The word ‘care’ is very much associated with nursing profession, because Nurses are not only responsible to facilitate in curative care. However, they are also responsible to provide holistic care and healthy environment to promote patient recovery. This paper is discussed in the light of Florence Nightingale's theory on environment in the relation of concepts in nursing practices. Her theory has more of a focus on health promotion than a curative focus. She has focused in her theory four main assumptions, for example, Nursing, Person, Health and environment and their association with each other. A small effort by a nurse can help to improve the patient's health and decrease the burden of disease.
Working as a nurse in a hospital is always very challenging, however, it always enhances the knowledge and practice of health care workers as the time passes. Nurse is not only responsible to facilitate in curative care, however she is also responsible to provide infectious free healthy preventive able environment to patients. Healthy environment promotes patient recovery.
A fifty years old female patient had been admitted in the surgical special care unit with a head injury. It was the fifteenth day of her admission. During a head assessment, the patient's Glasgow Coma Scale (GCS) was found to be 9/15 compared with a normal score of 15/15. The patient was unresponsive but had spontaneous eye opening. She had multiple surgical scars on her scalp which were covered with dressings. To maintain intracranial pressure (ICP), one extra ventricular drain (EVD) was inserted so that the extra fluid could be removed. She also had a tracheostomy for ventilation which needed repeated suctioning. There were multiple intravenous (IV) lines present on the patient's upper limbs for medication and intravenous fluid. A Percutaneous Endoscopic Gastrostomy (PEG) was present on her abdomen for feeding purposes. A Foleys catheter was placed for urine output. A cardiac monitor was attached to the patient to monitor her vital signs and her cardiac rhythm. That cardiac monitor continuously beeped when parameters fluctuated. During examination, the author observed second degree pressure ulcers on the patient's sacrum and heal covered with comfeel dressings.
The special care unit was equipped with an air conditioner (AC), and the temperature was so cold that it was unbearable for even a well person, so I questioned how a patient could bare it. The patient, in fact, started shivering after some time. There were three female and two male patients admitted in the ward, and only one female registered nurse (RN) and one male nursing assistant (NA) were present in the ward. We can understand that nurse patient ratio was unequal in the unit. The RN was very busy because she had to complete her tasks within the time allotted and I observed that she was taking many short cuts during her care giving. Many times she failed to wash her hands after touching an infected patient and, cleaning the I/V port and emptying the urine bag; However, many infections could be transferred through invasive lines. She also missed one important task, which was the back massage of the patient and changing their position, as all patients were continuously on the bed at the risk of developing pressure ulcers. It was also observed that multiple doctors came for the patient's round; some of the doctors examined the patient without wearing gloves. Since the morning, patient was very disturbed and her parameters were very high, but after some time she became more settled. Unfortunately, the team of the doctors came and started examining the patient again. Suddenly, the patient woke up again and her respiratory rate was increased and heart rate started fluctuating.
On the second day of my duty, when I received the same patient, she had a high grade fever and her blood pressure was also very high. The reason for this was identified as an infection that had developed in the cerebral spine fluid (CSF).
The above mentioned scenario will be discussed in the light of Florence Nightingale's theory on environment in relation to concepts in nursing practices. Her theory has more of a focus on health promotion than a curative focus. She has focused in her theory four main assumptions for example Nursing, Person, Health and environment and their association with each other. These assumptions give awareness, that nurses provide a therapeutic environment to boost patient's recovery. In the Nightingale's concepts of environment Tomy & Alligood, (2011) shared her assumption, that poor patient would get benefit from environment that would benefit both their bodies and their minds (p.78).She highlighted in her book, “Notes on Nursing”, many components of the environment can improve the patient's health; at the same time, if health care providers do not follow those components, the patient may be put in danger. George (2011) states, “Nightingale viewed manipulation in the physical environment as a major component of nursing care” (p.50). Nightingale in her theory has focused on different components of the environmental health of houses, ventilation and warming, light, noise, variety, bed and bedding, the cleanliness of room and walls, personal cleanliness, taking food, the type of food, chattering and advice, petty management, and observation of the sick. To discuss every component briefly, it could be observed how these components affected the person's health. Nightingale considered the health of housing as very important. A clean house provides good ventilation, and pure ventilation compared with the effects of bad housing on the health of the people. (George 2011, p.50).Nightingale said, “Badly constructed houses do for the health what badly constructed hospitals do for the sick. Once insure that the air is stagnant and sickness is certain to follow” (1860, p.30).She put importance on the cleaning of the room and walls for good ventilation.
In the ventilation component it has been talked about keeping “the air he breaths as pure as external air, without chilling him.”(1860, p,8). It is the responsibility of the health provider to make sure that air temperature should not be very cool, dry or warm; when the patient remains on the bed for a long time, their health may be affected as the infectious patients are in the same room. She also believed that the people who frequently breathe in her own air would develop infections (George, 2011, p.51). If I compare this component with the above scenario, the patient was facing same situation. Two infected patients were admitted in the special care unit. One patient had infection in her tracheostomy and other patient had infection in her wound. Both patients were taking their breath in the same environment, patient was continuously on bed; as well as the air in the room was very cool. George (2011) mentioned that, “the patient should not be too warm or too cold. The temperature could be controlled by appropriate balance”. (p.51). It is the responsibly of a nurse to take care of the room temperature, so that it should not destroy the patient's health.
In addition, Nightingale also put emphasis on reducing noise in patient areas, a small whisper can disturb the patient's sleep, Nightingale stated “if it is a whispered conversation in the same room, then it is absolutely cruel” (Nightingale f.1860, p.65). In the above scenario, the entire time the cardiac monitor beeped near the patients' head. During doctor's rounds, all discussion was carried out at the patient's bedside, and medical jargon was also used during the discussion. George (2011) shared that, “Nightingale was very critical of noises that annoyed the patient, such as a window shade blowing against the window frame. She viewed it as the nurse's responsibility to assess and stop this kind of noise” (p.51). One more observation I made was that staff discussed their lunch break and tea break at the patient's bedside. Moving steel trolleys and vital signs trolleys was another regular feature of the ward that created noise. Trolleys are not properly oiled and so they increase the noise more.
Nightingale paid attention to the bed and bedding and suggested that the bed should be cleaned and sheets changed frequently, because if it is wrinkled and soaked it can damage the skin, especially the pressure points (George, 2011). Nightingale states in her book that, “if there is any danger of bed sore, a blanket should not be placed under the patient. It retains damp and acts like a poultice” ((1860, p.116). Nightingale put importance on this concept that “it remains important for the nurse to keep bedding clean, neat, dry and to position the patient for maximum comfort” ( George, 2011, p. 52).
In the personal cleaning component, she not only focused on the patient's hygiene, but also the hygiene of the nurse as being equally important. Lack of hand washing among health care providers was observed in the hospital area. It can cause the transmission of infection from one patient to another patient easily. “Every nurse ought to wash her hands very frequently during the day” (Nightingale, 1860, p.53). There are many hospital acquired infections spread due to lacking in appropriate hand washing practice. Specially, high touch areas in the hospital are the source of transmission of infection, for example, telephones, door knobs, stethoscope, over head tables and call bells etc, Housekeeping staff need to be trained to focus on high touch, as these sites require thorough cleaning with detergent or disinfectant (Motacki, Omara, Kapoian, 2011, p.97).In the component of personal cleanliness, Nightingale puts emphasis on the cleaning of the skin, as broken skin can cause diseases. In the above scenario, the patient also developed an infection, staphylococcus aureus, which entered through broken skin. The patient's multiple invasive lines were also sources of possible entry for this organism.
Light and variety of environment are also main components of Nightingale's theory. She illustrates that light has a good effect upon the human body, and the patient who remains continuously on the bed requires a change in environment (George, 2011, p.51).
Adequate nutrition is also an important component for the patient's recovery. Nightingale suggested that it was essential to plan activities in a way that did not disturb the patient while he is eating. It is important to ask about the patient's likes and dislikes before providing meals. It is very essential to check food and meals for temperature and expiry date. It may cause abdominal distention or diarrhea if food is out of date.
Chattering, hopes and advice were talked about by Nightingale and she suggested that false assurance should not be given to family and friends regarding the patient's disease process or recovery as it may increase their hopes unrealistically. Lastly is petty management and observation of sick which is about the management of the patient when you are not there and how things are done by other staff members. Nightingale said, “By not knowing how to manage that what you do when you are there shall be done when you are not there” (1860, p.49). The authors thinks that when staff leave for break, leaving patient with other staff properly is very important. Patient observation is another important concept she has discussed here. Nursing staff should never leave the patient unattended as it can increase the risk of fall.
To analyze the above scenario with Florence Nightingale's theory, I have noted that a core component of nursing which is care was missing. I have found many issues; first of all, the work load of the assigned staff which directly and indirectly affected the environment and patient's care. She was the only female RN assigned to work with five patients and the other staff was an NA who was allowed to perform only basic skills. The RN had to perform multiple tasks like administering medication, feeding the patient, helping in the patient's wound dressing, attending doctor's round and so on. There were three patients who were also females so she had to change the patients' incontinence pads and urinary bag too. I observed during her shift that one patient suffered a cardiac arrest and the RN helped in managing the emergency. The excessive workload seemed to make it difficult for her to follow all policies and procedures. Ball, Murrells, Rafferty, Morrow, and Mgriffiths (2013) have done in one of the studies that shortage of staff can worse the patient care. Results were shared that due to lack of time, some activities are left that are 66% providing comfort and taking patient, 52% giving education, and 47% developing nursing care plan (p.1). In the above, patient's positioning was missed and that can raisen the chances of bedsores.
Secondly, the overcrowding of visitors in the ward caused disturbance. This was considered culturally normal and positive; however, it also increased complication for patient. This patient had multiple intravenous lines and dressings and family members sometimes touched those lines thus increasing the risk of transfer of infections. When the nurse tried to explain to them the importance of not touching equipment, the family simply ignored it. There was no respect shown for the nurse; the reason could be the attitude of the nurse or lack of therapeutic communication. “Therapeutic communication techniques are specific responses that encourage the expression or feeling and ideas and convey acceptance and respect” (Potter & Perry, 2013, p.320). Here Nurse failed to build the therapeutic relationship with the patient's relative to motivate them about treatment regime and patient's safety.
Thirdly, the author observed lack of advocacy for the patient especially when frequent rounds of the consultant team were made which included, residents and interns, and caused disturbance to the patient. The author observed that when the patient was getting settled, the team again disturbed the patient. Nightingale also mentioned in her, “Notes on Nursing” that the patient should never be wakened intentionally or accidentally during the first part of sleep. ((1860, P.63). Client centered care is another core component of nursing, and therapeutic touch was missing. Most of the time we are dealing with patients as a subject instead of human being; The author thinks that we are becoming more mechanical than being human.
While reviewing the scenario and applying Nightingale's theory to patient, the author was able to make a hypothesis:
To conclude, the author was really inspired with the environmental theory of Nightingale. She has discussed many different concepts, sub concepts and assumption in great detail. This theory helps a nurse to improve the care of the patient and improve their critical thinking also. This integration of concepts will help the author as a nurse to make nursing plan for her future. This theory is not only applicable in the community but also at a hospital level. First of all, it increases the author’s critical thinking to understand the integration of this theory in hospital area. The author has also learned the hidden concept of this theory. In undergraduate studies, she learned this theory in the fundamentals of nursing but was unable to relate it properly to practice. This paper broadens her vision to understand the depth of this theory. This exercise also taught her the integration of nursing care with environment.
Secondly, the author has learned how these components help to promote the health of a person. She has also learned that a small effort by a nurse can help to improve the patient's health and decrease the burden of disease. It is a quality of a good nurse to keep his/her eyes open to observe changes in the patient's health. Her little negligence can put the patient in danger.
The key aim of a health care staff is to provide safe care with learned competent skills. In addition, health care agencies should review patient care policies timely, and monitor as compulsory. Staff education and awareness sessions should get special attention, as patient remains most of the time with them. Staff appreciation is also equally significant, as it increases staff motivation towards their profession.