As nurses continue to advance in their roles within the healthcare sector, their primary role as caregivers should not be forgotten. Modern nurses, including Advanced Practice Nurses, take the roles of clinicians, administrators, and team leaders but still have to put their role as caregivers above everything else. A prime example of excellence in caregiving can be attributed to Florence Nightingale, arguably one of the greatest modern nurses. Nightingale believed that nursing was an independent profession by itself, based on a caregiving relationship between the patient and the nurse (McEwen & Wills, 2014). It is towards the furtherance and betterment of this relationship that Nightingale's environmental theory was both predicated and developed. The theory ignores clinical processes and focuses on improving the patient’s health and quality of life through caregiving. It emphasizes on the five environmental factors of fresh air, pure water, effective drainage, absolute hygiene, and proper lighting (Iram, 2018). Whereas a number of these factors have been upheld by modern healthcare standard in the USA, there is still a major problem when it comes to fresh air, and the problem is gradually worsening, more so for patients in the lower segment of the social stratum (Kisacky, 2017). An urgent solution is thus needed to the fresh air problem in American hospitals and healthcare institutions in order to uphold the tenets of Nightingale's environmental theory.
Summary of the Theory
Background of the Theory
Nightingale's environmental theory is purely predicated on the care-based obligations of a nurse with little if any reference to clinical care and pharmacological interventions. The primary prerequisites of modern nursing differ from the environment envisaged by Nightingale as she developed the theory. For a start, Nightingale proposed a practice in nursing where nursing was a free-standing profession, instead of being subordinate to clinicians, as evidenced in most modern institutions (McEwen & Wills, 2014). Secondly, Nightingale envisaged a nursing practice where nurses were primarily focused on care, without getting encumbered by clinical procedures. Unfortunately, the modern nurse spends a lot of time adhering to instructions that have been given by physicians and other specialists. Conversely, nursing includes a myriad of clinical duties that have little to do with caregiving such as diagnosis, prescription, assisting in surgery, updating patient records and many others (McEwen & Wills, 2014). The focus on Nightingale's environmental theory seeks to rekindle focus and passion on caregiving, which is the core of nursing.
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Components of the Theory
Under this theory, a nursing officer has an obligation to ensure that five primary factors are met as a bare minimum for every single patient. First, the nurse must ensure that the patient is enjoying sufficient volumes of fresh air, which is congruent to the air outside the confines of the hospital or related institution. Secondly, the patient should have access to pure and unadulterated water in an unlimited quantity. The third factor relates to drainage and regards the effective disposal of all sewerage and wastes that emanate from the day-to-day processes within a healthcare institution (Iram, 2018). Absolute hygiene is the fourth factor, which combines the cleanliness of anything that is given to the patient, the personal hygiene of the patient, clean and fresh beddings, and a clean environment around the patient. Finally, patients should be able to enjoy sufficient lighting that is as natural and comfortable as possible. Sufficient light does not merely mean the ability to see but enough illumination to ensure a bright environment for the patient (McEwen & Wills, 2014). The totality of the above provides the bare minimums that the nursing officer should provide for every patient.
Current Application in The USA
A careful evaluation of available research shows that Nightingale's environmental theory forms a core of modern nursing practice as far as caregiving is concerned. Research and development have been invested t o develop best practices in regards to patient hygiene. Indeed, when it comes to the licensing of hospitals, hospices and any other environment where professional care is given, hygiene is among the areas of primary focus (Iram, 2018). Among the easiest ways that an institution can lose its licensing is for it to be credibly accused of lack of hygiene. Similarly, efforts have also been made to ensure that the general level of hygiene is maintained when it comes to air and water accessibility for patients. The subject of lighting has also been the subject of a lot of research with best practices been developed to ensure that patients get as much lighting as possible including natural light where practicable (Alligood, 2014). Finally, waste disposal in healthcare has developed into a billion dollar industry that is carefully regulated with different means of disposal having been developed for different kinds of waste.
Problem or Issue in Practice or Education that is an Area of Concern
Despite the best efforts being put in place, American hospitals have a serious and gradually exacerbating problem when it comes to clean air. The kind of fresh air that Nightingale envisaged when she developed the instant theory is almost inexistent in the urban USA where most hospitals are situated. Nightingale had indicated that the air inside the room where the patient is being retained should be as pure as the air outside as much as possible. Unfortunately, in modern urban centers, measures have to be put in place to protect patients from the pollution outside, more so if the hospital is near an industrial park or major highway (Kisacky, 2017). Secondly, the size of the modern hospital has grown exponentially, making it hard for most patients to access natural air through windows that open to the outside. Furthermore, most modern community hospitals where the majority of the poor get treatment are architectural marvels, developed through pilling up of layers, storeys, and wings upon the old, smaller units that were there at the beginning. In the mid-20 th century, the plight of lack of sufficient fresh air came to the fore as hospitals got bigger and more congested. Charles F. Neergaard, for instance, came up with an innovative solution to the problem by designing the ideal hospital interior design as reflected below to solve the problem (Kisacky, 2017).
(Kisacky, 2017)
However, a variety of issues including economies of scale, lack of sufficient funds, poor policies and supervision, and an increasing number of patients requiring clinical care have made it difficult to maintain standards such as the ones indicated above, more so in hospitals that cater for Americans in the lower echelons of the social stratum (Kisacky, 2017). Based on this, most hospitals rely on complicated and in most instances, insufficient air conditioning systems. In some cases, the air conditioning will be carrying a load that is higher than it was designed for, poorly maintained, or even faulty. Even in the best case scenarios, it is hard for these systems to provide air that is as clean and as pure as Nightingale envisaged. With some effort, some hospitals have been able to invest heavily and provide fresh air for patients in most areas but in some areas such as the emergency rooms, the proviso of pure fresh air in sufficient volumes is still a challenge for most hospitals.
Design an Intervention that 'Fits' the Theory
The problem of providing sufficient fresh air for patients is driven in part by the need for careful balance between limiting costs and providing better services. The average cost of health care in the USA has risen drastically based inter alia on the cost of developing medicines, the training of professionals, and development of related technology (Alligood, 2014). The other factors within Nightingale's environmental theory also push up costs exponentially. These limit the abilities of most hospitals to provide clean air for their patients and still remain solvent contemporaneously. The instant problem, therefore, can only be solved through innovation and circumspect application of relevant technology.
With regard to innovation, Bivolarova Melikov, Kokora, Mizutani, and Bolashikov (2016) report on a form of technology that has been developed to provide clean air to a patient in bed, by using the bed itself as an air cleaning mechanism. The solution provided by the research envisages the use of a gadget known as the Integrated Local Exhaust Ventilation System to supplement the available air conditioning unit in the hospital. The approach operates on the understanding that it might be difficult and extremely expensive to improve the quality of air all over the hospital to the level demanded by the theory canvassed herein. However, the theory never canvassed how much fresh air should be available in the hospital or even how hospitals should be run or managed. Instead, Nightingale focused on the patient, and how much fresh air is available to the patient. The solution suggested by Bivolarova et al. (2016) is, therefore, especially suited for solving the problem of availability of fresh air, as under the Nightingale theory.
It must, however, be noted that the patient is mostly not alone in the room, thus the air that will be generated in the room needs to be sufficient for the patient even when it is being shared with a clinician, a nurse, or any other professional. Bivolarova et al. (2014) report on a research on technology that can be used to solve the instant segment of the problem. Based on the reported research, it is possible to investigate and establish how much air is enough for a patient under different circumstances. Among the circumstances tested include a patient during a visit by a clinician and a patient during a surgical operation where several other people are present. Bivolarova et al. (2014) establishes that it is possible to provide the right amount of air at the right places and at the right time cost-effectively due to a reduction in the propensity for wastage.
Recommendation for a Possible Solution
The proposed solution for the fresh air problem is based on the totality of the related research as outlined above with the ideas in the different articles and books contributing to the overall solution. The solution begins with the policy, rules, and regulation segment where proviso of fresh air should be emphasized upon and where possible, updated. Air purity should henceforth be a key concern whenever a hospital, hospice, or related structure is being constructed, renovated, upgraded, or expanded. Emphasizing on air purity will give it a better priority during planning and sharing of funds for healthcare issues.
The second component of the proposed solution relates to specialized research in every hospital and related institutions, based on the research outlined in Bivolarova et al. (2014). The research would include every hospital conducting relevant research to establish how much air meets the criterion set by Nightingale in all the relevant rooms and areas within the hospital. For example, how much fresh air is needed in the operating room when there are a patient and six professionals? Similarly, how much fresh air is needed in the emergency room when it is in its maximum and minimum capacity respectively? Similar testing should be done in shared and unshared rooms.
The third component of the solution is to invest in an air conditioning and purification system that meets the necessary quota of air supply as arrived at by the research outlined above. The basic idea is to cut cost by not providing too much and to adhere to Nightingale ’s environmental theory by not providing too little air. The research above will also ensure that too much fresh air is not wasted in areas where it is not needed while areas with patients do not have enough air. Blanket air conditioning systems that provide the same amounts of air in all corners of a hospital with thousands of square feet must, therefore, be phased out. Finally, when the system is not able to provide enough fresh air for the patients, the Integrated Local Exhaust Ventilation System as recommended in Bivolarova et al. (2014) can be utilized. When used together, it will be possible to ensure that patient’s get sufficient amount of fresh air that was envisaged by Nightingale in her theory.
Conclusion and Reflection
Nightingale ’s environmental theory has always been relevant to the nursing profession and may be relevant now more than it has ever been, based on the above research. Nursing as a profession is arguably at its most advanced stage in history which is a good thing but one that has come with some vagaries. As nurses play a larger role in hospitals, hospices, and related institutions, it is easy for their core role as caregivers and patients’ champions to be forgotten. Adhering to the Nightingale’s environmental theory keeps these traditional care-based roles active and alive. It must be noted, however, that most of the tenets outlined in Nightingale’s theory form a core basis of modern practice. Modern Evidence-based practices (EBP) have envisaged the tenets of Nightingale’s theory in many areas, including the fundamental issue of hygiene. Nurses are still the patient’s champion, fighting for the physical and emotional wellbeing of the patient. They ensure the comfort, safety, and well-being of the patient from a holistic perspective in pursuance to the legacy of Nightingale. However, when it comes to the issue of clean air, the exponential increase in population, the expanded need for clinical services and limited resources have become a major concern. Despite all efforts, patients in most modern hospitals do not have access to sufficient clean air. However, based on the recommendations specifically outlined above, the fresh air problem can be solved definitively to ensure that Nightingale’s environmental theory is fully applied to modern nursing.
From a reflective perspective, there is a major area that the spirit enshrined in Nightingale ’s environmental theory and also the legacy of Nightingale herself ought to be allied to future research and policy development in nursing. From a holistic perspective, the theory regards to both what nurses do for patients and who nurses are to patients from a perspective of interpersonal relationship. Nightingale does not just talk about what nurses should ensure that it is done for patients but rather what nurses should do for patients. I am in a hands-on area of nursing practice for over 25 years mainly focusing on the overall hygiene of patients. I consider it key when my own hands work on the patients and their environment with the tender care and love, just as my mother did for me as a small child. I am, however, concerned that the proliferation of secondary roles for nurses may erode the primary role of nurses as envisaged by Nightingale. For example, the modern advancements in IT ensure that nurses spend more time in the computer than sharing interpersonal time with patients. Further, the clinical and administrative roles of nurses are taking time away from the care-based roles envisaged by Nightingale’s environmental theory. The theory should thus be considered and factored when determining the ever-expanding roles of nurses.
References
Alligood, M. R. (2014). Nursing theorists and their work . St. Louis, Missouri: Elsevier/Mosby.
Bivolarova, M. P., Melikov, A. K., Kokora, M., Mizutani, C., & Bolashikov, Z. D. (2014). Novel bed integrated ventilation method for hospital patient rooms. In Proceedings of ROOMVENT (pp. 49-56)
Bivolarova, M. P., Melikov, A. K., Mizutani, C., Kajiwara, K., & Bolashikov, Z. D. (2016). Bed-integrated local exhaust ventilation system combined with local air cleaning for improved IAQ in hospital patient rooms. Building and Environment , 100 , 10-18
Iram, M. (2018). Ensuring holistic care: Application and evaluation of Florence Nightingale’s Environmental Theory on tuberculosis patient. Global Journal of Medical Research. 18(3). ISSN: 2249-4618
Kisacky, J. (2017, June 14). When fresh air went out of fashion at hospitals. Retrieved from https://www.smithsonianmag.com/history/when-fresh-air-went-out-fashion-hospitals-180963710/
McEwen, M., & Wills, E. M. (2014). Theoretical basis for nursing . Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
