Running head: NIGHTINGALE THEORY

A Critique of the Environmental Theory by Florence Nightingale

Virginia C. Petrikonis

University of Virginia

GNUR6050

Fall 2011

On my honor as a student, I have neither given nor received inappropriate aid on this

assignment.

Virginia Petrikonis

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NIGHTINGALE THEORY

Abstract

Florence Nightingale developed the first model of nursing care that is grounded in the belief that

alteration of the environment will prevent disease (Nightingale, 1859). This paper critiques

Nightingale’s Environmental Theory and reviews its relevance to nursing using a guide for

critical reflection of theory (Chinn & Kramer, 2008). In critiquing the Environmental Theory,

several strengths and weaknesses are found. While Nightingale’s theory lacks a common

structure and explicit definitions of concepts, she provides descriptions and examples of nursing

that represent a holistic view of nursing that focuses on interpersonal interactions between the

nurse and the patient (Nightingale, 1859). In addition, Nightingale emphasizes the need for

observation and data collection, which has evolved into what is now known as evidence-based

practice. The Environmental Theory has led to improving healthcare, the development of nursing

schools, and the improvement of sanitary conditions of hospitals (Tourville & Ingalls, 2003). The

Environmental Theory, a result of Nightingale’s work as a nurse, has proven to be an invaluable

and enduring contribution to the field of nursing.

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A Critique of the Environmental Theory by Florence Nightingale

Florence Nightingale never formally developed a nursing theory, but some reviewers

credit her as the first nursing theorist (Tourville & Ingalls, 2003). Parker & Smith (2010) explain,

“The remainder of all nursing theory may be viewed as mere branches and ‘acorns,’ all fruit of

the roots of Nightingale’s ideas” (pp. 46-47). Nightingale is unique because she never produced a

formal theory, but she did develop the first model of nursing care. A product of the Victorian

age, Nightingale did not theorize in a way that we are familiar with today, yet she is still viewed

by many as the founder of modern nursing (Parker & Smith, 2010). Through published works,

Nightingale was able to lay a theoretical framework for nursing. In Notes on Nursing,

Nightingale (1859) describes the concepts she believes are the foundation of nursing practice

through the development of the Environmental Theory. Furthermore, Nightingale contributed to

values that nursing has placed on theoretical development and implementation into nursing

practice (Clements & Averill, 2006).

The purpose of this paper is to evaluate Nightingale’s Environmental Theory and review

its relevance to modern nursing using a guide for critical reflection of theory by Chinn and

Kramer (2008). It is important to first understand a theory so that it can be analyzed. In critiquing

a theory, description and reflection are imperative if a nursing theory is to be applied to practice

and research (Chinn & Kramer, 2008).

Summary of Environmental Theory

Nightingale’s Environmental Theory is grounded in the belief that keeping people

healthy is dependent upon environmental control (Nightingale, 1859). Nature is seen as the great

healer, which is able to cure disease (McCabe, 2000). Nightingale (1859) states that “nature

alone cures” and the goal of the nurse “is to put the patient in the best condition for nature to act

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upon him” (p.102). The main idea found within the Environmental Theory is to manipulate the

environment so that the best possible health outcome is achieved. If one manipulates the

environment in a positive manner, health ensues. During the Victorian age, people believed that

germs led to disease. Nightingale was skeptical of the relevance of the germ theory and

maintained that environmental manipulation, such as hygienic practices, are the most relevant

way to prevent or decrease disease (Nightingale, 1859).

Nightingale defines disease as a reparative process in her published works (Nightingale,

1859). Nightingale (1859) states, “Shall we begin by taking it as a general principle – that all

disease, at some point or other of its course, is more or less a reparative process, not necessarily

accompanied with suffering: an effort of nature to remedy a process of poisoning or decay…”

(p. 1). Since the environment is seen as the main agent acting upon the patient to produce

disease, the nurse is viewed as a change agent of both the environment and the patient (Wagner

& White, 2010). Nightingale’s focus on caring through environmental alteration was in direct

opposition to medicine’s focus to cure disease (Selanders, 2010). Nightingale (1859) goes on to

explain, “…the symptoms or the sufferings generally considered to be inevitable and incident to

the disease are very often not symptoms of the disease at all, but of something quite different –

of 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” (pp. 1-2).

Nightingale describes 13 canons, or concepts, that are of utmost importance in order to

keep a patient healthy through environmental means (Figure 1). The core of the Environmental

Theory is assessment so that a nurse is able to evaluate the environment’s positive and negative

effects on a patient. In order to assess a patient, Nightingale underscores the importance of

experience and observation, which she believes is the only reliable way to obtain and validate

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information (Parker & Smith, 2010). Nightingale presents the patient as the integral component

of the total environment with the patient at the center of the Environmental Theory (Clements &

Averill, 2006). Thus, Nightingale used a patient-centered approach that involved the concept of

caring for the whole person (Tourville & Ingalls, 2003). The concept of caring for the whole

person presents nursing as a helping process and a holistic art. Thus, according to Nightingale

nursing is seen as both an art and science (Parker & Smith, 2010).

The Environmental Theory has established a significant impact on nursing ever since

Nightingale created it. The elimination of risk factors and germs have proven to decrease

morbidity and mortality such as through the use of hand washing, which can actually be

attributed to Nightingale with her influence on hygienic practices (Nightingale, 1859).

Nightingale also demonstrated how to assess, analyze, implement, and evaluate nursing practices

through detailed organization, which has provided a framework for nursing research (Clements

& Averill, 2006). Ultimately, the Environmental Theory focuses on the ability to maintain and

restore health through environmental control (Parker & Smith, 2010).

Critique

Clarity

The environment is the major concept found within the Environmental Theory.

Nightingale describes 13 canons, or sub concepts, that are required in order to manipulate the

environment to keep patients healthy (Nightingale, 1859). In this manner, the view of person and

environment is compatible. While no hierarchical arrangement is made, Nightingale sees

ventilation as the most important concept (Selanders, 2010). Nightingale (1859) states, “The very

first canon of nursing, the first and the last thing upon which a nurse’s attention must be fixed…

is this: to keep the air he breathes as pure as the external air, without chilling him” (p. 5). No

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specific hierarchy is created within the 13 canons, but certain canons, such as ventilation and

light, are viewed as most important (Nightingale, 1859). In addition, no specific definitions are

given for the concepts found within the Environmental Theory. With no distinct definitions

provided, it is possible for different nurses to make varying and potentially detrimental

inferences for each of the 13 canons. While some of the concepts are straightforward and perhaps

do not need definition, such as light and personal cleanliness, other concepts are not as concrete

and would benefit from definition, such as chattering hopes and advices (Figure 1). However, all

13 canons are explicitly described in Notes on Nursing, which Nightingale (1859) wrote in order

to teach nurses how to function within their career. While the Environmental Theory is

somewhat lacking in terms of clarity, Nightingale did produce a general guideline with helpful

examples within it that explains how each of the 13 environmental canons can affect health in a

useful manner (Nightingale, 1859).

No common structure is found within the Environmental Theory. The theory is based

upon the concept of the environment along with the 13 canons that describe how to effectively

alter the environment to prevent disease (Nightingale, 1859). A caring relationship is what links

the 13 canons together in a linear fashion with the objective of environmental control. Overall,

the structure moves all concepts toward health and includes health promotion, disease

prevention, health restoration, and rehabilitation (Selanders, 2010). Although Nightingale goes

into great detail to explain the 13 canons, the lack of specific definitions of concepts and the lack

of common structure provide a weakness for the Environmental Theory in terms of clarity.

The underlying assumption of the Environmental Theory is that the patient will remain

free of disease by means of a healthy environment (Nightingale, 1859). This assumption can be

derived from various contexts such as when Nightingale (1859) states, “If a patient is cold, if a

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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” (p. 2). In this manner, it is assumed that

the patient is able to recover from disease, the nurse is able to manipulate the environment, the

environment is able to cure, and health can be achieved. These assumptions are located before

theoretical reasoning with no hierarchical arrangement as all assumptions are equally valuable

and necessary throughout the Environmental Theory (Nightingale, 1859). At the time

Nightingale developed the Environmental Theory, the underlying assumptions were not factually

verified. However, it has now been proven that not all disease can be prevented through

environmental manipulation, such as genetic diseases (Selanders, 2010). Therefore, the

assumptions found within the Environmental Theory are a major weakness of the theory.

Simplicity

The major relationship found within the Environmental Theory is the nurse-patient

relationship where the nurse places the patient in the best possible condition for nature to act

(Selanders, 2010). This relationship implies a helping, or caring, relationship and emphasizes

interpersonal relations. All 13 canons, the sub concepts of the overall concept of the

environment, focus on the environment by means of a caring relationship. The caring

relationship found within all 13 canons is uniformly directed at preventing disease by means of

environmental manipulation with the ultimate goal of health and wellness (Nightingale, 1859). In

addition, all 13 canons can be combined without losing theoretical meaning. In fact, some of the

canons overlap such as bed and bedding and light (Figure 1). The Environmental Theory

describes nursing actions, explains the importance of nursing actions, and predicts that health

will ensue if a nurse positively alters a patient’s environment, which furthermore creates

meaning for the necessity of adhering to the 13 canons (Nightingale, 1859). In this manner,

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Nightingale creates guidelines for the implementation of a simple goal. Thus, the Environmental

Theory is fairly simplistic in its approach to nursing.

Generalizability

The overall purpose of the Environmental Theory is to provide a direction for nursing

through environmental adaptation and manipulation so that the person receiving care attains

positive health changes (Nightingale, 1859). The theory is specific to nursing because the nurse

is viewed as the change agent (Wagner & White, 2010). In order to effectively produce change,

nurses must first understand both the patient’s condition and the environment (Selanders, 2010).

The Environmental Theory is broad in scope and can be applied to a plethora of nursing

domains. Specifically, the Environmental Theory is used in pediatric acute care settings with the

use of contact precautions. Pediatric acute/chronic nurse practitioners must be knowledgeable in

terms of understanding various modes of transmission of infectious agents so that they are able

to appropriately place orders for children and adolescents to be placed on contact precautions.

For example, standard precautions are supplemented with transmission-based precautions in

order to reduce the risk of contact, droplet, or airborne transmission. In these instances, use of a

mask, respirator, gown, gloves, and/or protective eyewear is necessary (“Infection Prevention,”

2007). While it is clear that the Environmental Theory has many positive benefits in terms of

health and wellness and can be applied to the majority of nursing care, it is not applicable to all

instances of nursing because environmental manipulation is not able to counteract certain disease

processes such as genetic and autoimmune disorders (Selanders, 2010). However, the application

of the Environmental Theory with adherence to the 13 canons is able to improve quality of life

for nearly all patients.

Accessibility

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The concepts found within the Environmental Theory are broad in scope and accompany

a holistic view of health (Dossey, 2005). The holistic view of nursing can be applied to a variety

of nursing domains. For example, the Environmental Theory includes the sub concept of variety

and can be used in pediatric nursing by stimulating children with art and décor, and providing

them with games in their hospital rooms in an effort to prevent boredom that can benefit children

psychologically. Nightingale did not differentiate between physical, emotional, and social

aspects of the environment, but discussed them all as one entity (Wagner & White, 2010).

Nightingale also did not provide definitions within the Environmental Theory, but she did

explain each of her concepts and how to use them within the field of nursing (Nightingale, 1859).

While the main concept, the environment, is abstract, the 13 sub concepts are highly empiric

concepts that represent objects, properties and events. Nightingale wrote in great detail about the

importance of observation and writing down observations (Nightingale, 1859). The concept of

observation developed into assessment, diagnosis, planning and implementation that are all used

in nursing practice today (Salotti, 2003). Nightingale’s work underscores the importance of

nursing research. In fact, Nightingale has been credited with being a pioneer in the pie graph

display when she utilized a pie graph to compare death rates among military hospitals in the

Crimean War (Kudzma, 2006). Nightingale proved to be a brilliant statistician in her work with

William Farr, and her belief in the necessity to collect data and evaluate statistics has developed

into evidence-based nursing practice (Parker & Smith, 2010). The Environmental Theory has

proven its accessibility over time and is still used today.

Importance

The overall purpose of the theory is to provide a direction for nursing through

environmental adaptation and manipulation so that the person receiving care attains positive

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health changes (Nightingale, 1859). The purpose of the Environmental Theory is consistent with

nursing in that it aims to create a better quality of life for all patients. In this manner, the

Environmental Theory is futuristic. For example, Nightingale used sensory observation to

recognize that washing was a significant and therapeutic nursing intervention (Clements &

Averill, 2006). Over time, research has proven that contaminated hands are the predominate

mode of transmission of infectious agents (“Infection Prevention,” 2007). Nightingale (1859)

clearly stated, “Every nurse ought to be careful to wash her hands very frequently during the

day” (p. 72). Hand washing has transformed into a form of primary prevention and is used

throughout the field of nursing. Nursing is vital to the Environmental Theory because the nurse is

viewed as the change agent in terms of altering the environment (Wagner & White, 2010). The

Environmental Theory is broad in scope and can be applied to a plethora of nursing domains. It

is used regularly within the field of nursing, nursing education, and nursing research (Selanders,

2010). Therefore, the Environmental Theory is vital to the field of nursing.

Summary & Conclusion

The overall focus of Nightingale’s Environmental Theory is to prevent disease through

alteration of the environment (Nightingale, 1859). This concept demonstrates an altruistic action

that is consistent with the field of nursing. One of the biggest overall weaknesses of the theory is

the assumption that disease is always a direct result of the environment (Nightingale, 1859).

While disease can be caused by environmental factors, it is also caused by other factors such as

genetics and trauma (Selanders, 2010). In addition, the Environmental Theory is limited to the 13

canons that were created during the Victorian era, and it is necessary to adapt or alter these sub

concepts to better meet present day issues. For example, while air quality is important, especially

for patients with chronic lung disease such as asthma, it can be detrimental to use external air

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quality as a standard particularly in regards to pollution. Nightingale (1859) appears to write

almost exclusively from the context of the Crimean War in Notes on Nursing, which limits her

scope of practice since it seems to be based on only one experience. Even so, the applicability of

the 13 canons to various other nursing contexts is possible. It would be more beneficial if the 13

canons had explicit definitions so that individual inferences are not possible. Additionally, the

definition of health is not explicitly stated. Nightingale explains health as the process of being

well and having the ability to use every power an individual possesses (Selanders, 2010). From

this statement, various inferences and assumptions regarding the meaning of health result as

health is defined in an abstract manner. Nightingale also never clearly defines the construct of

caring even though it can be seen in her actions (Parker & Smith, 2010). Fortunately,

Nightingale’s actions are well documented and seem to speak volumes even when her written

definitions are lacking.

The Environmental Theory was formed as a result of Nightingale’s work as a nurse. The

environment is an umbrella concept found within Nightingale’s Environmental Theory that grew

out of her empirical observations such as her observation that unsanitary conditions led to

disease and death among British soldiers during the Crimean war (Selanders, 2010).

Nightingale’s framework for nursing emphasized the utilization of empiric knowledge and

statistics (Chinn & Kramer, 2008). A major strength of the Environmental Theory is its reliance

on observation and data collection, which has transformed into evidence-based practice. Another

strength of the Environmental Theory is how it gives nurses an active role while also

encouraging patients to take a key role in their health with the need for self-healing (Parker &

Smith, 2010). This type of active nursing promotes compassion, support, and the giving of time

and self while also encompassing knowledge, skills, and expertise in a variety of settings

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(Wagner & White, 2010). In this manner, nursing is seen as both an art and a science.

Furthermore, the Environmental Theory promotes the necessity of an expanding body of nursing

knowledge that is distinctly separate from medical knowledge (Macrae, 1995). Moreover, the

greatest overall strength is Nightingale’s creation of holistic nursing care. In this manner, nurses

become therapeutic partners with their patients while utilizing nursing knowledge, theory,

research, expertise, intuition, and creativity (Dossey, 2005).

While several weaknesses are present in the Environmental Theory, its strengths

definitely outweigh its weaknesses. The generic vision of Nightingale makes her theory

applicable to everyone, particularly nurses (Dossey, 2010). The Environmental Theory has

proven to be timeless with its theoretical principles of nursing lasting throughout time (Bunkers,

2008). Nightingale’s wisdom and vision have proven to be applicable from the mid-Victorian era

to the present (Selanders, 2010). Perhaps Tourville and Ingalls (2003) explain the significance of

Nightingale’s Environmental Theory best, “The foundation of all model or theories is

Nightingale and the metaparadigms of person, environment, health, and nursing. It is through her

work and teachings of caring, being accountable, seeking ways to improve avenues of care, and

emphasizing the professionalism of nursing that nursing has reached its present high standards”

(p. 30). Nightingale is certainly worthy of praise and gratitude for her creation of a nursing

theory that continues to shape nursing practice.

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References

Bunkers, S. S. (2008). The timelessness of nursing theory. Nursing Science Quarterly, 21(3),

211-212.

Chinn, P.L. & Kramer, M.K. (2008). Integrated Theory and Knowledge Development in Nursing

(Seventh Edition). St. Louis, MO: Mosby Elsevier.

Clements, P. T., & Averill, J. B. (2006). Finding patterns of knowing in the work of Florence

Nightingale. Nursing Outlook, 54(5), 268-274.

Dossey, B. (2005). Florence Nightingale and holistic nursing. Imprint, 52(2), 58-60.

Dossey, B. M. (2010). Florence Nightingale's vision for health and healing. Journal of Holistic

Nursing, 28(4), 221-224.

Infection prevention and control in pediatric ambulatory settings (2007). Pediatrics, 120(3), 650-

665.

Kudzma, E.C. (2006). Florence Nightingale and healthcare reform. Nursing Science Quarterly,

19(1), 61-64.

Macrae, J. (1995). Nightingale’s spiritual philosophy and its significance for modern nursing.

Journal of Nursing Scholarship, 27(1), 8-10.

McCabe, P. (2000). Naturopathy, Nightingale, and nature cure: A convergence of interests.

Complementary Therapies in Nursing & Midwifery, 6(1), 4-8.

Nightingale, F. (1859). Notes On Nursing: What It Is And What It Is Not. New York, NY: Barnes

and Noble.

Parker, M.E. & Smith, M.C. (2010). Nursing Theories and Nursing Practice (Third Edition).

Philadelphia, PA: F.A. Davis.

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Salotti, R. (2003). Notes On Nursing: What It Is And What It Is Not. New York, NY: Barnes and

Noble.

Selanders, L. C. (2010). The power of environmental adaptation: Florence Nightingale's original

theory for nursing practice. Journal of Holistic Nursing, 28(1), 81-88.

Tourville, C., & Ingalls, K. (2003). The living tree of nursing theories. Nursing Forum, 38(3),

21-30.

Wagner, D. J., & White, B. (2010). An exploration of the nature of caring relationships in the

writings of Florence Nightingale. Journal of Holistic Nursing, 28(4), 225-234.

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Figure 1

Nightingale’s 13 Canons

Ventilation & WarmingViewed as the first rule of nursing. Describes how air inside should be as pure as air outside and includes taking patient outside and/or opening windows.

Health of HousesDescribes the maintenance of pure air, pure water, efficient drainage, cleanliness, and light.

Petty ManagementDescribes the management of a house, including designation of tasks, and underscores the role and importance of management.

NoiseDescribes the elimination of unnecessary noise and prevention of unnecessary waking so that patients get proper rest.

VarietyDescribes the providing of a variety of settings to stimulate patient and prevent boredom and underscores the importance of psychological benefits, aesthetics, and holistic care.

Taking FoodDescribes the importance of food, nutrients, and nourishment as well as noting amount of food ingested.

What Food?Describes the providing of a variety of foods to meet patients’ nutritional needs in order to repair waste.

Bed and BeddingDescribes the importance of clean bed linens as well as airing out sheets and placing patients in sunlight with a view.

LightViewed as the second most important canon. Describes placing patients in the sunlight and going outside and/or opening window(s) when possible.

Cleanliness of Rooms and WallsDescribes the importance of hygiene and emphasizes the maintenance of a clean environment.

Personal CleanlinessDescribes the importance of clean clothes and clean skin since toxins can be removed via skin.

Chattering Hopes and AdvicesDescribes the opportunity for nurses to distract patients and help with coping, but should be kept to a minimum as it uses up a patient’s energy and nurses need to maintain boundaries.

Observation of the SickViewed as the most important nursing lesson in regards to nursing education. Describes the importance of observation and experience as key components to nursing care.

Note. Description of 13 canons is from Nightingale, F. (1859). Notes On Nursing: What It Is And What It Is Not. New York, NY: Barnes and Noble.

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