Nurses are facing many challenges in this competitive era in health care settings and the one biggest challenge among the others is the application of theoretical concepts into practice. Moreover, the knowledge about nursing theory and its application into clinical practice is the hallmark of evidence-based practice, which is the focus of today's health care environment. The purpose of writing this paper is to show explicitly, the close relationship of nursing theory into clinical practice in order to prove evidence-based practice. Florence Nightingale is regarded as a pioneer in the nursing profession. Nightingale has given her notes on nursing in the form of theory of environment which is very useful for nurses to apply those concepts into clinical practice in order to improve the health care standards. All the major concepts of Nightingale's theory have been incorporated into the clinical scenario.
A 54-years-old male has presented in the emergency department with a history of uncontrolled type II diabetes mellitus and hypertension and complain of severe pain in his right foot. On examination, it was identified that he has an abscess on his right foot with gas gangrene. He was admitted for antibiotic therapy and analgesics to relieve the pain on an immediate basis. He was planned for wound debridement in operation theatre. His wound was debrided; abscess drained and dressing was applied. The patient was shifted to ward, but he didn't get relief from pain. He was shifted to a Surgical Unit in a general ward where there was no vacant bed and so he was shifted on stretcher.
Next, a nurse approached the patient and introduced herself and asked how could she help him. Next, she proceeded for history and physical examination. By taking the history of the patient, he stated that, he was prescribed for oral hypoglycemic but he did not take on a regular basis. There was no record of blood sugar level for the last two years. He has no diet plan to control his blood sugar level. His hygienic condition was also very poor. He also stated that his wife is efficient in making different recipes and he enjoyed eating all the day. The Patient stated that, “I am not following up my treatment plan because I cannot visit the hospital due to transport problem”. He stated that “I did not get bath for the last one week since the time I was admitted in hospital”. He also shared his concerns for his poor hygienic condition with the nurse as he stated,“I cannot move to the bathing area and cannot bend to bathing tub and so on”. He didn't get sleep enough for the last four days because of pain, fever and environmental change and so on. The Patient has been suffering with continuous fever for the last one week; since he got an abscess on his foot. His temperature didn't settle down during his stay in hospital even though he took antipyretics for high grade fever. The Patient also felt difficulty in moving from one side to another side, since he was lying on the stretcher a stature. On physical examination, the vital signs are: temperature 103F, pulse 110, and blood pressure 160/100mmHg. His blood sugar level was 567mg/dl.
The Nurse has shifted the patient from the stretcher to bed. She took a complete history of the patient and did a physical examination and then developed nursing care plan by incorporating all the aspects of care from the patient's own way of choice. She has given towel-bath to the patient as it doesn't need to move the patient, to bathing area and preserved his dignity. She also encouraged the client to take more fluid intake and kept the patient's bed side window open for fresh and cool air to breathe easily and get relief from fever. She put on the fan over the patient's body. She also kept exposed patient's head, foot and extremities to evaporate heat from the body. Moreover, she provided surface cooling by sponge bath for evaporation and conduction of heat. As the patient's temperature became normal, nurse wrapped the patient’s extremities by a towel, so that he may not shiver due to environmental effect.
Nightingale has focused on the four nursing meta-paradigm concepts in her notes on nursing as follows.
NursingNursing is much different from other health professions. The main target of nursing is to abide the patient in such a state, which suits the environment to act upon the patient's health and recovery. Nightingale explained the term nursing in different perspectives. She described nursing as an intervention which is for the promotion of health. The action for promotion of health can be possible by any person who is supposed to be a nurse.
PersonNightingale referred the name of the person to a patient. According to Nightingale's concept, people have a diverse nature of the group. The Nurse should assess the patient from all perspectives of his health. Nurses should perform tasks for the patient and control patient's environment to enhance recovery. Nurse was taught to inquire the patient about his or her selection, which reveals the belief that Nightingale saw each patient as an individual. Nurses should not take the patient for granted. They should deal the patient as an individual and not as a general.
HealthNightingale proposed that, conservation of health is only possible through prevention of disease by strict environmental control and social responsibility. She saw disease and illness as a reparative process that nature instituted when a person did not attend to health concerns. Nightingale considered a disease as “the reaction of kindly nature against the condition in which we have placed ourselves” (Nightingale, 1969, p.56).
Environment"Poor or difficult environments led to poor health and disease" (Nightingale, 1959, p. 52). Environment could be changed to improve conditions, so that the environment would permit healing to occur. Nightingale accentuated that nursing is “to assist nature in healing the patient” (Nightingale, 1992, p. 54).
Nightingale's notes on nursing contain her philosophical suppositions and opinions regarding all essentials found in the meta-paradigm of nursing. These essentials used in her conceptual model has great efficacy in practice setting and bids framework for research conceptualization.
Nightingale's theory focused on the environment, although Nightingale has not once used the word environment in her notes on nursing. She did define and describe in detail the impression of airing, temperature, light, diet, sanitation, and clamor as constituents of surrounding that have come to be known as the environment. She believed that the healthy work surroundings were necessary for proper nursing care. Proper ventilation for patient seemed to be of greatest concern to Nightingale; her charge to nurses was “TO KEEP THE AIR HE BREATHES AS PURE AS THE EXTERNAL AIR, WITHOUT CHILLING HIM” (Nightingale, 1969, p. 12).
Nightingale's emphasis on proper ventilation indicates that, she seemed to recognize this environmental component as a source of disease and recovery. The concept of light was also important in Nightingale's theory. In particular, she identified direct sunlight as a particular need of a patient.
Cleanliness as a concept is another important factor. In this regard, she specifically addressed the patient, nurse, and physical environment. Even if the environment is well ventilated, the presence of organic material created a dirty area. Finally, Nightingale advocated bathing patients on a frequent, even on a daily basis. And their clothing should be clean, and nurses should wash their hands frequently.
Furthermore, Nightingale's idea of sanitation and disease prevention is also valued by Monteiro (1985) in reference to the importance of public health nursing.
Besides this, Nightingale also stressed on the respect for every individual's ethnic and cultural background and focused on patients' values and beliefs for therapeutic purposes. Andrew (1992) also supported Nightingale's concept of cultural competent care and states that nurses are the culturally sensitive care providers.
Nightingale also included the concept of quiet and diet in her environmental theory. Nurse was required to assess the need for calm and quiet environment. The Nurse should manipulate the environment as needed. She should also be concerned about the patient's diet. She instructed to nurses not only to assess dietary intake, but also meal schedule and its effect on the patient's health.
Another concept of Nightingale's writing was a description of petty management. The Nurse was to control the environment to protect the patient from receiving upset news, from seeing visitors who could negatively affect recovery.
Nightingale's writing shows three major relationships as followingShe supposed that environment was the main aspect that produced illness in a patient and she observed disease as “the reaction of kindly nature against the condition in which we have placed ourselves” (Nightingale, 1969, p. 56). She analyzed the relationship between good environment and health status as well as potentially harmful environment and disease process. She focused on nurse's practice to manipulate the environment for patient recovery from illness.
According to her discussion, nurse is a key element to control environment according to the patient's need. Proper hand washing and cleanliness are also conveyed in her writing for nurse's daily practice. So, there is a durable relation between nurse and environment.
Her writing reflects another major association between patient and nurse; as she talked about patient’s comfort level, eating habits and dietary pattern. So, nurse should take the patient as an individual. A mutual relationship must be developed between patient and nurse to build trust and confidentiality for sharing important information about the health status of patient (Forchuk & Brown, 1989). According to her notes on nursing, nurse should observe and measure outcomes as an important aspect of her practice. Finally, it is fascinating to note that Nightingale suggested methods of quality improvement based on nursing observation. Moreover, Nightingale has highlighted the significance of spiritual therapy in patient healing and Nightingale's this idea was also appreciated by Macrae (1995) in time of modern nursing.
Florence Nightingale's environmental theory has described the fundamental aspects of hygiene i.e. direct sunlight, fresh air and cleanliness that advances health.
According to Florence Nightingale's environmental theory, there is a concept of ventilation and warming. The above mentioned clinical scenario is deeply concerned with this concept of Nightingale that, because of poor ventilation patient had not relieved from fever; even though he is taking oral antipyretic medication for fever in routine as advised by the doctor. There should be proper ventilation to get relief from fever and also for fresh breath to relieve from pain. As nurse opened the window and kept it open for some time; patient has perspired and got relief from fever.
In the above mentioned case scenario, the patient didn't sleep well because of noisy environment. It is the obligation of a nurse to keep an eye on the patient's comfort level, his rest and sleep time. According to Nightingale's theory, as the nurse puts off the lights of the patient's bed side, he took rest and got fresh. He had no other issue related to his disturbed pattern of sleep. In another case, Nightingale emphasized for sunlight for recovery of the wound and also for disinfecting the usable items.
As far as the patients diet is concerned, particularly for diabetic patients the diet plan is much important. According to Nightingale's theory concept, a nurse can do best practice of applying this concept in recovery of the patient's disease. The Patient had no knowledge about which diet suits to his health status as he was taking everything which his wife made at home. In the above mentioned clinical scenario, the nurse made diet plan with consultation of patient's dietician and pasted that diet chart in front of the patient. The Nurse also taught to the patient, which diet suits his health status more, in order to manage his disease by incorporating his food preferences and choices. Again here, Nightingale theory is applied, as the nurse asked the patient for his preferences and choice for food, because Nightingale has emphasized to take a patient as an individual.
Cleanliness as a concept, is another critical component of Nightingale's environmental theory. Hygiene is an important aspect of healthy living. The Nurse has planned to give bath to the patient. Daily bathing is also a healing rite. Moreover, it is also a comforting experience for a patient that enhances his/her health status. The patient has experienced that bathing is a soothing experience and it also reduced his aggression. The Patient was relaxed after having a bath. Patient's wound recovered gradually as he adopted strict personal cleanliness habits.
Florence Nightingale is a unique figure in the history of nursing profession. Florence Nightingale proved to be a professional ideal for nursing. By applying Nightingale's environmental theory, nurses can enhance their practice and put a patient in a more comfort and ease position. Nightingale's theory helps a lot in the recovery of patient's disease process by just focusing one element of this theory which is the environment. Usually nurses apply this theory in practice many times but not consciously. Furthermore, the logic and common sense that is personified in her notes on nursing can assist to inspire fruitful thinking for individual nurse and the nursing profession. In addition, it is also the demand of today's health care system to follow evidencebased practices which would also be the part of implication of theoretical concepts into real practice. It would also enrich research in the nursing profession by applying the theory into practice and put forward some more incorporating concepts into its addition or development of a new theory.