Florence Nightingale's nursing theory and environmental health principles

Florence Nightingale

The Life and Theories of Florence Nightingale

Florence Nightingale's theories formed the basis of modern hospital administration and nursing practice. Born into a wealthy, upper class family, she used her education to advance the field of nursing and to take the first steps to that transformed nursing into its modern form today. Nightingale emphasizes cleanliness, proper diet, and proper ventilation as the keys to maintaining health and preventing disease. This research discusses her theories and how they continue to apply in today's nursing profession.

The Life and Theories of Florence Nightingale

Florence Nightingale is credited with developing the theory and practice that would shape modern nursing practice. During her work in the Crimean War, Nightingale perfected her technique and theories. She not only saved the lives of many soldiers hurt during the war, but her theories about cleanliness and sanitation would save the lives of countless millions through her influence on the nursing profession.

I chose the theories of Florence Nightingale for my project because they still stand today. Modern nursing practice was built on the theories of Florence Nightingale. Developing a thorough understanding of her practices provides a solid base for the exploration of modern nursing topics. Nightingale provided not only the best clinical care for her patients, she nurtured their mental well-being as well. She listened to them and treated them as the humanity that they represent. Carrying this attitude into modern practice results in the most effective nurse that one can be.

Identification of Theory

Florence Nightingale developed her theories over the course of her lifetime and works. Her theory was based on observations in the various institutions in which she worked and taught. Her theory was not written down formally, as with modern theories based on a single academic study. Her theories were formalized after her death by those who summarized them and presented them as a cohesive whole, but they were never formally written down in such a form when Florence Nightingale was alive.

Some of the components of Florence Nighingale's theory existed as thoughts contained in letters to various individuals. Florence Nightingale's theories exist as a concept and a way of caring for the ill. Although many of her observations were proven to be true by scientists who would come later, many were never formally proven. Yet they have become an important philosophical basis for modern nurses in their daily work.

The most important of Nightingale's concepts are those that have to do with the importance of cleanliness, ventilation, and reduction of moisture in the wards. These concepts are no longer considered a theory, but are considered a must. Now it is not the nurse that is responsible for them. These tasks fall on facilities managers and are built into the design of modern hospitals. However, they began with the theories of Florence Nightingale.

Reasons for Choosing this Theory

Even though Florence Nightingale never formalized her own theories and they remained as the principles that drove her practice, they form the basis of modern hospital management. The systems are much more complex than they were in her time, but the underlying principles are still the same. I chose her theories, as they are still the basis of modern nursing practice and continue to hold true in order to provide quality care in the modern nursing profession.

Overview of Research

This research paper will explore life and development of Florence Nightingale's nursing theories. It will provide an overview of her life and experiences that led to the development of her theories. It will explore the metaparadigm according to the theory. It will explore the major relationships between the concepts of the theory. Finally, it will provide a critique of the theory and how it can be applied to nursing practice today.

Life and Influences

Paradigimatic Origins of the Theory

Unlike other nursing theorists, Florence Nightingale did not rely on the works of others before her to form the paradigms that would eventually form the underlying theory of her nursing practice. Her paradigms did not develop all at once, but rather built upon the concepts learned throughout her and works. Florence Nightingale based her paradigms and the principles upon which she ran her nursing school on the observations throughout her life works.

Early Life

Florence Nightingale was born in 1820 into a wealthy Unitarian family. She grew up in a household with liberal ideals (Atwell, 1998). Her father was a Member of Parliament for 46 years, campaigning successfully for religious rights and to abolish the slave trade (Atwell, 1998). This gave Florence the perspective of how we fit into the grander scheme of things. She was naturally inclined to consider the problems of larger society, rather than focusing on individual successes or failures. She saw the bigger picture, which is a key to understanding her actions later in life. It was this liberal upbringing and life in the eyes of the public that prepared her for the challenges that she would face.

The education of Florence and her sister Penelope was supervised by her father, who was educated at the University of Cambridge (Atwell, 1998). He taught them Latin, Greek, history, philosophy, mathematics, modern language and music. He felt strongly in the importance of educating women at a time when their education was ignored by society (Atwell, 1998). Florence had a natural talent for academics and later helped Benjamin Jowett with his translation of Plato's Dialogues (Atwell, 1998).

Although Nightingale was highly educated, society gave her little chance to use that education in her early and teen years. She felt stifled by the role that society relegated to women, particularly women of her social status. At the age of 17, she had a mystical experience that culminated in a conviction to a larger purpose that would last the rest of her life (Atwell, 1998). Florence Nightingale had incredible abilities and craved action to fulfill her desires.

In 1845, Florence asked to become a nurse at Salisbury Infirmary. Her parents refused on the basis that nursing was relegated to women of lower status. Women on high social class were not supposed to engage in that type of menial labor (Atwell, 1998). In 1848, Florence went to teach poor children at the Ragged School in Westminster. Her time there exposed her to the poverty and social conditions that existed in the lower classes (Atwell, 1998). She decided that this was a place where she could do some good. However, she was denied this opportunity as well because her position was considered by her parents to be below her station in life.

Florence continued to have a desire to help the greater good. In 1849, she went on a tour of Egypt and Greece. While there she made extensive notes about the social conditions and archeological sites that she saw. On her return trip, while traveling through Germany she passed through Kaiserswerth, near Dusseldorf, where Pastor Theodor Fliedner had established a hospital, orphanage, and school. At age 30, against her parent's wishes, she returned to begin training at Kaiserswerth to become a nurse (Atwell, 1998).

Florence was an avid student and after three months was asked to publish an account of life at Kaiserwerth for English audiences (Atwell, 1998). Florence promoted Kaiserwerth as a place where women could get an education that would be useful. In 1846, a theme began to develop through correspondence with her father. She developed the idea that theory and practice were not congruent. She felt that in order for progress to be made, one had to be willing to take a chance and make some trials. These would serve as the stepping stones for others to follow (Atwell, 1998). This ideal became a key tenet of her nursing theory.

Development of Nightingale's theories

Florence Nightingale continued to promote her ideals about the women's intellectual need for knowledge and a place where these ideals could be practiced. From 1851 to 1854, she began supplementing the experience gained at Kaiserwerth by visiting hospitals throughout the United Kingdom and Europe (Atwell, 1998). She collected her notes and began systematizing her experiences. She analyzed and reflected upon hospital reports and governmental publications on public health. This material formed the basis for the own theories. Florence Nightingale's theories are a result of the synthesis of the information gained during this time period.

In 1853, she visited Lariboisiere Hospital in Paris. Here she was impressed by the wards, which were built on a pavilion plan (Atwell, 1998). The wards were designed to admit light and fresh air, while allowing 'noxious airs' or 'miasmas' to become dispersed between the long, narrow ward blocks (Atwell, 1998). This hospital had a reduced mortality rate, confirming her notions about 'miasmas' (Atwell, 1998).

Nightingale's work at Lariboisiere developed into her theory that disease arose spontaneously in dirty, enclosed spaces. Much work had been done in the United Kingdom by the Public Health agencies to lay sewers and provide clean water supplies. These reforms were key to the reduction of disease in the city (Atwell, 1998). In 1858, Louis Pasteur identified germs, proving that diseases did not 'spontaneously' arise as nightingale thought (Atwell, 1998). However, it was Nightingale that began work as to the conditions that promoted the growth of germs, but she would not know this for many years.

The Crimean War: Putting Theory Into Practice

When the Crimean War broke out, she began work at once in a British hospital. Her emphasis was placed on maintaining proper hygiene and the importance of the nurse's role in managing the environment. Nightingale tied her religious beliefs to theory about the causes of disease, distinguishing her from other disease theorists of the time. She believed that god create miasmatic disease so that man should learn its causes through observation. Man was then supposed to prevent its reoccurrence through management of their environment (Atwell, 1998).

She believed that nurses had a special responsibility in this process and thus, a chance for spiritual advancement through this practice (Atwell, 1998). She felt that one could learn the nature of God through learning his laws of health (Atwell, 1998). Nightingale did not learn what she knew about disease through her formal training at Kaiserwerth, but through her own careful observation and reflection (Atwell, 1998). Her nurses training programs reflected what she had learned through observation and reflection.

One of the key difficulties that Nightingale had in her positions as nurse was that she needed to make her ideals known. However, society was not ready to accept women in leadership roles. Doctors and nurses were set up in a hierarchy that could not be broken. Nightingale had to be careful to acknowledge that hierarchy. Otherwise it could lead to the rejection of her ideas. In order to get her ideas across, she had to work within the established social system.

When Nightingale began working in the hospital during the Crimean War, she felt that she could improve the conditions at the hospital with her knowledge. The Secretary of the State for War also saw the logic in her methods. He appointed Nightingale to superintend a group of nurses. This was the first time a woman had held an official position in the Army (Atwell, 1998).

These experiences during the Crimean War allowed Nightingale to put her theories into practice for the first time. She recognized the problems with the system immediately, but had to step lightly in order to preserve her ability to continue working in this setting. She immediately placed her nurses under the orders of the doctors and immediately established a hospital laundry (Atwell, 1998). Within a month she had provided new bedding, significantly improved conditions there, and improved hospital diets (Atwell, 1998).

Nightingale not only saw to the medical and physical needs of the patients, she saw to their emotional needs as well. She wrote letter for them, devised a method for remitting money to their families, and provided reading rooms and games for those that were convalescing (Atwell, 1998). She walked the floors at night with a lamp, keeping watch. She became respected among the men for her treatment of them (Atwell, 1998).

She also provided for setting up a pathology lab and insisted that junior surgeons continue to attend lectures during their service time (Atwell, 1998). She also insisted that soldiers refrain from the problems associated with the drink and promiscuity (Atwell, 1998). Upon returning from the war, Nightingale began a public campaign to reform civilian hospitals as well. She was not satisfied with the mismanagement of hospitals that caused 16,000 deaths from disease, while only 4,000 had died in battle. She caused quite an uproar and demanded an investigation by the government, seeing those deaths as senseless (Atwell, 1998).

In 1859, Florence Nightingale established the Nightingale School for the training of nurses (Atwell, 1998). This training school emphasized hands-on training over textbook knowledge. This school transformed the field and perception of the nurse from a lower level member of society to that of a respected professional. Soon her theories and philosophy spread all over the world and formed the basis for modern nursing practice.

The Theories of Florence Nightingale

One can easily see how Nightingale's life and experiences led to the development of her theories. Her existence outside of the social circles of the upper class gave her a unique perspective. She saw the problems and used her social influence and education to further her ideas. Although it is important to understand how Nightingale's thought patterns developed in connection to her theories, her autobiography is not the focus of this research project. The focus of the research is on the theories themselves and how the impact that they have on modern nursing practice.

Metaparadigms of the Theory

Metaparadigms in the field of nursing are those concepts that identify the principles of central interest to the profession. These four concepts are health, person, environment and nursing (Tomey and Alligood, 2006). Health is the main nursing concern for the population in question. Florence Nightingale was one of the first to promote the concept of public health. Not only was she concerned about the health of individuals. She was concerned about improving the health of the community as a whole.

The second metaparadigm of the nursing profession is the person. Florence Nightingale established reading rooms and game rooms in order to help with the person's mental health. She believed in treating the whole person, not just the part affected by disease or injury. She worked to make patients comfortable, as well as treating their injuries. She would often write letter home for them and sit and talk with them in order to comfort them. She treated the whole person, which is a key metaparadigm of the nursing profession.

The third metaparadigm of the nursing profession is the environment. Florence Nightingale made tremendous strides in improving the environment within hospital wards. She increased the light, air flow, and provided better meals. However, she also demonstrated concern for the environment of the community by her participation in the development of public works to help promote health and sanitation in the city.

The fourth metaparadigm is the principle of nursing itself. Florence Nightingale promoted the concept of health through not only her daily practice within the professional scope, but also she worked to make the nursing profession a respected field of study. She insisted that her nursing students remain upright citizens of the community both in and out of the work setting. Only those with dedication and a true desire were allowed to remain in the school and continue their profession. This key concept still drives those that choose the nursing profession today.

Although these metaparadigms are the ultimate abstraction of the concepts of nursing practice, Florence Nightingale was able to put them into practice on a macro level. The work of Florence Nightingale exemplifies how these concepts can become guiding concepts that result in real changes for personal and public health. They demonstrate how the nurse can affect real changes on the health status of the community in which they live.

Nightingale's theory was unified through the idea that a nurse's training could not be separated from their spiritual and moral development. Her theory of learning emphasized practical skills. It can be summarized in the following quote.

"Observation tell how the patient is; reflection tells what is to be done; training tells how it is to be done. Training and experience are, of course, necessary to teach us, too, how to observe, how to think, what to think. (Nightingale, 1882, in Atwell, 1998).

This statement guided Nightingale nursing training and formed the core of her nursing theories. Nightingale emphasize teaching the nurse to learn how to learn. She did not believe that training stopped after the nurse finished her schooling. She saw nursing as a never-ending process of acquiring knowledge and putting it into practice.

Not surprisingly, this metaparadigm led to her protest against the registration of nurses after they received their training (Atwell, 1998). She felt that after they attained their registered status that they would discontinue the nursing practice. Nightingale's major theory was based on the idea of continual improvement, one that still drives the nursing profession today. Nurses of today depend on Nightingale's model of continual learning and improvement as the basis for professional development.

Education and continual improvement were the major paradigms of Nightingale's theories. All of the other concepts and methods had to meet these two tests and standards. Nightingale emphasized education both inside and outside of the hospital setting. She sponsored educational workhouses for the poor (Atwell, 1998). Nightingale believed in treating everyone as equals, not matter what their station in life happened to be. Humanitarianism was the first, and most important overriding tenet of Nightingale's theory throughout her life.

Nightingale philosophy is laced with elements of her profound devotion to God and her "calling" into the life and works. She had a very real interaction with God and elements of her beliefs can be found throughout her writings. She had a Protestant work ethic and was inclusive of all people, not only the wealthy and upper society (Shaner, 2006).

Seven Assumptions

Seven key assumptions served as the basis for model development and theory. These are known as the 7 Nightingale Philosophical Assumptions and are still the key tenets that form the foundation of the Nightingale nursing school. The following will examine these assumptions and their connections to her theory and practice.

1. Natural Laws. Nightingale believed in the presence of natural laws that control and govern how the world works. She also believed that these laws could be defined through experience and statistical analysis (Shaner, 2006). This key assumption was the foundation of her concepts regarding scientific discovery and methodology. Statistics served as part of her observation and theoretical development process.

2. Mankind can achieve perfection. Nightingale believed that each person was the master of their own destiny. She believed in the concept of self-determination, self-realization, and that every human seeks perfection in his or her own way. She believed that the journey to self-determination is through self-perfection (Shaner, 2006). In the area of health care, this translates into seeking perfect health. This philosophy closely resembles the Unitarian philosophy of her childhood and represents her worldview.

3. Nursing is a calling. Nightingale believed that God called everyone to do a service and that they should perform that service with enthusiasm and seek perfection in their endeavors. She saw nursing as a religious act that should be pleasing to God (Shaner, 2006). She expected all of her students to pursue the field of nursing with the same enthusiasm that she did every single day.

4. Nursing is an art and a science. She believed that nursing would be practiced by educated persons and was not menial labor of the lower classes. She believed in using the most current scientifically derived knowledge, as well as a sense of compassion and common logic. (Shaner, 2006).

5. Nursing is achieved through environmental alteration. Nightingale saw the nurse as a facilitator of natural processes within the patient. The nurse's job was to create the proper environment for nature to take its course (Shaner, 2006).

6. Nursing requires a specific educational base. Nightingales' concept of education for nurses is an extension of her philosophies of educating women in general (Shaner, 2006). She believed that the education of nurses should blend theory and clinical experience (Shaner, 2006). This tenet of Nightingale nursing theory was influenced by growing up in a household where the father supported and facilitated education for women. This ideal was against the ideals of society at the time, but it is more accepted now.

7. Nursing is separate from medicine. The final assumption of Nightingale's theory is that nursing should not be viewed as subservient to medicine, but rather that they existed as distinctly different branches (Shaner, 2006). The two are distinguished by their purpose and focus. The focus of nursing is caring through alteration of the environment, whereas the focus of medicine is to cure disease (Shaner, 2006).

These assumptions underlie all of the specific theories of Nightingale in regards to the nursing practice. These seven assumptions demonstrate the degree with which Nightingale's nursing theory was interconnected with her religion and life philosophy. For Florence Nightingale, nursing theory and life purpose were not separate. They both sought to exist in a state of balanced perfection.

Nightingale's Key Theories

Nightingales' key theories are stated much more simply than their application in daily practice would suggest. To visualize Nightingale's theory, one could see the environment as the roof. Anything else could be seen as either an internal or external part of that environment. The environment is defined as anything that assists in placing the individual in the best possible condition for nature to act (Shaner, 2006).

Internal conditions that influence the person's ability to heal are food, water, and medications. External elements are ventilation, light, noise control, stimulation, and room temperature. Of these, ventilation was stressed as the most important, above all other environmental conditions (Shaner, 2006).

The following figure illustrates the key theoretical concepts of Nightingale's theories.

Nightingale differentiated between personal health and public health. She saw individual health as the individual needing nursing care (Shaner, 2006). She saw societal health as the groups result of individual health. She felt that improvement in health of the individual led to healthier families, which in turn improved the health of society (Shaner, 2006). This can be viewed as the first formal public health theory. Florence Nightingale often saw the bigger picture and although the concepts were applied on the individual level, she saw the larger results of these individual acts. Her sights were always set on more than what was right in front of her. She saw her work and benefiting the greater good, in addition to the individual patients that she helped on a daily basis.

Nightingale developed the six D's of Disease. This principle was based on the need to improve the environment of the patient in six key areas. The six D's can been seen as external environmental factors that can be modified by the nurse (Shaner, 2006).. The six D's of Disease are:

1. Dirt. Dirt refers to conditions of general hygiene. This concept extends to the person, the home and interpersonal contact among people.

2. Drink. Nightingale knew that clean drinking water was essential to health. She worked with the public works department to institute measures to improve the drinking water on a community level.

3. Diet. Nightingale saw the necessity of a proper and balanced diet. She insisted on this basic necessity in her nursing wards. This was one of the first changes that she made in hospitals during the Crimean War.

4. Damp. The need for a dry, warm environment was seen as an essential for preventing disease. She learned this through observation and reflection.

5. Draughts. Nightingale believed that draughts could lead to a disease condition.

6. Drains. Nightingale insisted on the need for proper drainage and sewage systems. She observed that where these were absent, disease ran rampant. This was another project of her public works projects.

Now it would be easy to see these six D's as simplistic. However, one must consider that in some developing nations these basic conditions do not exist. In these areas disease runs rampant, for the very reasons that Nightingale outlined. It is easy to take these things for granted in developed nations, but one must remember that in Nightingale's time, these conditions were not always available. Now, one could not imagine living without these basic necessities.

Model Development and Relationships

Nightingale's seven philosophical assumptions and theory of nursing were the basis for the development of her model of the nursing profession. Her model was based on the relationships between these different elements. The importance of the environment in the prevention of disease formed the unifying concept of all of the other elements. Nightingale felt that ventilation was the most important of all of the other elements.

The individual elements of Nightingale's theories were all considered important. She insisted that all of them be adhered to in order to prevent disease. If only one element were out of place, she felt that a disease condition could exist. She saw the importance of every element of the patient's environment as essential to the prevention of disease. The combination of these elements created the best atmosphere for the prevention of disease and to allow nature to take its course.

Nightingale believed that nature had the ability to heal the body, but only if it were in an environment that allowed it to do so. She believed in striving for perfection in everything that God commanded her to do. Therefore, she believed that it was essential to provide for the optimum environment for the healing of the body. The interrelationships of the various elements of the theory cannot be dismissed, as they are consistent with the ability to Nightingale to see how the individual elements add up to the whole. She saw each element in relationship to the whole environment of the patient and their ability to heal. Nightingale's ability to see the entire picture and still distinguish the individual elements was the key to the adoption of a unified theory of nursing.

Critique of Nightingale's Theory

The theories and concepts of Florence Nightingale's theory formed the basis of her daily practice and the practices that were taught in her school of nursing. Marriner-Tomey and Alligood (2002) classified the major nursing theorists into two general categories, The first are the philosophical theorists. They included Nightingale, Wiedenbach, Henderson, Abdellah, Hall, Watson, and Benner. Others were classified as conceptual models or "grand" theories. These included Orem, Levine, Rogers, Johnson, Roy, Neuman, King, & Roper.

One of the key critiques of Nightingale's theory according the Marriner-Tomey and Alligood (2002). is that it is too general. It provides an excellent overview of the problem, but does not focus on detail or specific actions. This makes its usage limited as a framework to be used for study. This criticism is consistent with Nightingale's general style of writing. She tended to see the big picture and where it fit within the whole of the concept.

Mariner-Tomey and Alligood's criticism is easy to understand if one only bothers to read the major theories themselves. It if true that Nightingale did not give specific examples or illustrate her writings with specific examples that could be used in the field. However, one must remember that Nightingale believed that nursing training was a combination of theory and clinical practice. She did not believe that the concepts could be studied properly through the use of books.

Nightingale did not intend for her works to be stand-alone textbook that one could use to learn to be a nurse. She used her theoretical works to teach the general philosophy of nursing, as Marriner-Tomey and Alligood contend, but one cannot learn a profession based on philosophy alone. To learn an intended profession, one must find a mentor that will take them through the processes of the daily routines. Nightingale intended for her theories to be general and to introduce the concepts that formed the basis of her theories. However, she did not intend for them to be used as a replacement for clinical instruction.

Marriner-Tomey and Alligood's classification of Nightingale's theories as philosophical are correct. However, this is was intentional on the part of Nightingale. This cannot be viewed as a flaw in the theory that renders them useless, but rather as an integral part of the theory. Nightingale's philosophy was contained in her formal theory, but she demonstrated the practical application of it to her students every day in her practice. They learned how to apply the philosophy through specific actions by the careful tutelage of their instructor, rather than through reading it from a book.

Marriner-tomey and Alligood's critique of Nightingale's theory is objective, but it does not consider the purpose that Nightingale had in mind when she wrote it. Marriner-Tomey and Alligood were searching for theories that could be applied on a daily basis in the nursing practice. They were searching for those that provided detailed instruction in the nursing profession. They ignored the original purpose of Nightingale's theory and applied their own criteria to it. They also failed to acknowledge how Nightingale's theory influenced others that followed with more specific theories that could be put into daily practice. Marriner-Tomey and Alligood's critique of Nightingale's theory is accurate, but not fair in the context in which Nightingale wrote her works.

Application of Nightingale's Theory

Marriner-Tomey and Alligood did not feel that Nightingale's theories could be applied in a practical manner to the field of nursing. However, one finds the remnants of Nightingale's theories in many hospital settings and in a variety of clinical applications. One of the most prevalent applications of Nightingale's theories is in the field of nursing education. Nursing schools continue to emphasize a balance between theory and practice.

Clinical nursing remains one of the most important elements of the nursing profession. A recent study found that nursing students often experience stress during clinical portions of their training, This study contends that education, the provision of mentors and mindfulness training is a key in reducing stress during clinical training (Moscaritiolo, 2009). Another study investigated how to teach critical thinking among RN to BSN student participating in a human patient simulation (Rush, Dyches, & Wakdrop, 2008). Patient simulator sessions are essential in learning to apply critical thinking skills learned in the classroom (Ravert, 2008). These techniques are in traditional Nightingale fashion, combining theoretical classroom learning with practical application.

Reflective journaling is still a part of the nursing training for modern nurses (Lasater & Nielsen, 2009). This study is an exact emulation of Nightingale's concept of observation and reflection as the key to continual learning in the nursing. These studies demonstrate that Nightingale's model of combining classroom theory with clinical practice are still the foundation of nursing education today. Only, now students can use technology and simulators to practice before they apply what they have learned to live patients, a convenience that early Nightingale students did not have.

Nightingale's research methods of observation and statistical analysis are still very much in use today. They are now considered a standard element of research in almost any field. They have been refined since the time of Nightingale, but the essential elements of observation and statistical analysis are still alive and well in almost any field of science into which one wishes to explore. These steps became permanently ingrained in the field of empirical research and scientific method.

Evidence-based nursing is a direct result of Nightingale's concepts of applying only concepts that could be observed and tested to patient care. Now it would be considered incompetent and completely unacceptable to do anything in the nursing field that is not evidence based. Everyday, nurses hear the term evidence-based and never stop to think about how this concept originated with Florence Nightingale's introduction of the scientific method into the nursing profession.

The field of nursing has become much more technologically-based than it was in Nightingale's time. However, one can still find remnants of the concept that nursing is a much an art as a science. The nurse must use their creativity to apply evidence-based practices to help the patient regain a state of health. A recent academic article highlights the need to apply evidence-based techniques in the education of nurses (Emerson & Records, 2008). This article contends that nursing education practice should strive to, "challenge each of us to reach higher levels of excellence in the practice of nursing education" (Emerson & records, 2008). This quote is almost verbatim Nightingale's concept of continual improvement and striving for perfection.

One only needs to go to a modern hospital to see evidence of how Nightingale's concepts regarding the environment have influenced modern hospital design. However, many of these elements are no longer solely in the hands of the nurses. They are an integral part of the design of the hospital. Hospitals are designed with aesthetics and the need to make the patient feel comfortable in mind. Hospitals still provide for the basic needs identified by Nightingale in her seven assumptions and six D's of disease. Many of her concepts have worked their way into mainstream public health and are things that we take for granted, such as clean drinking water or an appropriate sewer system. The technical aspects of these elements have become complex, and nurses are no longer the ones that provide those things to the patient, but they all developed from Florence Nightingale's original theory and practice.

The concept of cleanliness has developed into sterility and modern sanitation methods. However, their roots were in the concepts of Florence Nightingale's original work. The hospitals of Florence Nightingale's time were primitive compared to modern standards. The medical profession was just beginning to understand the disease process and the importance of germs in the development of disease. Even though the modern hospital is much more advanced and we now have things such as surgical masks and anti-bacterial soap, the basic concepts regarding dirt and conditions that promote disease are still intact.

Many remember Nightingale for her improvements in clinical practice and in education. However, many forget that she was an administrator and made many changes that still hold true today. (Henry, Woods, & Nagelkerk, 1990). Nightingale reminds us to handle conflict skillfully and not to take actions that jeopardize the established relationships and hierarchies. However, she believed in placing the needs of the patient first, regardless of the wishes of administration.

Her concepts about administration can be better studied through her actions rather than by her writings. She often had radical ideas and at times had to oppose authority for the sake of her patients. She never did so in a manner that made the other person defensive. She worked within the established social hierarchy so that those in power did not oppose her new and radical concepts.

Applying the Concepts

Florence Nightingale's theories were general and philosophical. Although, they hold much truth in them, it is often difficult to determine how to apply them in daily clinical practice. The following will examine a case study and will apply Nightingale's techniques to the situation for the best outcome of the patient and hospital.

In this case, a nurse is caring for an 82-year-old woman who has been hospitalized several weeks due to burns sustained on her lower legs during a cooking accident. She had lived alone and has no surviving family. Her support system consists of others that live in her neighborhood, also elderly. Most of them are unable to visit frequently due to a lack of transportation. One of the neighbors is caring for the pet Yorkshire terrier.

The lady begs to see her Yorkshire terrier at the hospital. She complains that none of the other nurses has listened to her requests. She begins to cry and tells the nurse that they have never been separated. The early morning report indicated that nurses were concerned about the well-being of this patient. She has been eating little and seems depressed. The following will discuss the specific interventions that should be taken according to Nightingale's principals.