Florence Nightingale was a leader in nursing whose writings led to the foundation of many of our current nursing philosophies

Nursing Science Quarterly 26(3) 211 –219 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0894318413489255 nsq.sagepub.com

Theoretical Concerns

The first influential thinker to delineate nursing values and beliefs, Florence Nightingale based her writings on a mosaic of influences. Nightingale did not distill her philosophical beliefs into a theory, yet rudimentary elements of a grand theory emerge from her writings. The author of this article extracted her philosophical beliefs that ground the environ- mental theory from her letters, writings, and biographies.

Florence Nightingale was deeply rooted in spirituality and profoundly practical, so spiritual pragmatism pervades her ontological foundations (Attewell, 1998), as evidenced by her statements: “Education is to teach men not to know, but to do” (Nightingale, 1873a, p. 576); “The way to live with God is to live with ideals, not merely to think about ide- als, but to do and suffer for them” (Cook, 1913, p. 175). Her call from God at the age of 16 launched a lifelong pursuit of these ideals (Bostridge, 2008).

Nightingale lived in a time of class distinctions so embed- ded in the social fabric that they seemed impenetrable. While she viewed the world from her privileged class, she recog- nized and acted to redress human suffering. She found a way to reconcile her class distinction with her calling to serve those suffering, even if the actions posed a risk to her. She followed her impulse to put things right wherever she could, using her considerable resources to devise better environ- ments to foster health. She was impatient with disorder, often tackling multiple projects simultaneously to restore order (Bostridge, 2008).

Early Theoretical Foundations—1820-1836

A child of keen intelligence and insatiable curiosity, Nightingale was gifted with a classical education from her wealthy father, whose Cambridge education instilled ideas

about improving society. By the time she was a teen, she was fluent in six languages and had mastered complex mathemat- ics (Bostridge, 2008). A voracious reader, she studied phi- losophy, challenging her to think broadly about bold ideas that were discussed openly with many influential visitors (Slater, 1994). Her propensity to correspond was legendary; she wrote some 13,000 letters (Bostridge, 2008). Since the Nightingales traveled in a wide social orbit, she was exposed to political and social leaders. As she observed her father and grandfather influencing decision makers, she learned the art of political persuasion (Bostridge, 2008). She assumed the genteel presence of a society lady, yet ached to break out of constraining societal expectations (Nelson & Rafferty, 2010).

The Nightingales were devout Unitarians, so Florence’s character was embedded with Unitarian ideals of respect for human dignity and a call to enlightened conscience through intellectual reason. Newly authorized, Unitarianism was spurred by ideas of personal liberty emanating from the French Revolution (McDonald, 2010). Called muscular Christians, Unitarians were committed to put religious con- victions into action to improve lives. They embraced scien- tific advances such as geology, astronomy, and statistics. They pursued social justice (Attewell, 1998). Nightingale’s maternal grandfather, William Smith, lived out the Unitarian call for social justice by serving four decades as a humanitar- ian Member of Parliament, where he campaigned to abolish the slave trade long before the American Civil War. Unitarians

489255NSQXXX10.1177/0894318413489255Nursing Science QuarterlyHegge research-article2013

1Distinguished Professor, South Dakota State University

Contributing Editor: Sandra Schmidt Bunkers, RN, PhD, FAAN, Professor of Nursing, South Dakota State University, 1119 Plum Creek Road, Sioux Falls, South Dakota 57105. Email: [email protected]

Nightingale’s Environmental Theory

Margaret Hegge, RN; PhD; FAAN1

Abstract This author extracts the environmental theory from Florence Nightingale’s writings and recorded experiences. As Nightingale’s experiences broadened to other cultures and circumstances, she generated an ever-widening commitment to redress unjust social policies imperiling human health. She mobilized collaborators, shaped public awareness, and championed the cause of those suffering as a result of unjust policies. Nightingale challenged nurses to create environments where population health is a realistic expectation.

Keywords environmental theory, Nightingale, suffering

212 Nursing Science Quarterly 26(3)

pursued ideals of respect for all people, regardless of class. Unitarian belief in a wise, benevolent God instilled in Nightingale the courage to initiate bold social reforms (McDonald, 2010). Florence Nightingale’s personal attri- butes gave rise to her environmental theory. (See Table 1.)

Awakening of Social Consciousness—1830-1850

Wealthy families provided charity for villagers through an unwritten expectation of Noblesse Oblige (Nelson & Rafferty, 2010). Nightingale complied with these obligations by teaching children (Attewell, 1998). She accompanied her mother on home visits to the poor, distributing goods to sup- plement their meager existence (Slater, 1994). As a teen, she went beyond obligation to find new ways to improve the lives of villagers. She ventured into overcrowded villages, observing the ravages of poverty and suffering among refu- gees from the Irish potato famine (Bostridge, 2008). She visited workhouses, appalled at the deplorable conditions of desperate people who were essentially punished for their plight (Attewell, 1998). Each of these observations left an indelible stain on her conscience as she contrasted them with her own pampered status. Throughout her life, she pursued social reform of education, housing, and workhouses (Cook, 1913). When she perceived a call from God at the age of 16 to serve others, these images of deprivation and squalid liv- ing conditions were already embedded in her consciousness (Bostridge, 2008). The moral imperative to alleviate suffer- ing of those in peril was a persistent theme of Nightingale’s early letters. The seeds of an environmental theory had already taken root.

Nightingale’s beliefs about human beings crystallized during her formative years. She thought each individual had worth and dignity and could play an active role in restoring his own vitality (Nightingale, 1860). She clung to the Unitarian beliefs about people that “within human nature is a

revelation of eternal existence, eternal progress for human nature” (Cook, 1913, p. 235). Nightingale observed that peo- ple were inseparable from their physical environments, either flourishing or deteriorating in relation to their living condi- tions. Epidemics were rampant in turbulent environments of filth and overcrowding. Nightingale deduced that people liv- ing in environmental degradation were in peril. The prevail- ing miasma theory explained this, as sickness occurred where foul odors and noxious fumes concentrated (Nelson & Rafferty, 2010). Nightingale observed that forces of nature could ameliorate these fumes. Light, ventilation, and clean water could be used to convert unhealthy environments into habitats where people could flourish (Nightingale, 1860).

As Nightingale explored the root causes of disease, she became convinced that filthy water, rancid food, and raw sewage were the reservoirs of illness (Bostridge, 2008). She dug deeper to ask hard questions about why impoverished people lived in such squalor imperiling their health. This line of inquiry led her to social policies contributing to unem- ployment and substandard housing. Nightingale looked beyond housing to unjust social policies as the root causes of illness among the impoverished. Social justice, aligned with her Unitarian beliefs, became the overriding centrality of her life. She was compelled to take action to correct injustice. “I think one’s feelings waste themselves in words. They ought all to be distilled into actions which bring results” (Cook, 1913, p. 94). The origins of Nightingale’s ideology are dis- played in Table 2.

Nightingale believed that the health of suffering villagers was imperiled by a turbulent environment caused by unjust social policies. Her conjecture was that nature could be har- nessed to foster health through reconfiguring the environ- ment. (See Figure 1.)

First Glimpse of Nursing—1851

Nightingale resisted the call to become a nurse for several years due to harsh parental disapproval. Caring for the sick carried a stigma of unclean menial labor not suitable for soci- ety ladies (Nelson & Rafferty, 2010). Despite parental oppo- sition, Nightingale entered Deaconess Training at the German Kaiserswerth Institute, where she studied for 3

Table 1. Nightingale’s personal attributes fueling environmental theory (developed by Hegge, 2012).

Florence Nightingale Displayed •• Keen Intelligence •• Insatiable Curiosity •• Ability to Reason with Mathematical Precision •• A Voracious Appetite for Reading •• Prodigious Letter Writing •• Courage to Take Risks •• Impatience with Environmental Turbulence •• Consummate Planning and Organizational Skills •• A Propensity to Record and Analyze Observations •• Ability to Tackle Many Issues At Once •• Restless Struggle to Escape Constraints on Victorian Women •• Political Acumen to Influence Decision Makers •• Sensitivity to Suffering of Others •• A Commitment to Follow a Call from God to Serve Others

Table 2. Origins of Nightingale’s Ideology (developed by Hegge, 2012).

Classical Education (Tutoring by Father) Noblesse Oblige (Instilled by Mother) Spiritually Driven Pragmatism (Unitarianism) Social Justice (Unitarianism) Noble Human Dignity (Unitarianism) Humanitarianism (Maternal Grandfather, MP) Political Influence (Parents’ Social Circle) Scientific Advances (Statistics) Population Health (Irish refugees, workhouse tenants)

Hegge 213

months under Lutheran Pastor Theodor Fliedner (Bostridge, 2008). Here a spiritual community brought women together to address social problems by caring for orphans, the sick, the poor, and those in crisis. This experience was the crucible in which her ideology was distilled and launched to serve suffering people. She learned to solve everyday problems to make life better for them. This spiritual pragmatism grounded her theory in reality (Attewell, 1998). “So never lose an opportunity of urging a practical beginning, however small, for it is wonderful how often in such matters the mustard- seed germinates and roots itself “ (Vallee, 2007, p. 390). Nightingale was cognizant that individuals were in peril because of unjust social policies that endangered their lives, such as unemployment, desperation, filthy living conditions, and oppression.

Nightingale flourished within an organized system of care that brought environmental turbulence under control. Kaiserswerth Hospital was a transition environment for those needing assistance to regain vitality or pass peacefully into the afterlife. She realized that nature heals, so she found ways to harness the power of nature to foster healing. The first ideas of altering the environment to promote healing emerged. Her definition of environment coalesced during this time: it was “the proper use of fresh air, light, warmth, cleanliness, quiet and the proper selection and administration of diet, all at least expense of vital power to the patient” (Nightingale, 1860, p. 3).

Nightingale’s definition of nursing emerged as “Nature alone cures . . . and what nursing has to do in either case, is to put the patient in the best condition for nature to act upon him” (Nightingale, 1859, p. 1). Later she expanded this defi- nition as follows: “Nursing is putting us in the best possible conditions for nature to restore or to preserve health—to pre- vent or to cure disease or injury” (Chambers & Chambers, 1893, p. 806). She believed nursing was to assist nature’s reparative process so that vitality could be restored (Nightingale, 1860).

Nightingale was intuitively drawn to the bedside of suf- fering patients, providing comfort in those sacred moments of deep intimacy. Such authentic exchanges often needed no words but conveyed meaning to both nurse and patient. Comfort was the nursing fulfillment of her spiritual impera- tive to serve (McDonald, 2010). “The very alphabet of a nurse is to be able to interpret every change which comes over a patient’s countenance without causing him the exer- tion of saying what he feels” (Nightingale, 1860, p. 196). Her definition of health also began to emerge at that time: “Health is not only to be well, but to use well every power we have” (Nightingale, 1893, p. 186). Fliedner believed strongly in an afterlife and so encouraged nurses to assist the dying to pass peacefully to eternity (Bostridge, 2008). A peaceful death became an integral component of Nightingale’s definition of health. The ontology of Nightingale’s environmental theory appears in Table 3.

Figure 1. Nightingale observes impoverished immigrants in slums, Hungary 1840’s.

214 Nursing Science Quarterly 26(3)

Figure 2 portrays nursing as Nightingale experienced the practice at Kaiserswerth Institute, interfacing with individu- als in peril within a transition environment where elements of nature were applied to foster health. The overriding influ- ence of unjust social policies was acknowledged as a root cause of suffering.

Environmental Theory with Women—1852-1853

Nightingale returned to England to begin nursing as the Superintendent of the Establishment for Gentlewomen in Harley Street, a position for which she received no remu- neration (Selanders & Crane, 2010). These Gentlewomen patients were unmarried women making a living as govern- esses, cooks, servants, or prostitutes. Because no welfare system provided for them when they were ill, this charitable Establishment was funded by wealthy patrons who spon- sored ill women whom they deemed worthy (Selanders & Crane, 2010). The Establishment was a transition environ- ment for women to regain health or pass away peacefully.

One of Nightingale’s first hurdles was challenging a dis- criminatory policy of admitting only women of Anglican faith. Threatening to resign, she insisted that those of any reli- gion (or none at all) would be welcome and treated with respect (Selanders, Lake, & Crane, 2012). The governing body relented, so she had successfully challenged an unjust social policy. She was unapologetic about overturning poli- cies to ensure respectful care for all women. This brave stance set off bursts of opposition from patrons. “Let whoever is in charge keep this simple question in her head, not how can I always do the right thing myself, but, how can I provide for this right thing to be always done” (Nightingale, 1860, p. 24).

Nightingale realized the prevailing social conventions that placed these women in subservient, demeaning roles, trapping them in lives of poverty and deprivation. Her care for these women was grounded in a profound respect for their dignity and well-being (Selanders, Lake, & Crane, 2012). Her definition of health expanded to include the reparative process of restoring vitality and function (Selanders & Crane, 2010). She noted that the women’s internal environment shaped the healing process. Those determined to recover usually did so, whereas those

drowning in suffering deteriorated. She cautioned against giving patients false hope when recovery was not possible. She advised nurses to sit quietly with patients, providing comfort to ignite the hope that they needed to regain vitality or pass into a peaceful death (Nightingale, 1860).

Nightingale found ways to configure the environment to promote healing (Selanders, Lake, & Crane, 2012). Creating an organized system of care, she provided hot water to all floors, installed a dumb waiter for efficient meal delivery, brought color and artwork into the wards, inaugurated com- munal dining in a pleasant parlor, and bought reading mate- rial for the women (Nelson and Rafferty, 2010; Selanders & Crane, 2010). She applied nature’s remedies from herb gar- dens and kitchens (Bostridge, 2008). Her seven tenets framed her reforms: light, ventilation, warmth, bed and bedding, quiet, cleanliness, and food (Nightingale, 1860). She person- ally comforted the women in their recovery or peaceful death (Selanders & Crane, 2010).

Nightingale realized that working-class women needed education to become competent nurses, so she began design- ing educational elements that would later be used in the Nightingale School of Nursing (McDonald, 2009). She instilled the ability to harness the healing powers of nature and a love of learning. “Nursing is above all, a progressive calling. . . . Year by year, nurses are called upon to do more and better than they have done” (McDonald, 2009, p. 749).

Nightingale taught nurses the importance of observation and recording, adding these two essential components to her definition of nursing. She expected “a nurse who is at once a careful observer and a clear reporter” (Nightingale, 1860, p. 95). “The most important practical lesson that can be given to nurses is to teach them what to observe, how to observe, what symptoms indicate improvement and what the reverse” (Nightingale, 1860, p. 105).

Nightingale differentiated nursing from household man- agement, hiring laundresses, cooks, and cleaners so nurses could concentrate on patient care (Bostridge, 2008). She challenged an unjust social policy by providing a previously prohibited role for middle-class women to earn a living through nursing. For the first time, women were working for women in an establishment serving women. This unprece- dented control over nursing and education of women gained her a reputation as a formidable manager (Attewell, 1998). Her environmental theory had been initiated and refined. While running the Establishment, she began to codify her beliefs about nursing, forming the scaffolding for books and nursing school curricula (Selanders, et al., 2012). Figure 3 depicts Nightingale’s design of the Harley Street Establishment for nursing of women. Suffering women in peril were cared for within a transition environment where an organized system of care employed elements of nature to foster health. Nightingale acknowledged and addressed the unjust social policies that kept these women in peril and cre- ated avenues for them to rectify their situations through edu- cation. (See Figure 3)

Table 3. Ontology of Nightingale’s environmental theory (developed by Hegge, 2012).

Each Person Has Dignity and Worth The Person and Environment Are Inherently Linked Individuals find Meaning in Life by Using their Powers Fully Individuals find Meaning in Suffering and Death Each Individual has Power to Heal Her/Himself The Healing Power of Nature can be Harnessed Alteration of the Environment Fosters Health Whatever Imperils Human Health Must be Challenged

Hegge 215

Figure 2. Nightingale at Kaiserswerth Institute, 1851.

Figure 3. Nightingale, Superintendent of Institute for Gentlewomen in Distressed Circumstances, Harley Street, 1853.

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The Environmental Theory in War and Suffering—1854-1856

Now a prominent figure, Nightingale was asked by the Secretary of War, Sir Sidney Herbert, to organize a nursing brigade to care for wounded soldiers at Scutari (Cook, 1913). This was a pivotal moment, an irreversible turn, and a step into the perilous unknown. Directing her considerable intel- lect and organizational powers to this venture, she brought 38 ladies of good breeding to the Crimean War in Turkey in October 1854 (Cook, 1913). Since no women had been to a military outpost, medical officers resented their intrusion. She immersed herself in the Scutari barracks with an unmatched ferocity. Undaunted by a turbulent, chaotic envi- ronment with virtually no organized system, she set about to build an infrastructure to support care, including a laundry, a kitchen, and a rebuilt barracks (Attewell, 1998). She attacked the vermin-infested barracks with a frenzy of cleaning. She ordered, inventoried, and deployed provisions as this func- tion was being hindered by massive red tape (Cook, 1913). A woman challenging a male-dominated military system was alarmingly unprecedented. Opposition became overtly hos- tile as she mobilized resources in England to provide funding and supplies to support care. Nightingale dealt with opposi- tion and outright rejection with resolve and persistence. She would not be dissuaded from her mission. A skilled tactician, she enlisted partners, experts, donors, political allies, elected officials, consultants, and advisors to keep her informed and supported (Bostridge, 2008).

Nightingale was profoundly disturbed by the human suf- fering of war, attributing these atrocities to unjust social poli- cies. War was an isolating experience for poorly trained young soldiers far from home. Lives were broken by the car- nage of war as the insidious erosion of hope settled like fog over Scutari. Traumatized soldiers were displaced, maimed and dying for a cause with no defensible justification in her opinion. “I stand at the altar of murdered men and while I live, I fight their cause” (Woodham-Smith, 1951, p. 181). Although despair threatened to overtake her, she persisted to initiate reforms in rapid succession to improve care of sol- diers. She did not allow inner turmoil to envelope her. She challenged military and medical ineptitude that endangered soldiers’ health, for which she was maligned both at Scutari and in

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