Nightingale’s Philosophy in Nursing Practice
Kim Bolton
I use the word nursing for want of a better. It has been limited to signify little more than the administration of medicine and application of poultices. It ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet—all at the least expense of vital power to the patient.
History and Background
Nightingale was born in 1820 in Florence, Italy. Her parents were very wealthy and often traveled abroad. Nightingale was beautiful and was expected to behave like every other Victorian lady, filling her time before marriage with music, reading, embroidery, and learning how to be the perfect hostess (Brown, 1988).
Nightingale had other ideas. She had felt different from those around her even at a young age, and by the time she was 17, believed she was called by God into His service (Woodham-Smith, 1951). She had great compassion and sympathy for people of all types, and as she grew older, she believed she had been called to help mankind. She desired to help the truly poor but suffered in silence for years because it was improper for someone of her upbringing to involve herself with actual physical work (Brown, 1988).
At the age of 24, Nightingale decided she needed to help the suffering masses and wished to work in a hospital. This was met with opposition from her family, and they fought about it for years before finally allowing her to go to Kaiserworth, Germany, to learn nursing from the Institution of Deaconesses (Brown, 1988; Woodham-Smith, 1951). She studied there for 3 months and then returned to the service of her family. It was another 2 years before she was allowed to practice nursing (Brown, 1988; Woodham-Smith, 1951).
She developed what we have come to refer to as her nursing theory after her travel to Scutari to care for wounded soldiers during the Crimean War. Her writings, which included philosophy and directives, were developed from a need to define nursing and reform hospital environments rather than for the purpose of providing nursing new knowledge. Nightingale worked endlessly during her lifetime to introduce many types of reform, in areas as diverse as the British military and the environment of England (Brown, 1988; Woodham-Smith, 1951). Because of her work in nursing and nursing education, she is known as the founder of modern nursing (Dennis & Prescott, 1985; Henry, Woods, & Nagelkerk, 1990). She started a school of nursing at St. Thomas Hospital in England and wrote many manuscripts about hospital reform and nursing care (Brown, 1988; Woodham-Smith, 1951). Nightingale (1969) clarified that “nursing knowledge is distinct from medical knowledge” (p. 3).
Overview of Nightingale’s Environmental Philosophy
Nightingale’s philosophy is environmentally oriented. This is evidenced by her many writings and her book Notes on Nursing: What It Is and What It Is Not (Nightingale, 1969). She believed that the environment of the patient should be altered to allow nature to act on the patient (McKenna, 1997; Nightingale, 1969). Her work focuses mostly on the patient and the environment but also includes the nurse and health. For instance, it was the nurse’s duty to alter the patient’s environment so that nature could act on the patient and repair health. The components of Nightingale’s philosophy, which is now recognized as theory in this theory era, are the following:
• Environment: Environment can be defined as anything that can be manipulated to place a patient in the best possible condition for nature to act (Selanders, 1998). This theory has both physical and psychological components. The physical components of the environment refer to ventilation, warmth, light, nutrition, medicine, stimulation, room temperature, and activity (Lobo, 2011; Nightingale, 1969; Reed & Zurakowski, 1996; Selanders, 1998). The psychological components include avoiding chattering hopes and advices and providing variety (Lobo, 2011; Nightingale, 1969).
• Person: Although most of Nightingale’s writings refer to the person as the one who is receiving care, she did believe that the person is a dynamic and complex being. Reed and Zurakowski (1996) state, “Nightingale envisioned the person as comprising physical, intellectual, emotional, social, and spiritual components” (p. 33).
• Health: Nightingale (1954b) wrote, “Health is not only to be well, but to be able to use well every power we have” (p. 357). From this statement we can infer that she believed in prevention and health promotion in addition to nursing patients from illness to health.
• Nursing: Nightingale believed nursing to be a spiritual calling. Nurses were to assist nature that was healing the patient (Chinn & Kramer, 2011; Nightingale, 1969; Reed & Zurakowski, 1996; Selanders, 1998). She defined different types of nursing as nursing proper (nursing the sick), general nursing (health promotion), and midwifery nursing(Reed & Zurakowski, 1996; Selanders, 1998). Nightingale saw nursing as the “science of environmental management” (Whall, 1996, p. 23). Nurses were to use common sense, observation, and ingenuity to allow nature to effectively repair the patient (Pfettscher, 2010).
Although the model seems linear, it has been observed that the nurse initiates mutuality of care and outcome between the nurse and the patient (Selanders, 1998). Nightingale assumed that the patient wanted to be healthy and would cooperate with and assist the nurse to allow nature to help the patient (Pfettscher, 2010). Using Nightingale’s philosophy in practice today fits well with the use of the nursing process. The nurse assesses the patient situation, identifies a need, implements a plan of care, reevaluates the situation, and finally changes the plan to better serve the patient. This is done as often as necessary until the main goal of nursing (improved health state) is accomplished. At each phase of the process, documentation occurs to allow other caregivers to follow the plan of care (Selanders, 1998).
Critical Thinking Using Nightingale’s Theoretical Philosophy
The term critical thinking was not in use in Nightingale’s day; however, she expected nurses to use their powers of observation in caring for patients. In her book Notes on Nursing: What It Is and What It Is Not (1969), she developed a whole section on observation of the sick. She wanted her nurses “to be clear thinkers and independent in their judgments” (Reed & Zurakowski, 1996, p. 47). She advocated for nurses to have educational backgrounds and knowledge that were different from those of physicians (Nightingale, 1969; Reed & Zurakowski, 1996; Selanders, 1998). She believed in and rallied for nursing education to be a combination of clinical experience and classroom learning. Nightingale states, “Neither can [nursing] be taught by lectures or by books, though these are valuable accessories, if used as such; otherwise what is in the book stays in the book” (Nightingale, 1954b, p. 355).
Using critical thinking for the application of Nightingale’s environmental theory requires use of her 13 canons (Selanders, 1998) and the nursing process. Table 5-1 illustrates the interaction of the nurse and the patient with the use of Nightingale’s environmental theory.
TABLE 5-1
Critical Thinking with Nightingale’s Theory
| Nightingale’s Canons (Nightingale, 1969; Selanders, 1998) | Nursing Process and Thought |
| Ventilation and warmth | Assess the client’s body temperature, room temperature, and room for fresh air (or adequate ventilation) and foul odors. Develop a plan to keep the room airy and free of odor while maintaining the client’s body temperature. |
| Light | Assess the room for adequate light. Sunlight works best. Develop and implement adequate light in the client’s room without placing the client in direct light. |
| Cleanliness of rooms and walls | Assess the room for dampness, darkness, and dust or mildew. Keep the room free from dust, dirt, mildew, and dampness. |
| Health of houses | Assess the surrounding environment for pure air, pure water, drainage, cleanliness, and light. Examples include removing garbage or garments from the area, removing any standing water (or ensuring that water drains away from the area), and ensuring that air and water are clean and free from odor and that there is plenty of light. |
| Noise | Assess the noise level in the client’s room and surrounding area. Attempt to keep noise level to a minimum, and refrain from whispering outside the door. |
| Bed and bedding | Assess the bed and bedding for dampness, wrinkles, and soiling, and check the bed for height. Keep the bed dry, wrinkle-free, and at the lowest height to ensure the client’s comfort. |
| Personal cleanliness | Attempt to keep the client dry and clean at all times. Frequent assessment of the client’s skin is needed to maintain adequate skin moisture. |
| Variety | Attempt to stimulate variety in the room and with the client. This is accomplished with cards, flowers, pictures, books, or puzzles. Encourage friends and relatives to engage the client in some sort of stimulating conversation. |
| Chattering hopes and advices | Avoid talking without reason or giving advice that is without fact. Continue to talk to the client as a person, and continue to stimulate the client’s mind. Avoid personal talk. |
| Taking food | Assess the diet of the client. Take note of the amount of food and drink ingested by the client at every meal or snack. |
| What food | Continue with the assessment of the diet to include type of food and drink the client likes or dislikes. Attempt to ensure that the client always has some food or drink available that he or she enjoys. |
| Petty management | Petty management ensures continuity of care. Documentation of the plan of care and all evaluation will ensure others give the same care to the client in your absence. |
| Observation of the sick | Observe everything about your client. Record all observations. Observations should be factual and not merely opinions. Continue to observe the client’s surrounding environment, and make alterations in the plan of care when needed. |
Although the 13 canons are central to Nightingale’s theory, they are not all-inclusive. She believed that the person was a holistic individual and thus had a spiritual dimension. She believed nursing was a spiritual calling, and with that belief she assumed that nurses could help those clients who were in spiritual distress (Nightingale, 1954a, 1969). This is an assumption because of the time period in which Nightingale lived; it was expected that Christians would help other Christians. She identified nursing of the sick (nursing proper) and nursing of the well (nursing general) (Nightingale, 1969). She believed the two to be almost identical, with the outcome being the major difference.
Because Nightingale believed in nursing well persons—or health promotion—it is logical that she assumed her nurses would complete some health teaching as they were caring for the sick or for those who were already well. The use of Nightingale’s theory, the 13 canons, as well as health promotion and spiritual distress is illustrated in the following two case applications.
