Florence Nightingale and Her Revolutionary Ideas

Florence Nightingale once said, “the very first requirement in a hospital is that it should do the sick no harm”. Not only does this quote apply to Nightingale’s experiences during the Crimean War, it also rings true today. Nightingale’s revolutionary ideals which place an emphasis on a holistic approach to the health care environment and on the importance of nursing education and training, continue to make a significant impact on modern day health care. According to Nightingale’s Environmental Theory, the hospital environment should promote and benefit the patient’s healing process through the provision of many factors with the five most significant being - clean air, pure water, efficient drainage, cleanliness, and sufficient light. Nightingale’s theory asserts that altering a patient’s environment will provide optimal conditions for healing and therefore, will provide a positive impact on a patient’s health. In other words, the hospital environment should be therapeutic and peaceful for patients causing them no maleficence during the healing process. Nightingale’s Environmental Theory places emphasis on both patient care and the nursing process. Her revolutionary patient-care theory played an integral role in influencing the primary focus of a nurse’s role as caregiver. Additionally, Florence Nightingale, often referred to as the founder of modern nursing or Mother of Nursing, transformed the nursing profession by raising the standards and educational expectations for the job.

Florence Nightingale was born May 12, 1920 in Florence, Italy to an affluent English family. Because of her social status, she was educated by her father who taught her history, mathematics, and geography and how to speak Latin, Greek and Italian. Despite her parents’ expectations to follow their rules and regulations regarding marriage and social life, Florence had other ideas. At the age of sixteen she received a “calling” from God to do something special to help others. As she grew older, she acquired an interest in healthcare. By her early twenties, against her parents’ wishes, Nightingale decided to become a nurse so that she could heal the sick and the poor. She attended nursing school at a famous hospital in Germany with some of her friends. Paradoxically, upon returning to England in 1851 as a successful and skilled nurse, her main nursing priority was providing care for her parents and sister who had fallen ill. In 1853, Nightingale began working as a superintendent for a private hospital in London caring for many sick people afflicted by a major cholera outbreak. Through this experience, Nightingale developed effective nursing and leadership skills that helped forge the path of her future by leading her to become one of the most influential leaders of nursing from the latter half of the 17th to the mid-19th centuries.

The significant turning point for Nightingale’s career occurred in 1854 at the start of the Crimean War where she served as a nurse coordinator and leader. The British were unprepared for the high numbers of sick and wounded soldiers. Therefore, the war camp hospitals were horrendous. As a result, death rates were extremely high. Nightingale, who happened to be close friends with the Secretary of War for England, was asked to organize and manage a group of nurses at a military camp hospital in Scutari. When Nightingale and her nurses first arrived at the hospital, it was understaffed by doctors’, overcrowded with patients, unsanitary and had insufficient medical supplies. Nightingale and her nursing brigade made it their mission to improve the military hospital conditions. Within six months, they transformed the unsanitary hospital into a healthy, therapeutic environment by providing the elements of “cleanliness, sanitation, nutritious food and comfort to the patients… such as writing letters home for the patients”, and in effect, caused the death rate of British soldiers to fall.

Florence Nightingale’s experience during the war highlighted how unsanitary environments can vastly affect and cause a deterioration in patient health. For this reason, when Nightingale returned to England in 1856, she continued her efforts for improving hospital environments. In 1859, she helped set up the Army Medical College in Chatham. That same year, using the same fundamentals she implemented to improve the military hospital environment Nightingale authored and published her book, Notes on Nursing: What it is, and What it is Not, in which she officially created and established her Environmental Theory.

Nightingale’s theory focuses on ten major concepts that Nightingale believed vastly affect a patient’s environment in relation their health: ventilation and warming, light and noise, area cleanliness, health of the houses, bed and bedding, personal cleanliness, variety, offering hope and advice, food, and observation. The theory establishes that if any of these factors are deficient it causes a decline in patient health. Hence, by modifying or improving a patient’s environment a nurse can affect change in the patient’s overall health state. According to the theory, if each of the environmental factors is met in a patient’s health environment, then the environment is considered therapeutic and a patient’s anxiety and stress levels will be reduced, thereby causing an accelerated patient recovery process state. In addition to the environmental factors, Nightingale also makes seven assumptions to define nursing and nursing expectations which are: 1) Mankind can achieve perfection, 2) Nursing is a calling, 3) Nursing is an art and science, 4) Nursing is achieved through environmental alteration, 5) Nursing requires a specific educational base, 6) Natural laws, and 7) Nursing is distinct and separate from medicine. Nightingale’s theory is often referred to as a patient care theory, because she chose not to focus solely on the nursing process, the nurse-patient relationship or an individual nurse’s needs. Instead, she chose to focus on how caring for a patient’s environment and a patient’s unique individual needs plays an important role in developing and maintaining a therapeutic environment (Petiprin, 2016). While Nightingale may have developed her theory in the 19th century in an effort to improve hospital environments, her beliefs and assertions are still applicable to modern day medical facilities and nursing practices.

Even though modern technology and medical developments have changed the duties and expectations of a nurse, many key attributes that Nightingale identified in her theory as essential to protecting a patient’s environment are still relevant today. Her environmental theory has had an influential impact on hygiene, which is a priority in many hospitals today regarding patient care, and is the sole basis of established infection protocols for both standard-based and transmission-based precautions. Standard based precautions, like hand hygiene, good cough etiquette, disinfecting equipment used by a patient, the use of personal protective equipment when necessary and several other types of precautions are used with all patients. Transmission-based precautions like droplet, airborne, and contact precautions are used for patients who are known to have an infectious agent to prevent the spread of the infectious agent to other patients and health care members. With infection protocols in place, numerous illnesses and health care associated infections can be avoided. Conversely, a lack of cleanliness and hygiene can lead to an increase of hospital acquired infections and illness, a major problem that still exists in modern healthcare due to “poor standards of cleaning effectiveness.” Other practices inspired by Nightingale’s Environmental Theory that are still in place today are exposure to nature and sunlight and the reduction of environmental stressors like poor air quality and glaring lights. Many modern-day hospitals and long-term care facilities have enclosed courtyards that allow patients access to nature and sunlight exposure. Additionally, most hospitals have made concentrated efforts to make their locations more patient-friendly by reducing environmental stressors such as poor air quality and glaring lights. In most hospitals, air is strategically ventilated to prevent the spread of airborne pathogens throughout a healthcare facility. For example, if a patient is placed on airborne precautions, they are placed in a negative pressure room so that the air they breathe is not recirculated back outside to the hallway. Both light and air quality were important concepts in Nightingales theory as well. Most hospitals have lights that are can be controlled based off of the situation and the time of day. In many hospitals, light levels are reduced in the evening time and the light has warmer tones. Thus, there are many practices still in place in hospitals today due to the standards and expectations that Nightingale not only upheld in her nursing practice but outlined in her Environmental Theory as well. 

One of seven assumptions in Nightingale’s Environmental Theory placed specific emphasis on nursing education and training stating that nursing requires a specific educational base. In 1860, in an effort to make “nursing a viable and respectable option for women who desired employment outside of the home,” (Selanders, n.d.) Nightingale became one of the pioneers of nursing education by establishing a school of her own, based on her theoretical beliefs, which was called, The Nightingale School of Nursing. Nightingale believed that nursing education programs should have special education components that are both theoretical and clinical, should be controlled by the school not the hospital, and should have a grounding in basic science. Additionally, Nightingale believed that nursing students should be regularly assessed on skills and educated by nurses who specialize in education. Most nursing education programs of today require pre-requisite science courses, are controlled by accredited schools versus hospitals, offer courses with both classroom and clinical components, employ experienced nurses with a teaching certification to instruct their students and regularly assess their students’ skills using both written and hands-on examinations (“American Nursing: An Introduction to the Past”). Because most nursing programs today still utilize many of the same educational components in their teaching curriculum that Nightingale outlined in her theory more than a century ago, she is regarded as an instrumental theorist of modern nursing.

Personally, I chose Nightingale because I think the theory she established hundreds of years ago remains as a core foundation for modern nursing practice. Without the influence of Nightingale’s theory and techniques, nursing and health care facilities might not have the high quality standards that exist today. It is likely the rate of illnesses and health care associated infections would be even higher than it is now. Additionally, Nightingale made nursing a reputable and trusted profession. In the sixteenth to the mid nineteenth century, nurses were viewed as servants and sometimes even criminals. Because it was common practice to draft criminals to work as nurses for punishment, the image of nursing was tarnished and caused people to view them as unclean and disorderly. Nightingale’s commitment to making improvements in both health care and nursing practices during the Crimean War she gained the respect of the physicians she assisted. After the war, her determination to reform nursing education and training helped transform the nursing profession is a highly respected job. Many physicians today have immense respect for the nurses and view their role and opinions as an integral part of the health care team. On another personal note, the first thing we learned how to do as nursing students in our clinical simulation lab was how to properly perform hand hygiene and how to wear personal protective equipment for transmission-based precautions. Reflecting back, it is inspiring how the first thing I learned as a nursing student is so deeply connected to Nightingale and her theory and it clearly shows me how great an impact Nightingale has had on nursing and nursing education. Lastly, I’ve personally seen how when one factor is lacking within the environment it can affect a patient’s whole experience. My uncle was in the hospital and the quality of care he received wasn’t always the best regarding personal cleanliness. Sometimes we would visit and you could tell he had been neglected to be given a bed bath or that his linens had not been changed recently and it was really upsetting to experience.

When Florence Nightingale became a nurse in the 19th century, she had no idea that she would make such a lasting impact on the nursing profession and health care environments. As a nursing student, I am inspired by her many admirable qualities - empathy, ambition, loyalty and discipline. As both a risk-taker and advocate for her patients, Nightingale did whatever it took to create a sanitary and healing environment for her patients. She once said, “When I am no longer even a memory, just a name, I hope my voice may perpetuate the great work of my life.” In my future practice as a nurse, I will strive to live up to Nightingale’s expectations of nursing by putting her theory into practice in hopes that I, too, can make an impact in the lives of my patients as well as the health care community.