Various concerns in nursing practices have been answered by implementing different nursing care models and theories. The theory of Nursing and Environment given by Florence nightingale is based on philosophical assumptions. The theory states that nurses modify the environment to keep the patient healthy. This paper analyzed a pediatric case scenario in the light of Florence Nightingale's Environmental theory. Nightingale explained 13 environmental canons, which are reflected in the case study. The paper further proposed recommendations that can be used to test relevant nursing intervention on the ground of Nightingale's theory, in order to avoid unpleasant consequences and similar scenarios. In conclusion of this paper Nightingale's nursing theory was proved to be applicable in guiding nursing care of pediatric clients with multiple infections.
In every field there have been people who contributed in the development of that particular field. Similarly, when we talk about nursing, the first name that comes in our mind is Florence Nightingale. She has made significant contributions to nursing and has developed modern nursing based on her life experiences. She was the pioneer who gave the concept of nursing education and was considered as the first nursing theorist ( Alligood, 2013). It was a Crimean war where serving as a nurse and observing dead patients forced her to develop an “Environmental theory”, which was published in 1860. The theory describes the relationship of people with their environment. According to her, disease is a reparative process, which is not always the cause of sufferings, but nurses ought to modify the environment for nature to act upon ( Kamau, Rotich, Cheruiyot, & Ng'eno, 2015). Selanders (2010) comments that “The principle of environmental alteration has served as a framework for research studies” (p. 88). Nightingales' environmental theory reflects a great consideration in providing holistic approach to the patients by inculcating four major metaparadigms which consist of individual, environment, health, and nursing. All the four concepts are interlinked with each other. An individual is a human being who is effected by the environment and acted upon by a nurse. Environment is a way which a nurse can manipulate for natural laws to act in order to make the human body healthy orvice versa ( Medeiros, Enders, & Lira, 2015). Health is viewed as a holistic level of wellness which is maintained by the customized environmental factors and facilitated by the nurses to maintain it. In the same way, for Florence, nursing is a separate entity in the field of medicine and the vital role of a nurse is to keep the patient in an environment where they remain healthy and where the maximum healing takes place. “The nurse is responsible for maintaining the environment in such a manner as to maintain the health of the patient” ( Selanders, 2010, p. 87).
These environmental alterations are represented as the canons of Florence Nightingale environmental theory, which are classified into 13 sub concepts. These canons, include ventilation and warming, health of houses, noise, light, nutrition, bed and bedding, personal cleanliness, variety, taking food, petty management, chattering hopes and observation of the sick. Nightingale believed that this is the duty of nurse to adjust the environment in a way that it can help the patient to have a better recovery. She emphasized that air a person breaths should be clean, odor free and room temperature should be moderate. Houses should be clean and well-constructed. A good sunlight and calm surroundings should also be considered, as they create tangible effects on body ( Parker & Smith, 2010). Patient and a nurse should practice hand hygiene as a Personal cleaning. Bed should be dry, wrinkle free and placed at the lowest portion. Individuals should be preferred to eat small frequent meals without any distractions. Patient should be provided hopes and all his concerns should be listened and addressed. Lastly, nurse should keenly observe patient and his environment. All these will help to provide patients with patient centered care.
This theory can be applicable in different clinical scenarios with different context but the author could best relate it to a clinical scenario related to her life experience, which stunned meduring her student life. It was one of the government hospitals where she was assigned in a pediatric ward with four years old patient suffering from pneumonia. Next to her assigned bed was a three years old baby boy who came with the complaint of dehydration. Child was on intravenous fluids and antibiotics.
While nurse was taking history from the mother, the author realized that he belongs to a poor family and has recurrent history of cough since after his birth. The child was recovering well and was advised to discharge. Few hours before his discharge, he developed small red scaly spots on the back which within 3-4 hours increased in size and spread to the extremities. The mother shared the concern with nurse, to which she said that these are just heat rashes, which can probably be due to hot weather. In order to provide comfort to baby, mother started applying heat powder on child's whole body, but the baby became restless due to itching and burning of rashes. After few hours, the rashes appeared on whole body including chest and face due to which the child was presented with respiratory distress. The mother started to cry due to which the nurse and doctor arrived. Nurse started to perform diagnosis on vital signs and she observed that baby's respiration and pulse were high. Doctor diagnosed these as anaphylactic reaction which were a result of urticarian rashes. The child was kept on triple regimen therapy including prednisolone and was suggested for allergy test and Complete Blood Count (CBC). Laboratory diagnosis revealed that WBCs were high and baby was reported as severely allergic to dust.
After this incident, the author was stressed up as a baby who was about to discharge, suddenly developed allergy which converted to anaphylaxis. She did a root cause analysis and identified the following possible reasons: i) baby was not bathed since three days, ii) there was no bedding changed, and iii) the room was full of dust heaps, eatables, and wet clothes.
After realizing its root cause, She changed the bedding and gave bath to the child. She has also taught mother the importance of personal hygiene, a regular bath, and its proper techniques.
The aim of this paper is to discuss the practical application of Nightingale theory to the care of pediatric patient in hospital setting.
The following are the objectives of the paper:
Keeping all the views into considerations, the above case the author had experienced is now to be related to the theory of Florence nightingale. In Nightingales four metaparadigm, Individual is a three years old baby who required proper environment. Dehydration is a disease due to which the patient was admitted. Unchanged bedding, dirty area, and lack of patient care are the environmental factors due to which the baby suffered from anaphylaxis and also other patient, staff and relatives were at risk. The nurse is the one who was assigned with baby, and did not pay attention on the environment. If a nurse having skills and knowledge, could have altered the baby's environment, then the baby would have not suffered with sever anaphylactic reaction. According to Florence (1860) “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” (p. 6).
By taking environmental theory into account, all 13 canons are important, but the most relevant canons which suits in above clinical scenario are ventilation and warming, health of houses, bed & bedding, personal cleanliness, and observation of the sick. Ventilation and warmth is the most important concept without which other concepts are nothing ( Nightingale, 1969M). The area where baby was present was dirty and full of the foul smell due to the presence of food and damp cloths. The damp cloth which dries in patient room can go into the air where patient was present. The eatables which were present without cover/lid, the moisture of that evaporates in patient area and can spoil the air. The nurse and mother were so insensitive that they were unable to recognize that patient is being treated in an unhygienic environment. “The more that is known about your child's environmental exposures and experiences, the more accurately one can predict the risk of immune dysfunction and immune-related disease” ( Dietert & Dietert, 2010). However, Nightingale strongly emphasized on the presence of fresh and clean air as well as avoidance of foul smell and fumigations. It is the air we breathe which purifies the blood. This impure air if provided with untidy room can be a disaster for the patient as he can develop numerous diseases. Nightingale explains the above factor in her concept Health of houses. The room in which the baby was admitted was full of dust and there was no one, including a nurse who noticed and rectified this factor. Therefore, dust heap was the main source of environmental impurity and patient's allergic factor. Another important canon is bed and bedding. The nurse did not follow the standard procedure to change the bedding regularly. The child, who was already sick and was depositing his exhaled sick breath and body's unsafe flora into the bed, had exaggerated his sickness due to the unchanged bedding. According to Nightingale, the large amount of moisture of exhaled air goes into bedding which contains organic matter and is noxious for health. Beita (2013) also emphasized that “It's a chore, but washing all bedding weekly in hot water is a sure way to get rid of dust mites”. Personal cleaning, be one of the important canons is also nicely related to the baby's health. Baby has not bathed since three days which made him more prone to infection and allergies. Nightingale in her theory intensely advised nurses to pay attention to patients' personal hygiene. She also gave consideration to sponging methods, usage of soft water and hand washing. Nightingale emphasized on the germ theory and its significance in terms of hygiene as an infection control measure ( McEwen, Melaine, & Willis, 2011). Last but not the least, observation of the sick is also a very essential canon to be integrated with the case. In this scenario, the nurse did not have a sound observation and she neglected patient care. Even, when mother of the baby made her realize that baby is having rashes, she ignored and gave falsify reason of having heat rashes. She did not observe that the environmental factors have become a cause of patient sufferings. While, according to Florence (1860),
Due to all these environmental factors, the baby in this scenario ended up with anaphylactic reaction which could have been prevented if all above measures would have taken care.
"The most important practical lesson that can be given to nurses is to teach them what to observe—how to observe—what symptoms indicate improvement—what the reverse—which are of importance—which are of none—which are the evidence of neglect—and of what kind of neglect".
Let us consider the impact of local context which affect the critical incident of the case. Primarily, the age of baby (three years old) and his history of recurrent cough made him susceptible to acquire infection and allergies. “Children, because of their smaller bodies are more vulnerable to the impacts of bad indoor air” ( Beita, 2013). Secondly, unidentified allergies during his admission badly affected baby's health. Misperception of the nurse that the red spots are heat rashes due to warm weather, resulted in anaphylaxis. Also, the nurse's lack of knowledge regarding environmental influence and her busy schedule compromised baby's hygiene care, which lead baby to undergo a severe life threatening condition. It is often seen that nurses are so loaded with the work that they tend to miss basic signs which later become alarming for patients.
The impact of this scenario is not only on the individual baby, but also be on all the patients admitted to the particular ward/ hospital. For the clients who belong to the poor family, the incremental cost of disease will be economic burden for their families due to which they tend to avoid brining their children to the hospital due to their past experiences.
The root cause in the scenario was the lack of awareness among staff regarding environmental hygiene. Therefore following recommendations are proposed:
Integrating Nightingale's theory in the clinical scenario has increased the authors knowledge regarding this particular theory and it helped her to view nursing as a discipline. This assignment has provided her with the theoretical concepts for understanding her own experienced observation, in a more meaningful way. Through this assignment, she has enhanced her learning curve as she realized how a nurse can provide a patient centered care and contribute to the society at large by identifying the problem and eliminating at the grassroots level. Through this assignment, it has been observed as how this theory was developed in early century, however its implication is still consistent with modern era and many health care professionals are consistently following it in some way or the other. This theory could be applied whenever and wherever it would be pertinent, as it helps to provide better care to patients.