Few theories have had such a dramatic effect on the history of nursing as environmental nursing theory, which was first introduced by Florence Nightingale in the mid to late 18th century. Historians argue over the details, but it is generally agreed to have had its roots in her field hospital experiences during the Crimean War, before being further developed in civilian hospitals and England’s first-ever nursing school.
By shifting thinking from a disease-centered model to one that focused on the patient and the patient’s surroundings, it drew on an emerging scientific understanding of the importance of hygiene to change the way that healthcare was provided, with immediate positive effects. Although understanding of precisely why it works has advanced in the years since, its key recommendations remain the same, and if studying nursing today, they will form an important part of that education.
The lady with the lamp
The legend of Florence Nightingale has been shaped over the years by attitudes that nurses today will find all too familiar. She is remembered first and foremost as a kind woman who brought comfort to wounded soldiers during the Crimean War, walking through the wards at night with her lamp; while her toughness, hard work, and scientific skill tend to be overlooked.
In the context of the war, much of what she did involved addressing already recognized problems. It was rare for nurses to be from well-to-do backgrounds such as hers; hence, she was able to use her status and education to threaten those in charge until they allocated resources to clean sewers, obtain basic medicines, and feed patients properly. She also discouraged fellow nurses that were giving their patients alcohol for comfort, which made her less popular.
The more important part of Nightingale’s work began after the war when she drew on funds from her family and other donors to set up a nursing school and instituted new protocols in hospitals in Liverpool and Aylesbury. These ventures were so successful that their influence quickly spread to other hospitals in the state-backed and charitable sector which, some 90 years later, would become the backbone of Britain’s NHS. They also influenced nurses around the world and had a particularly significant impact on those caring for patients during the American Civil War, setting new standards for healthcare in the developing USA.
Field hospitals are always chaotic places and even with today’s technology, it is rarely possible to create an ideal environment for treatment within them. Working in this environment, however, helped Nightingale recognize the biggest health hazards that were more widely present in hospitals because they were exaggerated to the point where no educated, observant person could overlook them.
In peacetime, most people avoided hospitals because historically they had been a place where people would contract the plague and conditions had not improved. Hospitals were only visited as a last resort; it was common to die from infections contracted there. Many people considered them a place to go to die when they didn’t want to burden their families, or had nobody to care for them.
Nightingale’s hospital reforms began with clearing away the straw that had traditionally been scattered on floors to soak up blood, and which often attracted vermin. Scrubbed stone floors made a big difference, as did proper ventilation and efforts to keep wards warm in cold weather. Gradually, hospitals were transformed into places where people had a real chance of recovery.
The success of these initiatives led to increased funding, particularly from industrialists, who recognized the economic value of enabling workers to overcome sickness or injury and return to leading productive lives. At a time when the economies of industrialized nations were booming and everyone was seen as a potential contributor to growth, businesspeople and politicians alike began to see the importance of investing in health.
To bring about meaningful change, it was necessary to change not only the way hospitals were set up but also the way in which nurses themselves performed their jobs. This became an important part of the wider process of professionalizing nursing. Within hospitals in the early 18th century, patients generally cared for one another, while untrained support workers performed essential tasks.
Furthermore, since these workers were the only people desperate enough to spend time in such a dangerous environment, they usually lacked education or skills of any kind. Some provided care out of a sense of religious duty, sharing knowledge as best they could. Nightingale’s introduction of professionally trained nurses made a massive difference in patient outcomes. The effect of standardizing the approach was in itself very important to progress because it made it much easier to identify what was and wasn’t working.
Nursing had traditionally been thought of as women’s work and while this would continue for a long time—86.6% of all nurses in the US today are women—attitudes toward what that meant would begin to shift. It was impossible to see the changes taking place in hospitals and not recognize that there was real skill involved. This led institutions to recognize that it was worth investing money in recruiting professionally trained nurses, and in instituting training programs of their own. Nurses acquired the economic value which would, in turn, lead to them being socially valued and even celebrated.
There are several different aspects to environmental nursing theory, but its cornerstone is cleanliness. Although Nightingale wasn’t the first person involved in healthcare to conclude that this was important, she was the first to back up her belief with statistics and present a case that people in power found impossible to deny. She was also the first person who had sufficient drive and ambition to seek overall change in healthcare practice rather than only improve her area of practice.
Her specific initiatives drew not only on personal observation but on the published work of Hungarian doctor, Ignaz Semmelweiss, who was the first person to scientifically prove that regular hand washing decreased the risk of infections being transmitted between patients in medical settings. Although this had been folklore for centuries, and was the norm within Jewish and Muslim communities, it was something that most European doctors had not previously taken seriously.
In addition to aiming to reduce the transmission of infection between patients in the wards, Nightingale understood that cleanliness played a vital role in surgical settings and in the management of wounds. New protocols included sterilization of equipment (usually via boiling water) and the regular changing of dressings on wounds, which also enabled necrotic tissue to be removed.
These simple interventions dramatically increased the survival rate of the soldiers she was treating and would go on to inform other areas of nursing, notably the developing midwifery movement, which subsequently saw a significant drop in the number of maternal deaths during childbirth.
Basic patient needs
Alongside cleanliness, Nightingale identified several other crucial factors that patients needed to recover effectively. These included access to food of reasonable quality, where previously patients had been given very basic meals of soup or potatoes or depended on what friends and relatives brought in for them. Also included was management of noise levels, making it possible for patients to sleep, and a changing light cycle, ideally with access to daylight (whose psychological and physiological effects were then undiscovered).
Nightingale insisted that patients should be given comfortable, adequately supportive beds and clean bedding, whereas previously it had not been uncommon for patients to be left on mats on the floor. Bed sharing continued for some time after this due to a shortage of facilities in many areas but was gradually phased out.
In addition to this, and more controversially, Nightingale argued that patients needed to be told what was happening to them, reassured as much as honestly permitted, and given practical advice on how to better care for themselves—a huge step forward in a sector which had tended to objectify them and dismiss their psychological well-being as trivial.
She called for variety in their environment, having seen patients fade away when left without any mental stimulation, and stressed the importance of giving them hope. These are all matters that remain as relevant to nursing today as they were in the 1850s, and they represent areas in which nurses continue to learn and innovate.
Patient discharge and home care
Environmental nursing theory doesn’t just concern hospitals, but rather the whole of the environment within which the patient lives. This is why the process of discharging a patient now involves discussing the environment into which they will be moving, who (if anyone) will be caring for them, and how they will manage any ongoing healthcare concerns.
Sometimes patient release must be delayed because the home environment is not suitable, and sometimes representatives of other agencies, such as social workers, must be brought in to improve conditions. This conversation also gives nurses the opportunity to identify previously undisclosed factors that may have contributed to the patient becoming ill in the first place.
For nurses in the community, observing the home environment during visits to patients is an important part of the job. Often, small changes can be made to improve long-term health. People who have ended up providing care to their friends or relatives are often figuring it out as they go along.
They may not understand everything that’s required to keep a space hygienic, let alone how to prepare healthy meals. Patients themselves may not understand the importance of their environment or may need help to improve it if they’re struggling on a low income. Assisting them in obtaining this is something that nurses can engage with in their role as patient advocates.
A revolutionary tradition
We may think of Nightingale primarily in terms of environmental nursing theory and the comfort she brought to wounded soldiers, but that’s not the only legacy she left for nurses, and it’s not the primary reason why she’s celebrated as a feminist icon. In today’s world, it can be difficult to understand what a huge step it was, back in the 1850s, for a woman to speak out the way she did, or what a tremendous effort it took for her to take on the healthcare establishment and bring about such drastic change. In doing so, she laid the foundations for a profession that encourages its members to speak up, to become advocates, to support each other, and to make sure that healthcare practice continues to move forward.
As every Elmhurst University student learns, earning a masters in nursing benefits not only benefits them but also their patients and the profession as a whole, because it empowers them to use their voice to effect change. Studies on this program enrich their theoretical understanding while the clinical hours in local institutions help translate that theory into practice.
Students are then able to make their own observations and contribute to improving nursing for everyone, especially if they decide to earn an advanced degree in the future. Nursing associations that appreciate the value of continual innovation offer support in pressing for ongoing positive change.
When people think about the future of healthcare, they tend to think first and foremost about scientists and about doctors developing innovative new techniques, but it is really nurses who have done more to shape healthcare than anyone else and have brought it into the modern age.
The holistic focus of the profession means that nurses have a unique advantage when it comes to understanding individual health as something dependent on the wider environment. Environmental nursing theory lies at the root of that but is important to much more than only the history of the profession. It reflects a vast area of potential that remains to be explored.