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Nightingale’s environmental model relates to two concepts: that of the environment and its effects on health. Her assumption was that sick individuals, by nature, will be invariably healed if they are well-supported such that all their energy will be spent in healing. Without a balance in the environment, the sick person increasingly becomes stressed and needlessly, expends energy to cope with the stress where this energy should have otherwise been used to deal with the pathology for the person to return to his/her normal or a better state of health. However, the environment acts influence not only on the sick but also on the healthy people so that the effects of an unbalanced environment can itself cause sickness.

The environment model identifies elements of the environment which impact on well-being and the capacity to attain wellness. These are ventilation, room temperature, sanitation, lighting, waste disposal systems, noise, nutrition, beddings, water quality and personal hygiene. Additionally, nursing care directly influences the environment where nurses are expected to ensure that care is of high-quality, continuous and consistent across caregivers. In addition to manipulating the environment, important components of nursing include communicating in order to promote psychosocial wellbeing, truth-telling when providing information, as well as making observations to monitor changes in health status.

Nightingale emphasizes the need to use data in nursing. Sources of data are the patients as subjective and observations of the nurse as objective. The nurse must possess the particular skills to ask the right questions and to make comprehensive observations. In obtaining subjective data, questions need to be framed in order to obtain accurate information about symptoms of disease, patient problems, the extent of these problems and the contributing factors. A diagnosis of the patient’s responses to the environment is based on data obtained during assessment. To ensure petty management or continuity of care, a plan must be formulated which will guide all nurses working with the patient regarding individual needs and the appropriate nursing actions. Interventions are geared to change all aspects of the environment to decrease discomfort and stress. Patient preferences are considered whenever it is possible. Meeting the basic needs or/and increasing patient comfort optimizes the body’s capacity to regain health. In this manner, the environmental model is patient centered and holistic. At the core is the patient-environment interaction. The art of nursing lies in nurses’ ability to manage effectively this interaction. Aspects of the environment may elicit detrimental responses in individuals but nurses can counter the negative impact of the environment to restore harmony, making the environment supportive to the movement from sickness to health.

Application to the Medical-Surgical Setting

The application of the environmental theory is broad since environment essentially plays a role in every clinical setting. However, the significance of modifying the environment as one of the main components of nursing intervention is greater in some areas over others. Specific patient conditions may predispose them to respond to the effects of the environment in more acute ways so that if unmanaged, aspects of the environment can lead to significantly poorer outcomes. The medical-surgical ward is one setting where this is documented. The patient population in this setting is composed of post-operative patients, persons experiencing exacerbations of chronic illnesses, patients with acute conditions and oncology patients. Medical-surgical nurses then need to know how the elements in the environment outlined in the Nightingale’s environmental model affect patient outcomes and how nursing care can be improved to address these issues. Each element of the environment is listed below and possible indicators reflecting quality of care and the adequacy or inadequacy of practice are provided. Obtaining information on these indicators specifies aspects of the environment that need to be manipulated in more or better ways. Across all elements, patient comfort levels are a common indicator.

Table 1. Environmental Elements and Quality of Care Indicators




Incidence of airborne nosocomial infections

Room Temperature

Thermoregulation in postoperative patients cases of hypothermia and dehydration

Sanitation/Waste Disposal

Rates of nosocomial infections transmitted through contact such as MRSA; incidence of wound infections


Stress levels, number of hours and quality of sleep


Energy level of patients, weight/BMI, nutritional deficits, rate of surgical wound healing


Development of pressure sores in patients with significant immobility (e.g. post-CVA, patients with paralysis, severe cancer-related cachexia); worsening of current pressure sores

Water quality

Rates of water-borne infections especially in patients with chemotherapy-induced immunosuppression

Personal hygiene

Skin and oral mucosa integrity problems (e.g. pressure ulcers, mouth sores), dental health, rates of postsurgical infection

In the process of effectively implementing a plan to incorporate the environmental model into practice, there is a need to obtain data which will serve as the basis of conclusions, and a principle advocated by Florence Nightingale herself. Moreover, current nursing knowledge needs to be assessed. Training needs assessment can be done by formulating a survey questionnaire about staff nurses’ awareness of the theory, if they include patient environment and patient responses to the environment in their assessment, whether they include environment-related interventions during planning and implementation, and patient observation as well as interviewing skills. Data obtained will shape both content and strategy, i.e. lectures, discussion groups, practical demonstrations or training, of in-service education that will be provided.

Using an evidence-based framework, practice must be assessed in terms of each element of the environment that has to be addressed. To determine adequacy of current practices, the indicators must be measured to quantify the impact of accepted practices and determine the practice gaps that needs to be addressed. Clinical audits are useful methods to gather the needed information. For example, the rate of pressure ulcer development in patients with physical immobility who otherwise did not have evidence of this during admission is obtained. If rates are unacceptable, standards and evidence from literature regarding the pathophysiology and environmental factors facilitating pressure ulcer development are obtained. The range of environment-related strategies and interventions employed as documented in studies is noted as well. Then, policies and protocols are examined to determine specific targets of change.

Henceforth, innovations consistent with the environmental model and appropriate to the specific medical-surgical context are adopted. Therefore, policies are modified and protocols are redesigned to incorporate the selected innovations. These become the components of a change project that will be implemented in the workplace utilizing the principles and theories of organizational management. Education does not only focus on theoretical knowledge deficits, but also on the translation of theory into practice such as to address nosocomial infection, patient comfort and wound care. The outcomes should show that nurses are more aware of the impact of the environment, incorporate the environment and patient responses in assessment, and utilize environmental modification as part of their nursing interventions.

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