupted sleep and she became increasingly confused. Her leg has become infected.
• Analysis of data: includes data gap.
• Nursing Diagnosis: Impaired sleep pattern related to environmental light and noise and
separation from family.
• Planning and implementation: nursing actions focus on changing the environment to support
more normal sleep patterns, that is, being awake during the day and sleeping at night. •
Evaluation: After two nights of uninterrupted sleep, normal sounds, and parental encouragement,
Nancy will demonstrate increased orientation to place being able to identify that she is in the
hospital.
ASSUMPTIONS OF FLORENCE NIGHTINGALE’S THEORY
The assumptions of Florence Nightingale in her Environmental Theory are as follows:
 Florence Nightingale believed that five points were essential in achieving a healthful
house: “pure air, pure water, efficient drainage, cleanliness, and light.”
 A healthy environment is essential for healing. She stated that “nature alone cures.”
 Nurses must make accurate observations of their patients and be able to report the state of
the patient to the physician in an orderly manner.
 Nursing is an art, whereas medicine is a science. Nurses are to be loyal to the medical
plan, but not servile.
NIGHTINGALE’S MODEL AND THE CHARACTERISTICS OF THEORY
Theories can interrelate concepts in such a way to create different way of looking at phenomena:
 Using her environmental model, new insights into the phenomena of interest to nursing
can be identified.
 Examining environmental aspects such as light, noise or warmth can provide new
insights into human responses to health and illness, which means that health and illness
not only influenced by the pathophysiology and psychosocial environment.
 Theories must be logical in nature.
• Her model is illogical.
• She built her conclusion from observations, she made her case, drew her conclusions
and then acted. She used logic to correct her conclusion.
 Theories must be relatively simple yet generalizable
• Her writings are simple.
• The beauty of her model is its generalizability, including its continued applicability
today.
 Theories can be bases for hypothesis that can be tested or for theory to the explained
• Nightingale has stimulated the development of nursing science with her work.
• She has had a profound effect on many of the other nursing theorists.
• The research related to the impact of the environment on client health has been
influenced by Nightingale.
 Theories contribute to and assist in increasing the general body of knowledge
• This theory seems to have more relevance to practitioners today than ever before.
• More and more data are becoming available to indicate the critical nature of the impact
of the environment on the health and well-being of the individual.
 Theories can be used by practitioner to guide and improve them
• Her work raises a consciousness on the nurse about how the environment influences
client outcomes.
• For example: controlling sound in the wards, mounting ventilation and light, put off
light during nights all and all help in recovery from illness.
 Theories must be consistent with validated theories, laws and principles but will have
open unanswered questions that need to be investigated.
• Works well with ecological, systems, adaptation and interpersonal theories.
• She did not believe in germ theory; however, the practices she recommended were not
inconsistent with scientific knowledge we have today.
• Many of her suggestions which she based on observation of client response to their
environment, have been documented on scientifically sound when tested with rigorous
application of modern research methods.
Critiques Of The Nightingale’s Environment Theory
• Although four major concepts are not explicit in Nightingale’s theory, they do offer nursing a
specific way of looking at particular phenomenon.
• The relationship between each concept is logical and consistent with similar assumptions.
• Nightingale’s theory, although limited, has a lot of generalizability.
• These ideas are basically simple to apply and easy to measure in terms of outcomes.
• Prevention of disease would be achieved through environmental controls.
• The environmental aspects of her theory remain integral components of current nursing care.
• Yet it is not clear that Nightingale intended to develop a theory of nursing, she did intend to
define the science and art of nursing and provide general rules with explanations.  
• The relation concepts-nurse, patient and environment are applicable in all nursing today.
• Nightingale rejected the germ theory and her inability to recognize a unified body of nursing
knowledge that is testable.
• She was only relying on personal observation and experience.
Strengths
The language Florence Nightingale used to write her books was cultured and flowing, logical in
format, and elegant in style. Nightingale’s Environmental Theory has broad applicability to the
practitioner. Her model can be applied in most complex hospital intensive care environment, the
home, a work site, or the community at large. Reading Nightingale’s Environmental Theory
raises consciousness in the nurse about how the environment influences client outcomes.
Weaknesses
In Nightingale’s Environmental Theory, there is scant information on the psychosocial
environment when compared to the physical environment. The application of her concepts in the
twentieth century is in question.
RESEARCH
The Florence Nightingale’s Environmental Theory: A Critical Analysis
By Ana Beatriz de Almeida Medeiros et al. (RN, BRAZIL)
Objective:
To analyze the environmental theory of Florence Nightingale based on the model proposed by
Johnson and Webber.
Methods:
Theoretical and reflective study conducted in the months of November and December 2012.
Theory analysis based on eight criteria: meaning, boundaries, language, concepts, formation of
propositions, variables and assumptions, theoretical knowledge helps explain and predict
phenomena and theoretical knowledge influences nursing practice.
Results:
The theory presents: clarity of meaning of ideas, clear boundaries, level of understanding above
90%, the main concepts, formulated propositions based on the concepts, variables and
hypotheses that help to understand and interpret propositions, influence on the practice of
nursing.
Conclusion:
The environmentalist theory of Florence Nightingale has concepts that serve today's parameters,
and its relevance is considered a landmark in the history of nursing.
Source- Esc. Anna Nery vol.19 no.3 Rio de Janeiro July./Sept. 2015
http://www.scielo.br/scielo.php?pid=S141481452015000300518&script=sci_arttext&tlng=en
SUMMARY
Florence nightingale is viewed as the mother of modern nursing. She synthesized informa
tiongathered in many of her life experiences to assist her in the development of modern nursing.
Nightingale viewed the manipulation of the physical environment as a major component of nursi
ng care.  She identified ventilation and warmth, light, noise, variety, bed and bedding, cleanliness
of rooms and walls, nutrition as major areas of the nurse could control. When one or more
aspects re out of balance, the client must use increased energy to counter the environmental
stress.

CONCLUSION
The Environmental Theory of Nursing is a patient-care theory. It focuses on the alteration
of the patient’s environment in order to affect change in his or her health. Caring for the patient
is of more importance rather than the nursing process, the relationship between patient and nurse,
or the individual nurse.
In this way, the model must be adapted to fit the needs of individual patients. The
environmental factors affect different patients unique to their situations and illnesses, and the
nurse must address these factors on a case-by-case basis in order to make sure the factors are
altered in a way that best cares for an individual patient and his or her needs.

BIBLIOGRAPHY
BOOKS:
 Tomey, A.M., (1994). Nursing Theorists and Their Work. 3rd ed. Missouri: Mosby
 Ruth F. et al, Fundamentals of Nursing: Human Health and Function, 2003, pp.56
 Barbara Kozier et al, Fundamentals of Nursing: Concepts, Process and Practice, Second
Edition, 2004, p.38
JOURNAL:
 George, J. (1995). Nursing Theories: The Base for Professional Nursing Practice. (4th
edition). Norwalk, CT: Appleton & Lange.
INTERNET:
 Neelam Yadav, Florence Nnightingale Theory of Nursing , Slideshare, content available
at - https://www.slideshare.net/neelamyadav7161/florence-nightingales-environmental-
theory-of-nursing
 Josephine Ann Neecor, Florence Nightingale’s Environmental Theory , slideshare,
content available at- https://www.slideshare.net/JosephineAnnNecor/01-florence-
nightingales-environment-theory
 Angelo Gonzalo, Florence Nightingale’s Environmental Theory, Nurses labs, conent
available at- https://nurseslabs.com/florence-nightingales-environmental-theory/