Abstract
Objective: The purpose of this paper is to explore nursing research that is focused on the impact of healthcare
environments and that has resonance with the aspects of Florence Nightingale's environmental theory.
Background: Nurses have a unique ability to apply their observational skills to understand the role of the
designed environment to enable healing in their patients. This affords nurses the opportunity to engage in
research studies that have immediate impact on the act of nursing.
Methods: Descriptive statistics were performed on 67 healthcare design-related research articles from 25
nursing journals to discover the topical areas of interest of nursing research today. Data were also analyzed to
reveal the research designs, research methods, and research settings. These data are part of an ongoing study.
Results: Descriptive statistics reveal that topics and settings most frequently cited are in keeping with the current
healthcare foci of patient care quality and safety in acute and intensive care environments. Research designs
and methods most frequently cited are in keeping with the early progression of a knowledge area.
Conclusions: A few assertions can be made as a result of this study. First, education is important to continue the
knowledge development in this area. Second, multiple method research studies should continue to be
considered as important to healthcare research. Finally, bedside nurses are in the best position possible to begin
to help us all, through research, understand how the design environment impacts patients during the act of
nursing.
Keywords: Evidence-based design, literature review, nursing.
INTRODUCTION
The environmental theory developed by Florence Nightingale 1 in the second half of the
nineteenth century in England, has focused primarily on the environment, interpreted as all
external conditions and influences that affect the life and development of an organism, that
are able to prevent, suppress or contribute to disease and death1.
The disease is considered, in this theory, a restoring health process and the nurse's function
is to balance the environment, in order to save the patient's life energy to recover from the
disease, prioritizing the delivery of an stimulating environment for the development of the
patient's health1,2. Here lies, then, the conception of the human-being as a member of
nature, an individual whose natural defenses are influenced by a healthy or unhealthy
environment1.
Nightingale believed that providing a suitable environment was the difference in the
recovery of patients, and in this perception underlies the Environmentalist theory. Thus,
Nightingale became known for her actions that have brought innovative results to treatment
of patients2.
In her writings, Nightingale addresses the provision of factors for maintaining an
environment that is favorable to the facilitation of the healing and healthy living processes
such as: ventilation, cleaning, lighting, heat, noise, odors and feeding, so that the
recovering process, established by nature, is not prevented1.
In nursing, such concern about the environment has existed since the foundation of
professional nursing in the second half of the nineteenth century. It can found on the
present days, in a humanized care, based on environmental control around the patient,
which is seen as a being that is part of relationships and interactions with the environment
in which this one can be found3.
It should be noted also that the ambience is just one of the devices for the development of
humanized care, but it can be added, among such devices: hosting with risk rating,
collegiate managers, training program in health and work, reference teams and matrix
support, ambience projects, companion rights and open visit and the construction of
collective monitoring and evaluation processes of humanization activities 4.
Thus, the goal of the nursing field is to provide assistance for patients in maintaining their
vital capacity, satisfying their needs. Therefore, Nightingale shows that nursing is a non-
healing practice, in which the patient is placed in the best condition for the action of nature 1.
In this perspective, the focus of nursing care is on environmental hygiene, the most basic
concept and characteristic of her works. In those, Nightingale lists the tasks that nurses
must perform to assist sick individuals, and many of them are relevant even nowadays 5.
The use of nursing theories is of great importance due to the practice foundation. It
provides the appreciation of the knowledge of the profession and its relation with the
performance of the nurses. Therefore, it is important to make a critical analysis about the
theory in focus, bearing in mind that carrying out a critical analysis study of a theory assists
in ensuring the validity of such and its correct use, providing relevant information for its
development.
Analysis or evaluation theory is the process of examining systematically a theory by using
criteria that vary depending on the authors that propose methods of analysis, which are:
examination of the origins of the theory, meaning, logic appropriateness, usefulness and
possibilities of generalization and test5.
The primary purpose of the analysis of a theory is to determine its potential contribution to
the scientific knowledge. It also contributes by adding knowledge, to the perspective of
practices, providing its greater solidification, and allowing the identification of faults and
inconsistencies as for the use of the theory in practice5,6.
In order to critically analyze a theory, many authors have proposed methods to conduct this
process such as: Walker and Avant6, Meleis7 and Johnson and Webber8. The criteria of
critical analysis of these last ones were used in this study to examine the Environmental
Theory of Florence Nightingale1.
Based on the critical model based on criteria that was proposed by Johnson and Webber 8, it
will be discussed in this article the following: significance, boundaries, language, concepts,
propositions, variables, hypothesis and the influence of the theory in the practice of nursing.
Thus, the aim of this study is to analyze the Environmental Theory by Florence Nightingale
through the model proposed by Johnson and Webber.
METHOD
It is a theoretical and reflective study, conducted in November and December 2012, whose
analysis of the Environmentalist Theory proposed by Florence Nightingale was based on
Johnson and Webber's model8.
It was used as a primary source for the critical analysis of the Environmentalist Theory by
Florence Nightingale, its most widespread work, the book "Notes on Nursing - what it is and
what it is not" written in 1859, translated into Portuguese in 1989 1. Secondary sources on
the Environmental Theory2-4,9-11 were also used, which contributed significantly in the
preparation of this reflection.
Secondary sources were used as subside for the discussion of the critical analysis made
from the primary source. Such sources comprised books and scientific articles found in
online databases and sectorial libraries where the study was developed and it appears a
base for the adherence to the theme of reflection.
In order to analyze this theory, it was used the model of critical analysis based on criteria
by Johnson and Webber8, when examining the intent, concepts and propositions of the
theory and the construction of judgments about the usefulness of it at its practice,
demonstrating how the theoretical knowledge is embedded in the nursing practice.
This model is intended to help make judgments about the theoretical value and the use of
the theory in order to identify connections between the nursing practice and the theory,
assuring the achievement of its own examination8.
The criteria set forth by the authors8 to critically analyze a theory are: meaning of the
theory; consistency of boundaries; language comprehension; presence of important
concepts and definitions; formulation of proposals; variables and hypothesis; theoretical
knowledge to explain and predict the phenomenon; influence of theoretical knowledge in the
nursing practice.
The possible judgments that were possible to be made with this type of critical analysis
demonstrate how the theoretical knowledge is embedded in the nursing practice and
provides knowledge about the theory in which the practice is consolidated 8.
To facilitate the presentation of some of the criteria, five-point scales were used, proposed
by the authors8, to their measure along with the contribution of the literature concerning the
matter.
The criteria mentioned are organized and analyzed in three phases: the first phase -
Intention of a theory - comprises the first three criteria presented: meaning, limits and
language; the second - Concepts and proposals - refers to the criteria concepts,
propositions and variables and hypothesis; the third phase - Utility of the theory in the
nursing practice - shows the last two criteria: theoretical knowledge helping to explain and
predict the phenomenon and influence the nursing practice8.
RESULTS AND DISCUSSION
The results are shown and discussed according to the criteria explained by Johnson and
Webber8. It should be noted that the critical analysis of a theory proposed by these authors
is based on a judging process, which determines the utility theory to the practice of nursing.
Criterion 1 - The significance of the theory is clear and understandable
The first criterion focuses on the significance of the theory and the classification of its clarity
and understanding8. Nightingale presents as the meaning of the environmental theory the
fact the cause of the disease and/or non-rehabilitation of the patient is closely related to the
environment in which the patient is inserted, which is most often unhealthy. Therefore,
Nightingale advocated essential factors that would ensure the sanitation of dwellings such
as clean air, clean water, efficient drainage, cleanliness, lighting, prevention of infection,
among others1.
The care in the rehabilitation process of the wounded soldiers in combat or the ones coming
from surgeries, during the Crimean War, was the crucial fact that led Nightingale to develop
innovative thoughts to the context of care provided to individuals. Her experience enabled
the comprehension about what was effective and what was hindered this process. These
ideals are part of the context of the practice experienced by nursing professionals in
different areas2.
In her work, Nightingale succinctly stated what she believed to be important in the care of
the sick person5. The Environmental Theory, with its message of valuing the environment as
an essential tool to the healing process of people, highlights the importance of ventilation,
heating, sanitary conditions of housing, as for the housing hygiene 1,9.
Other factors for the patient's care are also presented by Nightingale, such as noise, the
varied, nutritive and punctual eating habits. In addition, the analyzed theory includes
information about the appropriate buildings in which patients should be treated in and about
the management of hospitals5.
Johnson and Webber8 show a form of measurement for this criterion with a five-point scale,
which was assigned value 5, indicating that the theory has clear ideas in meaning, given
that the reader does not need to have a vocabulary too far-fetched for the full
understanding of the work into focus.
Criterion 2 - Limits are consistent with the practice of nursing
The second criterion leads to the judgment as to the limits of the theory, if they are
consistent for the practice of nursing. Among the limits are included: for whom the nursing
care is directed, care scenarios, the role of nurses in the administration of this care and
responsibilities of other health professionals8.
Nightingale's work was written for caregivers at home, with methods and guidelines to
improve the health of patients, aiming to support the work of these professionals. She
directed her teachings to women, because they are those who were primarily responsible for
family care10.
The main scenario addressed by Nightingale in her theory was the home environment. She
taught how to create favorable environments to the recovery of the patient's health at their
home and later proposed modifications in the way of building hospitals and manage them10.
Nightingale sparked a revolution in the concept of the nurses back then, specially
considering the foundation of nursing as a profession by offering professional training for
nurses, which came to be seen as responsible for putting the individual in the best condition
to the action of nature, which occurs primarily through the impact on the environment 2. To
Nightingale, caring was minimum among the tasks for which she had been driven to1.
Other health professions were responsible for analyzing situations and making judgments
about the patient's health.Therefore, the caregiver, the main subject besides the patient, in
this theory, must know how to communicate effectively with these professionals, because
upon this relied the efficiency of the care and the patient's welfare10.
Before what has been presented and based on the characterization proposed by Johnson
and Webber7, it's possible to identify that in order to promote the criterion in of the matter,
the theory has a high consistency, and its limits are clearly identified.
Criterion 3 - Understandable language and includes minimum jargon
Throughout her work, Nightingale tells true and experienced stories by herself, often
demonstrating her opinion about them11. This format substantially facilitates understanding
of the information that the author intends to pass on to their readers.
Responding to the third criterion, an understandable language could be verified in all her
work, especially in the chapters added to the end of it, where weaving comments on the
meaning of being a nurse and behaviors that it must provide assistance in the various types
of patients can be found.
The very alphabet of a nurse is to be able to read every change which comes over a the
patient's countenance, without causing him the exertion of saying what he feels. What
would many a nurse do otherwise than she does if her patients were a valuable piece of
furniture or a sick cow? I do not know. Yet a nurse must be something more than a lift or a
broom. A patient is not merely a piece of furniture to be kept clean and ranged against the
wall, saved from injury and breakage - though to judge from what many a nurse does and
does not do1:161-162.
When she directed her words to the nurses who worked at house caring for children, she
used to make use of a colloquial and affectionate language, milder than that used for setting
what the profile of a good nurse would be. In this, Nightingale shows her hurtful mood,
showing a clear language, which was sometimes harsh12. "Immediately disappoint those
who, though devoted and obedient, treat their patients with the same efficiency that take
care of furniture, porcelain or even an animal"11:5.
We are confident that this little book will delight all who read it, for its historicity and
actuality, the clear and elegant style, sometimes openly ironic, so well captured by its
translator, and the mixture of passion and thought that runs through its pages11:7.
The jargons - enunciation of unintelligible words, professional slangs 13 - were not identified
in her writings as well as new words that could be added to our vocabulary were not
displayed.
The measurement for this criterion was also based on a five point scale value, with a score
of 5, which is representative of the understanding about the theory above 90%.
Criterion 4 - Important concepts are identified and defined
According to Johnson and Webber8, there are two categories of concepts: those commonly
understood and used in most theories can be called common concepts; and those more
specific, where not common concepts are used in theory studied.
In the Environmental Theory, the concepts are presented and explained in detail.
Nightingale addresses the concepts of health, illness, nursing and environment, as concepts
that belong into the first category.
For Nightingale, health goes beyond the absence of disease, it is to be well, being able to
use well all the powers one has. A disease is an effort of nature to restore health. Nursing is
the way to put the structure of the individual in such a state that there is no disease or that
may allow one recover from the disease, ie, the individual must be kept in the best possible
conditions for the nature to preserve or restore health, prevent or cure the disease or
injury1,5.
The concept of environment in this theory is included in both categories of concept, since it
is the Environmentalist Theory. So Nightingale conceptualized environment as the place
where the sick individual and/or the family members are, comprising the health institutions
and the domicile, and considering their physical, social and psychological components which
need to be understood as interrelated1.
Besides the one about environment, some non-common concepts are presented: aeration,
in regard to conserve the environment as pure as the outside ambient air; heating, to
provide a moderate temperature in the sick room avoiding its cooling; the sanitary
conditions of housing, in relation to ensuring the hygiene of the housing, emphasizing the
use of pure water, efficient sewer facilities, cleanness, with reference now to the prevention
of infections, and lighting, involving the light and direct sunlight1,9.
Moreover, among the concepts are also presented: the noise, unnecessary noises that are
harmful to the patient and cause an expectation in their mind, which undermine and disrupt
the need for the patient's home, suck as talks with the caregiver, audible by the individual,
the rustling of skirts, agitation, unnecessary questions and the strong stepping while
walking1.
The variety is also inserted within these concepts, specifically in the context of changing
furniture location, placement of paintings or different portraits and flowers that can be
enjoyed by the patient, leading them to diversify their thoughts. Nutritious and punctual
feeding, appropriate beds and linen and individual's personal hygiene were also concepts
presented by Nightingale1.
Nightingale brings in her work, the concept of nurse:
(...) one who is to be depended upon, a woman of delicate and decent feeling, she must be
a sound and close and quick observer, she must be sober, honest, religious and devoted,
that is, someone who must have a respect for her own calling, because God's precious gift
of life is often literally place in her hands1:168.
To analyze the criteria in question, a rating scale of the consistency of the concept is
proposed by Johnson and Webber7. The concepts presented for current and future practice
such as "moderate consistency" (value of 2 for the scale), before the presence of some
definitions that have been modified over time are characterized, as set forth below.
The Environmental Theory was presented by Nightingale in 1859. The fact it has been
written over 150 years ago can be regarded as a limitation on the consistency of the its own
concepts, because even though it endorses many current actions, some factors may be
identified as outdated. Among them we can mention the fact that only women used perform
nursing care and nursing was seen as an art not science.
Nursing practice was a female domain, but an independent practice of their own right, since
the nurses acted according to doctors whose prescriptions they should faithfully follow, even
though they were not subservient to them. Nursing was therefore seen as an art, while the
medicine was seen as science1.
Nursing has feminine traits, to the extent that this genre has a close relationship with the
gift and sacrifice, represented by the virtuous self-denial of Nightingale, and the provision of
care at all times14. However, even though, over the years, the number of women in nursing
continue growing much higher when compared to men, they are present in this occupation
and have gradually increased their admission number in undergraduate courses in nursing
and consequently there is the training of new nurses, who seek the profession because of
the wide field of action14.
Another concept that is little consisting if the fact nursing is seen as art and not as science.
Therefore, there should be considered the historical background throughout its more than
150 years since its foundation as a profession dedicated to the art of caring by Nightingale,
in the nineteenth century, to the investments that have been undertaken, gradually and
systematically, in building a scientific practice15.
Science consists of a set of descriptive information, explanatory and predictive of reality,
resulting from the observation and the experience over the phenomena. Through the
attempt of renovation or expansion of the nursing knowledge, there is the emergence of
theories, in which purposes, limits and possibilities are evidenced in the care and allow
reflection on nursing care5.
Criterion 5 - Concepts stimulate the formulation of propositions
As already mentioned, the legacy left by Nightingale has the environment as a fundamental
principle for the practice of the profession. The ideals concerning this principle were
grounded in the concepts referred in the Environmental Theory and were considered
essential to the success of the theoretical work, managing to reduce the deaths of wounded
soldiers infection and promoting the recovery of patients 2.
The above-mentioned concepts led to the development of several propositions identified
throughout the work studied1. Among all of them some of them are pointed:
A healthy environment is essential to healing;
The windows should be opened allowing the entry of light for all occupants and a
fresh air flow;
With the proper clothing you can keep, at the same time, the patient warm and in
well-ventilated environment;
The proper administration of the residence interferes with healing of the sick;
The nursing care involves the house in which the patient lives and those who have
contact with them, especially caregivers;
Noise is harmful and disturbs the need for rest of patients;
Nutritious food, beds and appropriate bed linen and individual's personal hygiene are
essential;
Cleaning prevents morbidity;
With the a clean environment the number of cases of infection decrease;
All external conditions and influences that affect the life and development of an
organism are able to prevent, suppress or contribute to disease and death.
Faced with the scale for the evaluation of proposals, proposed by the authors 8, it was found
that the formulation of proposals to the concepts and their definitions were "very easy"
(value 7 to the scale), as it was presented in the previous paragraphs.
Criterion 6 - variables and hypothesis help to understand and interpret
propositions
The following are presented as theory of variables: the fresh air, light, heating, quietness,
cleanliness, punctuality and assistance in the diet management. To Nightingale, the delay in
the patient's recovering is based on the lack of knowledge or attention to any or all of these
variables, causing the interruption of the restorative process1.
It was identified as hypothesis from the Environmentalist Theory the fact that the patient
feels cold, presents fever, suffers fainting, feels bad after meals or presents decubitus
ulcers, is generally not due to illness, but to nursing1. So Nightingale blames the process of
the individual's disease to the negligence of the nursing actions.
However, it is essential to emphasize that the responsibility for such an interruption is not
directed in its entirety to nursing, since deficiencies in sanitation and architecture, as well as
failure in the administrative organization, also can be considered as variables to influence
the nursing practice1.
The variables and hypothesis here contribute to the understanding and interpretation of the
proposals outlined in the previous criterion.
Criterion 7 - Theoretical knowledge helps explain and predict phenomena
This criterion concerns the utility of the theory to predict the results. It is in this criterion
that is made the relationship between theory, theoretical knowledge and nursing practice.
It's been tried to identify how the practice reflects on the theoretical knowledge and which
explanations can be given over the practice based on the theory under study 8.
Nightingale's knowledge was constructed through her experiences, therefore, the
environmental phenomenon influencing the health-disease process is backed more on her
practical knowledge than even in her theoretical knowledge.
(...) in this work Florence registers the result of her experience of more than fourteen years
in dealing with patients, nurses and hospitals. Her affirmations and suggestions, however,
derive from systematic observations, supported by statistics, and a permanent reflection on
the bedside care and ways to maintain good health11:4.
Not only the practical knowledge, but also the fact of knowing the patient and promoting an
empathetic relationship between them and the nurse are discussed by Nightingale, stressing
that it is highly necessary, in order to be able to identify its possible problems 16.
Given the above and knowing that the presented theory have full relationship with the
effective theoretical practice, this criterion is characterized - Theoretical knowledge helps to
explain and predict the phenomenon - with value 5 in the scale, which equates to "The
theory really makes a difference" in the practice of nursing.
Criterion 8 - Theoretical knowledge influences the nursing practice
The methods used in Nightingale's works served as a basis for the teaching of nursing for
more than a century, and as a matter of fact, they still exist in nursing programs nowadays.
It is clear, therefore, a lasting influence of her writings on the professional practice and
nursing education5.
Nightingale's ideas, even after a century of her death, have primary influence on the
professional practice of modern nursing, leading us to a reflection on the professional act,
particularly with respect to current ecological problems on the binomial health and the
environment9.
The theoretical representativeness is so relevant that many of her works continue to present
guidelines for nurses in the present days. The critical thinking mentioned by Nightingale as
a duty of the nurse in the reality of the care, characterizes what was done in this study 5.
Before the exposed and based on the scale that is how the theory influences in the nursing
practice, the value 5 of the proposed scale for this criterion was identified, supporting that
the theory makes a significant difference in the nursing practice.
As seen, eight were the criteria used in the theory analysis proposed by Johnson and
Webber8. It's possible to verify that most of the criteria present score scale given for each
criterion, however, the criteria 2 - Limits are consistent with the practice of nursing - and 6
- variables and hypothesis help understand and interpret propositions- do not use scales for
their analysis.
The study had as limitation the fact that the analysis was made on the translated work and
not in the original work. For this reason, some elements may have lost the sense noted by
the author in the original work, which may have influenced the analysis.
CONCLUSION
The study allowed us to critically analyze the Environmental Theory of Florence Nightingale,
through an attentive and reflective reading of the book "Notes on Nursing - what it is and
what it is not". It is noticeable that the theoretical principles were established and serve as
parameter nowadays, and their relevance can be considered a history mark in the history of
nursing.
We conclude, therefore, through the critical analysis carried out, that the theory in focus has
significances, clear and understandable language and concepts, which induce the
formulation of proposals and are explained and understood by variables cited by Nightingale
in the construction of the Environmental Theory and that there is the influence of the
practice of nursing.
New studies under the same perspective are essential because they will provide subsidies
for the theoretical development of the nursing practice, which can greatly contribute to its
development as a science.
