Nursing theory of environmentally safe healthcare and emancipatory knowledge

Environmental Theory and Emancipatory Knowledge of Knowing -- Nightengale's Nursing Theory

Introduction- Modern nursing is a rewarding, but challenging, career choice. The modern nurse's role is not limited only to assist the doctor in procedures, however. Instead, the contemporary nursing professional takes on a partnership role with both the doctor and patient as advocate caregiver, teacher, researcher, counselor, and case manager. The caregiver role includes those activities that assist the client physically, mentally, and emotionally, while still preserving the client's dignity. In order for a nurse to be an effective caregiver, the patient must be treated in a holistic manner. Within the subject of nursing, there are often times in which different aspects of the practice must be analyzed by using primary research from other scholars. Nursing scholarship is vital to the profession, as we have seen, in order for the modern nurse to remain current with scholarship and practice. Case histories, for instance, provide a way to examine different aspects of nursing theory with tangible, tactical solutions, as well as strategic intellectual repartee' (Alligood, 2009, intro. In order for a nurse to be an effective caregiver, the patient must be treated in a holistic manner. This view, of course, was not always the case. In fact, it took a single nurse -- operating against all odds during a time period in which women's opinions were not valued, to change the overall paradigm of nursing. That woman was Florence Nightingale.

Nightingale the visionary - Patient advocacy is another role that the modern nurse assumes when providing quality care. However, this is not a new paradigm or approach to nursing, but rather one in which there is a long historical tradition dating back to the late 19th century and ideals of Florence Nightingale, through the interpersonal advocacy model of Hildegard Peplau, and finally, epitomized and continually advocated by Jean Watson. Advocacy is the active support of an important cause, supporting others, or speaking on behalf of those who cannot speak for the elves (Kozier, Erb, & Blais, 1997). It is interesting to note, as well, that it was Nightingale's theories that formed the basis of modern nursing advocacy, the theory of the environment, and indeed, most of modern nursing practice.

Perhaps the most famous public nursing icon is Florence Nightingale, who loved from 1820 to 1910 and became famous for her patient advocacy during the Crimean War and influence on nursing practices during the American Civil War. In essence, Nightingale was the first nursing theorist, and perhaps because of her background in statistics, was able to objectively define the scientific problem and develop a program based on empirical training (Rehmeyer, 2008).

Florence was born into an upper class family, yet that did not stop her from using her education to address what she believed were some critical social and public health ills of the time. When she arrived at a British run hospital in Turkey during the Crimean War, she was appalled at the abject misery and chaos she observed. The wounded lay next to each other, many bleeding or septic. There was little fresh air; food and water were in short supply, and fewer basic medical supplies like bandages, iodine, and morphine. This all changed by the time she left Turkey after the war ended in July 1856. Most of the field hospitals were well-run, efficient, and fully stocked with mortality rates actually no greater than those in England at the time. However laudable this was, though, it was her diligent and continued efforts, her tireless lobbying, and her passion for her cause that she used her statistical knowledge to compile vast tables of data to show how many people actually died in the war, and in England, where and why. Through statistics, she discovered that in times of peace, soldiers in England had a fifty percent higher mortality rate than those of civilians. Principally, she found that lack of sanitation, inadequate food and supplies, and a basic lack of hygiene contributed to these findings. Some of the fixes were easy; replacing rotten flooring, flushing sewers, removing offal and animal carcasses. What made Nightingale stand out, though, was her willingness to break the protocol of the time and use charts to explain the statistical data, especially to Queen Victoria. Aside from nursing theory, then, one can say that Nightingale was one of the first to use statistics in a way to change health policy (Ibid.).

Besides being a forerunner for modern public health policy, Nightingale was an advocate of women's rights and Christian universalism. The first official nurses' training program, aptly titled the Nightingale School for Nurses, opened in 1860 with the advocacy noted that nurses should work in hospitals, assist the poor, and teach proper hygiene. Florence's ideas that nurses should be patient advocates and outgoing carry through in her theories, as well as basic expectations of nurses from her time forward (Bostridge, 2008).

It was in 1860 as well that Nightingale published her general theory of the nursing profession, Notes on Nursing: What it Is, and What it Is Not. While this is not a theoretical text, at least in the modern sense, Nightingale set down her ideas which have been subsequently translated into a theoretical vision that fits in with modern paradigm of patient care. Essentially, however, Nightingale's views were based on advocating some common sense principles for healthcare in general: ensure that medical conditions were as sanitary as possible in all circumstances; change the environment so it is more healthful for the patient and staff (adequate ventilation, light, warmth, low noise, cleanliness); use the environment of advocacy and caring to increase the recuperative powers of the individual. Certainly, her ideas about preventive medication and holistic health were far advanced for her time, yet as medical care in the 20th century evolved, more and more medical practices used Nightingale as their basic inspiration and standard for palliative care (Gill, 2004).

There are numerous museums, monuments, named hospitals and foundations all surrounding Nightingale. During the Vietnam War, for instance, her work in Crimea inspired a number of Army Nurses, which in turn sparked a renewal of study in her life and work in the general public (McDonald, 2005). Her name remains synonymous with the professionalization of nursing, and of patient advocacy and the importance of the nurse's role within the healthcare paradigm. Her very own commonsensical approach to care is best expressed in the conclusion to her 1860 book:

And what nursing has to do… is to put the patient in the best condition for nature to act upon him… You think fresh air, and quiet and cleanliness extravagant, perhaps dangerous luxuries, which should be given to the patient only when quite convenient, and medicine the sine qua non, the panacea. If I have succeeded in any measure in dispelling this illusion, and in showing what true nursing is, and what it is not, my object will have been answered… (Nightingale, 133).

Biography Early Life - Florence Nightingale, in fact, was the founder of the Nursing Movement, the second born daughter of wealthy landowner William Nightingale, who adopted the name Nightingale to get his inheritance from his uncle Peter Nightingale. Nightingale's father was against slavery, a Unitarian, and a Whig. . Nightingale was born during a trip on May 12, 1820, at villa Colombia, near the Porta Romana, in Florence Italy. Her name, Florence, was given to her after the city (Firenze). In1821, Nightingales family went back to England and settled in her father's home at Derbyshire where her father managed his lead work (Britain unlimited, 2009). Nightingale's mother was a daughter of a wealthy Unitarian family and liberal politician too (McEwens, and Wills, 2011), (Simkin, 2009), (Dossey, 2005). In 1823,Nightingale's family moved to Keynsham court in Presteigne, Herefordshire, and finally, in 1825 they moved again to Embley Park in Wellow, Hampshire.

Education - Nightingale was educated at home by her father, who was a graduate of Cambridge University. Her father taught her French, German, Greek, Italian, Latin, and mathematics. Later on, she became very knowledgeable in statistics, which helped her and others in her statistical planning (Britain unlimited, 2009), (Dossey, 2005-page 24, 66, 67), (McEwen, and Wills, 2011-page 123). In 1837, Nightingale became the "practical mystic" (Dossey, 2005-page 55-59). Nightingale said she was called by God, and started finding her path to a career. She refused to marry Lord Houghton, by whom she was being courted, simply because she wanted to continue with her mystical path. As she travelled to Italy, Egypt, Greece, and Kaiserswerth in Germany she became aware of her duty to the world, therefore she made her own choice and focused on it without paying attention to her parent's interest (Dossey, 2005, 57). That same year Nightingale's family went back to Europe and Nightingale met Mary Clark in Parish. Clark was a popular woman who was well-known to men in the political world. The Nightingale family returned to England in 1839 and Nightingale and her sister were presented to Queen Victoria at her birthday party. Nightingale met a friend Richard Monckton Miles in 1842. Then in 1844, Nightingale asked Dr. Howe if she could do a charitable job in a hospital like the catholic nuns, and refused her marriage to her cousin, Henry Nicholson. By 1845, Nightingale started training herself in the nearby Salisbury Hospital, but her parents were not happy about it, seeing nursing as an inappropriate job for a well to do woman like their daughter. In the next year, Nightingale began teaching herself from the government blue books. In the meantime, Monckton Miles wanted to marry her, but soon she travelled to Rome, Italy with friends to avoid him. (Britain unlimited, 2009). Finally, after she attended the Herbert's Charmouth convalescent home, her knowledge was recognized. In 1849, after refusing finally to Miles proposal, she decided to go to Egypt while accompanying her friends, the Bracebridges. They then travelled through Europe, and ended up at the Kaiserswerth Institution on the Rhine in Germany and Nightingale was asked by Pastor Theodore Fliedner to write a pamphlet about Kaiserswerth. In 1851 Nightingale studied for three months at Kaiserswerth, after her father sent her 500 pound for her studies, later she opened her own nursing establishment Gentlewomen (Dossey, 2005-page 24), (Britain unlimited, 2009),(McEwen, and Wills, 2011, pg.123).

Nightingale became very well versed with public health, hospitals, hospital building and construction, healthcare in general, army medicine, reform, philosophy, and religion in Europe. Being excellent in mathematics, she was able to statistically collect, analyze, and quantify data on many sanitary, hospital or nursing issues and was brilliant, well organized, and the personality type of a perfectionist (Dossey, 2005, pg.24, 76-77).

Work Experience - Nightingale developed her early personal professional experience when she was troubled by the constraints placed on her by her family and society. She wrote in her dairy of 1847-9,

Women are private martyrs. There are private martyrs as well as burnt or drowned ones. Society of course does not know them; and family cannot, because our position to one another is our families is, and must be, like that of Moon to Earth. The Moon revolves around her, moves with her; never leaves her. Yet the earth never sees but one side of her, moves with her, never leaves her. Yet the Earth never sees, but one side of her; the other side remains forever unknown (Selanders, 2005, pg. 65).

After she finished her training at Kaiserswerth, she gained her practical experience, and she was able to formulate her personal professional experience. In 1853, she became the superintendent at the Hospital for the Sick Gentlewomen in Distressed Circumstances, at 1 upper Harley Street, London (Selanders, 2005, pg. 66). As she continued to the build experience during the Crimean war in 1854, the Secretary of War for Great Britain, Mr. Sidney Herbert, asked Nightingale to nurse British soldiers. At Herbert's request, Nightingale took with her thirty-eight skilled nurses to Scutari Army Barracks Hospital in Turkey. Nightingale encountered much opposition from the military physicians. Never the less, that did not stop her from her vision. Nightingale provided care with a statistical proof of reduction of deaths from forty-eight percent to two percent within roughly two years (McEwen, and Wills, 2011, pg.123), (Simkin, 2009). Nightingale found that most of the deaths were likely occurring during the transporting of the patient, and the lack of proper sanitation such as open sewers, cleanliness, lack of air, and good nutrition. Nightingale implemented changes to address these problems. Nightingale became a hero to the troops and the troops wrote songs and poems about her. With the use of her personal knowing, she was called "Lady of the Lamps," as she made rounds, which became a therapeutic relationship with the patients. (Clement, and Averill, 2006, pg. 272). (Wikipedia, 2010). The military physicians opposed her recommendations even though they knew it would benefit the soldiers. Nightingale wrote many notes on the matter affecting health, efficiency of administrator of the British Army using her empirical knowledge she wrote notes that was almost thousands of pages long. She was quoted as saying, "I stand at the altar of the murdered men, and while I live, I shall fight their cause," but she also said "it must never be lost sight of what observation is for"? (Clements, and Averill, 2006, pg. 270). On her third trip to Scutari, she was already the supervisor of all the nurses (McEwen, and Wills, 2011, pg 123), (Dossey, 2005, pg.25). In 1855 a public subscription was raised in Britain to promote her work, unfortunately, Nightingale became very ill with Crimean fever. One year later the war ended, and Nightingale returned to England and she was invited by Queen Victoria and Prince Albert to relate her war experiences. In 1857, the government decided to a royal commission to take care of the disaster of the Crimean war (Britain unlimited, 2009).

Reconstruction of Professional Networks - Nightingale developed her philosophical assumptions, but because she was raised during the Victorian era, women were not considered to work outside their home, because they were too delicate for physical and mental endeavors. For Nightingale, work was considered as a means to an end. First, she took the job at Gentlewomen Hospital, and then accepted the request of the Secretary of State Mr. Herbert. While at her work at Scutari, Nightingale was very concerned with the patient's environment. She believed that a clean environment promotes healing and health. She included information about nursing care, proper building for treating the sick, and administration system (McEwen, and Wills, 2011), (Chin, and Kramer, 2008, pg.56-59). She defined environment as anything that through manipulations assist in putting the individual in the best possible condition for nature to act, this can be found in her Nursing notes (Selanders, 2005, pg. 101). She was concerned about the environment and the portal of transmission of disease in patients and society, which she said could be through dirt, drink, (dirty water), diet, draught, and drains such as stagnant sewages. Mostly she stressed hand washing. She applied all her Emancipatory knowing by defining healthy environment, reflected on her Victorian era of coal burning in the big cities in Great Britain (Selanders, 2005, pg, 110), (McEwen, and Wills, 2011). Ethically, she decided what was right and wrong; especially when hospitals were not allowing nurses to do what she believed was right, physician abuse of nurses, and the belief that nurses were the ones to protect vulnerable patients. She stressed that aesthetics in nursing was made visible through conducts, attitudes, narratives, action, caring with patient's families and colleagues, and person's environments. Through her personal knowing, she noted that nurses must understand and developed one's inner self (Dossey, 2005, pg.50-54).

Nightingale cared about her patients. She would make rounds on her patients at night with a lamp in her hand, (her "Lady of the Lamp" legacy) (McEwen, and Wills, 2011, pg.123), (Muro, 2010), (Wikipedia, 2010). In 1857, the government decided to form a Royal Commission to look into the disaster of the Crimean war. Since women were not allowed to serve on commissions in that era, Nightingale wrote a letter to them instead. (Britain unlimited, 2009). She worked to reform Army Medical Schools and instituted a program of record keeping of government health statistics. When the Sepoy rebellion in India escalated, Nightingale became very concerned about the problem of sanitation. She then assisted with the strategic planning for the public health system in India. At the same time, she was suffering from what would now be called "post-traumatic stress disorder," from her Crimean war experience (Britain unlimited, 2009).

Professional Contributions - She published a book with the title "Notes on Nursing" in1859, and the most notable work of her effort, which was widely remembered, was the St. Thomas School of Nursing, which she founded in1860. Sarah Wardroper was chosen to be the head. Nightingale began living close to the hospital to oversee the hospital's progress. She became the first female to be elected a fellow of the Statistical Society, for using statistics and graphs in nursing (McEwen, and Wills, 2011 page123), (Britain unlimited, 2009). She became a consultant for many nursing infirmaries in England. An example of this was that in December of 1844 a patient by the name of Timothy Daley died from filthiness due to neglect. Nightingale wrote a letter to Mr. Charles Villiers, president of the board of Directors for the Poor. Mr. Farnnall, the metropolitan district inspector was informed, and they came up with a form of inquiry for every workhouse of all the hospital units in London. In 1861 she was asked for nursing advice by the Union forces in the American Civil war, and in 1862 she published her "Observations" about sanitation on India.(Simkin, 2009). In 1867, she worked on rural hygiene especially that of Indian sanitation, then in 1871 she published notes on "Lying in Hospital."? In 1872, the founder of Red Cross, Mr. Henri Dunant, claimed that it was Nightingale's notable work for the public that influenced him to start the Red Cross. In addition to that, the British Nurses Association was founded in 1879. Finally, in 1907 Nightingale received the Order of Merit from King Edward the Seventh, the first time merit was given to a woman (Simkin, 2009). Nightingale worked as a consultant, and a mentor to many nurses and institutions around the world (Dossey, 2005), (Britain unlimited 2009), (McEwen, and Wills, 2011, pg. 125). Nightingale's training school was recognized in other countries, for example, the first schools built in the United States. Bellevue Hospital in New York, New Haven Hospital, in Connecticut and Massachusetts Hospital in Boston were built as the bases for nursing education. (McEwen, and Wills, 2011, pg.125).

Nightingale and the Environment - Nightingale also looked at negatives and positives that are the conditions, which could help make people recover and reach their actual potential, as also noted by Maslow hierarchy of needs. She did not look or speak directly of the disease per se, but rather, looked at air, clean water, environment, and sanitation. She published her book in1860 with the title a "Notes on Nursing: What it Is and What it Is Not," connecting human beings and quality of human life, and comparing the stagnant sewage she saw in Scutari, as well as in London. She wrote, "I have met a strong stream of sewer coming up the back staircase of a grand London house from the sink as I have ever met in Scutari."? This is probably still true to date. She talked about the negative influences such as apprehension, uncertainty, waiting and expectation, and fear of surprise can have on patient. This could be compared to the current waiting in an emergency room not knowing how serious the injury was, or even having any information. The prominent example is that of the patient who died in the Emergency Room at Bellevue Hospital earlier this year while waiting to be seen by a doctor. Her most negative health determinants were stagnant water, second hand smoke, air pollution, isolation, and impoverished conditions. The positive determinants were caring and compassion, healthy literacy, sense of family, nurtured infancy, clean water, and excellent nursing care. (Beck, 2005, pg. 142). From a global health perspective, based on the baseline of Nightingale's health vision, three international charters were ratified. The first to be ratified was the Declaration at Alma Ata in 1978. According to the World Health Organization, this charter focused on the health and mental, emotional, and economic, cultural, and social well-being. The second charter to be ratified was the Ottawa Charter formed in 1986, also focusing on health other than disease. The third charter to be ratified was the Jakarta Declaration on Health Promotion for the 21st Century. This charter also emphasizes on people's empowerment at the individual level first (Beck, 2005-page 146-7).

Nightingale lived and fought her healthcare battles during the Victorian Era, but in reality, she was actually focusing on the future. Nightingale instilled a program of emancipatory knowledge of knowing to her immediate generation and now it is being passed on to our generation so that we may able to practice with the praxis of nursing. In my opinion, Nightingale's beliefs are coming true. I believe that within ten years to come most underdeveloped countries will start living quasi-as the more developed countries do. It is very relevant to nursing that it is time that nurses should able to think outside of the box, that is to say, they can go internationally, and must go beyond following only doctors ' orders. Nurses will soon be able to practice independently, even though many doctors still oppose the idea (Villegas, and Carey, 2010). Nurses spend more time with patients. Nurses do more teaching of primary prevention, health maintenance, wellness, and spend a larger amount of quality time with a patient.

Nursing Theory - Theory is a set of related statements that describe or explains phenomena in a systematic way. A nursing theory refers to a set of logically interrelated concepts, statements, propositions, and definitions, which has been derived from philosophical beliefs of scientific data and from which questions or hypothesis can be deduced, tested, and verified. A theory purports to account for or characterize phenomenon (McEwen, and Wills, 2011, pg.26). A theory serves to uncover relationship that may not be overly apparent to the casual observer and theory development progresses through levels based on available data concerning a theory and its ability to portray conceptual interrelationships, which describe, explain, predict, and prescribe. A theory level begins at the descriptive level (Selanders, 2010).

Modern nursing, in fact, has gone through several stages since Nightingale, all which are directly relevant when discussing theoretical applications to medical models. After Nightingale, there was a new sense and realization that the field of healthcare had to evolve in order to provide the mission of saving lives. Of course, global tragedies in warfare in the late 19th and early 20th century, including World War I contributed to this need. After World War I, and in the 1920s and 1930s, nursing theory emphasized curriculum and education. It was during this time that nurses gained some clinical knowledge, expanded nursing programs, and developed a stricter rubric of training in basic nursing skills, many based on Nightingale's writings. World War II brought new techniques and the necessity of applying new theory to practice, and nursing in the 1940s and 1950s moved into higher education and developed as a scientific discipline. In the 1960s and 1970s, the Vietnam conflict and societal changed moved nursing into even greater heights of academic professionalism. In the 1980s and 1990s, once again nursing changed as it tried to amass almost a century of theoretical ideas into the needs of the contemporary medical profession (Alligood and Tomey, 2002, p. 11).

Nightingale's Nursing Theory -- Nightingale's philosophy is almost completely environmentally oriented. To the modern reader, this seems like common sense, but in her time there was not the sense of correlation between external issues and internal health concepts. Nightingale believed that the environment of the patient under care could, and should, be altered so that positive forces of nature could interact to include both the nurse and patient and provide greater access to health. For instance, it is the nurse's duty to not only care for the patient, but to alter the environment so that it will be more conducive to care (McKenna, 1997).

In fact, it is easiest to break down Nightingale's theory into seven basic components, all of which she believed acted as standards, and were synergistic in their approach. In fact, these stages have become part of the modern way healthcare environments are standardized, as well as ecological engineering considerations. In regard to these maxi, one of her early biographers said, "she was not only 'The Lady with a Lamp,' throwing light into dark places but also a kind of galvanic batter stirring and sometimes shocking the dull and sluggish public to life and action" (Cook, 1942):

Principle/Canon

Nightingale

Contemporary Application

Ventilation and Warming

"Keep the air he breathes as pure as the external air without chilling him" (p. 8)

We know that fresh air invigorates the respiratory system and clears out stale, germ filled air. Extra oxygen also provides benefit to patient.

Noise

"Unnecessary noise, or noise that creates an expectation in the mind is that which hurts a patient" (p. 25)

Benefits of a calm, restful environment, perhaps soft music playing, allows for relaxation and greater sense of calm; reducing blood pressure and allowing patient's body and mind to heal.

Variety

Beauty, colors, flowers, even pets alleviate boredom.

Mind-Body connection

Diet

"Sick cookery should half do the work of your poor patient's weak digestion" (p. 38).

Diet and appropriateness of food for patient's condition are well documented.

Light

"It is the unqualified result of all my experience with the sick that second only to the need of fresh air is their need of light" (p.47).

Fresh air and light allow a cherry disposition for the patient; light contributes to Vitamin D absorption as well.

Chattering Hopes and Advice

Nightingale believed in talking to the patient by being friendly and engaging, but truthful, "Leave off this practice (false hopes) by making light of their danger and exaggerating their probabilities of recovery" (p.54).

Recent studies show that a patient needs to have personal responsibility and knowledge of their condition in order to assist in the healing process.

Cleanliness (Health of Houses)

Attention to cleanliness takes up a large portion of Nightingale's work; she emphasized hygiene even before germ theory was advanced.

We now know more about germs and health and acknowledge that it is vital to keep a hospital or sick room clean.

(Source: Nightingale, 1859, 2010 reprint)

Components of Care - Nightingale in her writings explains what she understood about the health and the art of care and caring which promotes healing and, obviously, leads to wellness. Wellness has to be the whole self, including mental, physical, social, political, and environmental fitness. In doing so, Nightingale meant for us to have the concept of Emancipatory knowledge of knowing, which encompasses the following components: Ethical knowing, Personal knowing, Aesthetic knowing, and Empirical knowing. These concepts function on the four domains. Our focus would be first on the person, which is the patient, who is an individual receiving care. Nightingale conceptualized that improvement of individual families leads to improved health of the society (Selanders, 2010). Secondly, we would focus on the environment. The environment includes everything as an umbrella concept, and those are things such as physical, social, and psychological well-being of the patient. The third thing we would focus on is health. The focus on health is accomplished by maintaining the patient's well-being by using the patient's power, which is consistent with the modern perception of health. Also viewed as a relative means and being the best one at any given point of time (Selanders 2010). The fourth thing we would focus on is maintaining control of the environment we are in (Nightingale, 1898), (Selanders, 2010). This grew out of Nightingale's empirical observations from the Crimean experience of filth, inadequate nutrition, dirty water, and inappropriate sewage, which led to the death of more British soldiers than by battlefield wounds (Selanders, 2010).