Theory of Florence Nightingale

1. Theory ofFlorence Nightingale Nursing 324 2/3/2012 Tina Bombe Sonja Wroblewski Nathan Dixon

2. Florence Nightingale’sNursing Philosophy The goal of nursing is to “put the patient in the best condition for nature to act upon him” (Nightingale, 1860) An excerpt from Light’s (1997) article eloquently summarized Nightingale’s philosophy: For Nightingale, the essence of nursing was to create an environment in which the natural healing force within the person could flourish. The patient was central to the healing process, and the nurse‘s task was to facilitate the natural healing process by manipulating the patient’s environment. (p. 33)

3. Historical Originsand OverviewofNightingale’sNursing Model

4. Historical Background and Development of Nightingale’s Philosophy Klakovich’s (2009) article highlights Nightingale’s earlier nursing history which led her to the development of her nursing philosophy. • When Nightingale was17 years old, she felt that God called upon her to serve him. • Nightingale’s affluent family opposed her to becoming a nurse. • At 17 she volunteered in village schools and poor neighborhoods in England. • She trained as a nurse at Sisters of Charity of St. Vincent de Paul in Egypt and for a few months at Kaiserwerth hospital in Germany. • In 1853,when she was 33 years old, she became superintendent of the London charity-supported Institution for Sick Gentlewomen in Distressed Circumstances. • In 1854 Nightingale organized a party of thirty-eight nurses, for service in the Crimean War. • Nightingale was appalled by the horrendous conditions and the number of deaths related to infection during the Crimean War.

5. Figure. 1 Diagram of the Causes of Mortality during the Crimean War. • She took meticulous notes during the war and was an early statistician on sanitary conditions and mortality rates. (See Figure 1) Source: Nightingale, Florence. Notes on Matters Affecting the Health, Efficiency and summarized Hospital Administration of the British Army, 1858.

6. Her research lead to better sanitary conditions thus reducing mortality rates by two-thirds. • It was during the years of 1853-1856 where Nightingale made most of her well renowned contributions and observations toward modern nursing. She documented those findings in 1860 in her book called Notes on Nursing: What it is and what it is not.

7. Origins and Influence • Much of the literature suggests that Florence’s philosophy started as a result of her own values and beliefs, and she called nursing “a divine calling” (Payne, 2010). • Her homeopathic influence likely resulted from her British upper-class upbringing (Light, 1997). • Her views were not common during her time, making her a pioneer in nursing. Although her ideas are not unique to just nursing, they were (and continue to be) unique to healthcare as a whole, including medicine and research.

8. Origins and Influence • Her collaboration with statistician William Farr was groundbreaking (Kudzma, 2006). The concepts developed through their relationship are still very much applicable today, probably more so than during her time. • She advocated for the use of statistics in improving patient care across the healthcare continuum (Kudzma, 2006). Today our use of statistics and epidemiology is called evidence based practice, and guides everything we do in one form or another.

9. Nightingale’s Philosophical Values, Nursing Knowledge and Development It was Nightingale’s empirical work during the Crimean War that molded and influenced her values and philosophy in nursing. These influences, observations, and writings of Nightingale echo the framework of the nursing process used today. In Freeman, L., & Mornhinweg, G. (1992) article they summarized the works of Nightingale by stating: The nursing care Florence Nightingale advocated was truly “holistic”. She collected data through subjective and objective measures related to a variety of area, including diet, environment, and emotions. She developed goals and plans of care to eliminate the identified problems and evaluated the outcome. It has been demonstrated that Nightingale’s philosophy of nursing / caring was truly holistic in nature. (p. 353-354)

10. Nightingale’s Historical Timeline May 12, 1820— Florence is born in Florence, Italy while her family was on vacation. 1837— God called Florence to serve him. 1853-1856 Crimean War— Florence introduced modern nursing skills and first noticed the importance of sanitation and nutrition for healing. 1855— Nightingale Fund created for the training of nurses. 1856— Florence plays a central role in the establishment of the Royal Commission on the Health of the Army, which investigated the disasters of the Crimean War. She provided statistical reports about sanitation for healing and helped to define its recommendations. This led to a major overhaul of army military care. 1860— Florence opens Nightingale Training School at St. Thomas’s Hospital. 1860— Florence publishes “Notes on Nursing, what is and what is not” a small book that became the curriculum for the Nightingale School as well as other nursing schools.

11. Nightingale’s Historical Timeline 1870s— Florence trained Linda Richards, “America’s first trained nurse,” who returned to the USA to establish high-quality nursing schools. 1883— Florence awarded the Royal Red Cross by Queen Victoria. 1907— First woman to receive the Order of Merit. 1908— Awarded the Honorary Freedom of the City of London. August 13, 1910— Florence dies at 90 years of age. http://lib.byu.edu/exhibits/nightingale/downloads/Nightingale-TIMELINE.pdf

12. Information and ConceptsContent of the Nursing Model

13. Information and ConceptsContent of the Nursing Model Florence Nightingale’s distinct nursing model consists of the four global concepts –human being, health, environment, and nursing. Her model puts the patient (human being) at the forefront and suggests that there is a dynamic relationship between the health and recovery of a patient (health), the patient’s surroundings (environment), and the skill of the nurse providing care (nursing).

14. Human Being Florence Nightingale saw the patients as a people with several needs: • They want to reside in a comfortable environment. They want to be warm, to breathe fresh air, to eat good food, and to be in a clean and quiet room. • They want to be respected. They do not want their confidential information shared, they value privacy, and they want their nurse to be punctual, pleasant, and calm. • They have spiritual and emotional needs. They require rest. They do not want to be abruptly awakened at night. They want to be informed and reassured. Nightingale F. (1860). Notes on nursing: what it is and what it is not. Retrieved from http://digital.library.upenn.edu/women/nightingale/nursing/nursing.html#XIII

15. Environment To meet patients’ needs, Florence Nightingale believed that the condition of the environment was important. • She believed that the healthcare setting should be clean, warm , and well ventilated. “Bad sanitary, bad architectural, and bad administrative arrangements often make it impossible to nurse“ (para.7). • The rooms should be free of clutter, overcrowding, and the décor should not be boring. Walls should be cheerful not monotonous. • Water should be fresh and food should be abundant, appropriate, well-balanced, and sanitarily prepared. • The environment must promote restful periods. Patients should not be suddenly awakened at night. The halls and the rooms should be quiet. Patients should be provided with diversion activities so that they do not have bad thoughts or anxiety. Nightingale ,F. (1860). Notes on nursing: What it is and what it is not. Retrieved from http://digital.library.upenn.edu/women/nightingale/nursing/nursing.html#XIII

16. Health • Although Florence Nightingale saw disease as a natural reparative process–”an effort of nature to remedy a process of poisoning or of decay,” she ultimately saw a patient’s ability to fight his or her disease and restore health as a product of the nursing environment (Nightingale, 1860, para. 1). • According to Florence, disease is often exacerbated when a patient has the “…the want of fresh air, or of light, or of warmth, or of quiet, or of cleanliness, or of punctuality and care in the administration of diet, of each or of all of these” (Nightingale, 1860, para. 3). • Florence studied statistics and epidemiology to prove that clean environments, adequate ventilation, and overcrowding reduces germs, sickness and death in patients (Kudzma, 2006, p. 62)

17. Nursing • Nightingale’s approach to nursing was centered around the human needs of the patients. She saw patients holistically, and that in order to heal their mind, body and spirit, they need to be in a comfortable environment. As a result, she believed that it was the nurse’s responsibility to promote an environment conducive to healing (Payne, 2010, para. 3). • In order to properly manage such an environment, Florence Nightingale believed that nurses must be properly trained. Therefore she established a nursing program. (Payne, 2010, para. 4). • Hence, she felt that poor nursing was responsible for many of the poor health outcomes of patients. She stated in her notes, “if a patient is cold, if a patient is feverish, if a patient is faint, if he is sick after taking food, if he has a bed-sore, it is generally the fault not of the disease, but of the nursing”(Nightingale, 1860, para. 4).

18. Nursing There are certain guidelines Florence pointed out in her notes that she felt that were necessary for good nursing. Listed are some excerpts on the role of educated nurses from her notes: 1. Provide clean environments. “It cannot be necessary to tell a nurse that she should be clean, or that she should keep her patient clean,–seeing that the greater part of nursing consists in preserving cleanliness”(Section X). 2. Show respect. “Always sit down when a sick person is talking business to you, show no signs of hurry, give complete attention and full consideration if your advice is wanted, and go away the moment the subject is ended” (Section IV). 3. Fight infection.“True nursing ignores infection, except to prevent it. Cleanliness and fresh air from open windows, with unremitting attention to the patient, are the only defense a true nurse either asks or needs” (Section II). 4. Prevent skin breakdown. “It may be worth while to remark, that where there is any danger of bed-sores a blanket should never be placed under the patient. It retains damp and acts like a poultice” (Section VIII). Nightingale ,F. (1860). Notes on nursing: What it is and what it is not. Retrieved from http://digital.library.upenn.edu/women/nightingale/nursing/nursing.html#XIII

19. Nursing 5. Control noise. “A good nurse will always make sure that no door or window in her patient's room shall rattle or creak; that no blind or curtain shall, by any change of wind through the open window be made to flap–especially will she be careful of all this before she leaves her patients for the night” (Section IV). 6. Provide adequate rest. “Everything you do in a patient's room after he is "put up" for the night, increases tenfold the risk of his having a bad night. But, if you rouse him up after he has fallen asleep, you do not risk, you secure him a bad night” (Section IV). 7. Provide and record nutrition. “I would say to the nurse, have a rule of thought about your patient’s diet; consider, remember how much he has had, and how much he out to have to-day” (Section VI). Nightingale ,F. (1860). Notes on nursing: What it is and what it is not. Retrieved from http://digital.library.upenn.edu/women/nightingale/nursing/nursing.html#XIII

20. Nursing 8. Provide activities for diversion. “A little needle-work, a little writing, a little cleaning, would be the greatest relief the sick could have, if they could do it” (Section V). 9. Document findings“again, I think that few things press so heavily on one suffering from long and incurable illness, as the necessity of recording in words from time to time, for the information of the nurse, who will not otherwise see, that he cannot do this or that, which he could do a month or a year ago” (Section XIII). 10. Maintain confidentiality. “and remember every nurse should be one who is to be depended upon, in other words, capable of being a "confidential" nurse. …she should never answer questions about her sick except to those who have a right to ask them” (Section XIII). Nightingale ,F. (1860). Notes on nursing: What it is and what it is not. Retrieved from http://digital.library.upenn.edu/women/nightingale/nursing/nursing.html#XIII

21. Nursing Paradigm andGlobal Concepts Nightingale’s Holistic Approach • Environment • Patient care was guided by family, social, and cultural factors, which she believed all played an equal role not just in the care of the sick, but in the process of healing the mind, body, and spirit (Payne, 2010). • Care was given to patients in clean rooms, and provided for good food clean water, and clean bodies. It included recreational activity and furthering one’s knowledge and intellect (Payne, 2010).

22. Nursing Paradigm andGlobal Concepts • Person • The person was viewed as a whole, involving mind, body, and spirit, as well as the environment in which the person existed. She treated patients with those components in mind at all times. • “Caring for the whole person required integration and collaboration with medicine, environment, family, and society” (Payne, 2010). • Health • Health was a sum of the effect of the surroundings on the patient. Nursing’s focus, unlike medicine, was on health, not illness (Chitty & Black, 2011). • Health was regarded as a balance between the person, the environment, and the Divine, and any imbalance in that realm was considered a state of disease (Light, 1997).

23. Nursing Paradigm andGlobal Concepts • Nursing • Nightingale brings all the previous concepts together to describe what professional nursing is. • We manipulate the patient and their environment in such a way as to restore health and prevent disease. • Continued education and skill-set advancement contribute to our success and professionalism. • “Today’s nurses like Nightingale are and must be scientists, humanitarians, environmentalists, policy-makers, social activists, communicators, facilitators and caregivers” (Payne, 2010).

24. Current Practice Nursing today is full of Nightingale’s holistic work. Although the article was initially written in 1997, Kathleen Light gives examples that most certainly still apply today, and will continue to apply as long as nursing exists: • Interest in holistic care is on the rise • The NIH established an Office of Alternative Medicine • Insurance providers are covering alternative medical interventions • Certifications in areas such as holistic nursing, healing touch, and aromatherapy exist. • Healing touch and aromatherapy are currently used at many facilities as pain interventions. • Pet therapy is still encouraged in some instances • Family presence and cultural preferences are honored Holistic nursing is gaining popularity, and shows no signs of slowing any time soon. Every day new organizations and practice standards reflect this approach.

25. Current Practice Examples of Florence in today’s nurses. • Current standards of care recommend the following: • Assessment (observation/information gathering) • Documentation (statistics) • Cleanliness (personal hygiene) • Noise reduction • Minimize disturbances in sleep patterns • Monitor intake and output (food and water) • Maintain a safe environment (falls prevention) All these things and more can be used in every practice situation (acute care, outpatient care, labor and delivery, OR, emergency care, critical care, research, etc.)

26. Application Across Nursing In essence, Nightingale’s approach created the nursing paradigm against which all theory and philosophy is compared today. Her ideas formed the basis on which most other theories and philosophies have been built. Nightingale’s ideas are specific to healthcare but can be applied to all areas of nursing, and these ideas have been applicable at all times since inception. At no time in nursing history have her ideas been obsolete.

27. Case Study Situation:| Mary is a 35 year old that has been in the ICU for 2 weeks. She sustained multiple injuries after falling off of her horse onto a pile of large, sharp rocks. She lives on a farm and has been training and riding horses since she was 14. When she arrived on the ICU she suffered a traumatic brain injury, a broken jaw, two large and deep lacerations on both of her thighs, and a broken right ankle. The physicians are unsure of the extent of her cognitive impairment. She is alert, but she is unable to talk. It is uncertain if she understands concepts. Sometimes she appears confused and becomes easily agitated. Other times she is calm. She is able to move all of her extremities. Her leg lacerations were sutured and her ankle repaired. She has two large dressings on her legs and her leg is in an immobilizer.

28. Scholarly Questions Questions:1. Based on Florence Nightingale's model, what do you think are important things the nurse can do for Mary to promote comfort. 2. Give an example of a therapeutic nursing intervention that may be done using Florence Nightingale's environmental model.

29. References Chitty, K.K., and Black, B.P. (2011). Professional nursing: Concepts and challenges(6th ed.) Maryland Heights, MO: Saunders Freeman, L., & Mornhinweg, G. (1992). Standards of practice by Nightingale. Journal Of Holistic Nursing, 10(4), 348-354. doi: 10.1177/089801019201000407 Garofalo, M., & Fee, E. (2010). Florence Nightingale (1820-1910): feminism and hospital reform. American Journal Of Public Health, 100(9), 1588. doi:10.2105/AJPH.2009.188722 Klakovich, M. (2009). Florence Nightingale: A Nursing Leader Ahead of Her Time. Retrieved February 6, 2012 from https://www.phoenix.edu/profiles/faculty/marilyn-klakovich/articles/florence- nightingale-a-nursing-leader-ahead-of-her-time.html

30. Kudzma, E.C. (2006). Florence nightingale and healthcare reform. Nursing Science Quarterly, 19(1), 61-64. doi: 10.1177/0894318405283556 Light, K. (1997). Florence Nightingale and holistic philosophy. Journal Of Holistic Nursing, 15(1), 25-40. doi: 10.1177/089801019701500104 Nightingale, F. (1860). Notes on nursing: What it is and what it is not. Retrieved from http://digital.library.upenn.edu/women/nightingale/nursing/nursing.html#XIII Nightingale, F. (1858). Notes on matters affecting the health, efficiency and hospital administration of the British army, 1858. Payne, K. (2010). Science, healing, and courage: The legacy of Florence Nightingale. Tennessee Nurse, 73(2), 8.