Part of the genius of Florence Nightingale was to design nursing as the agent to manage the environment of patients. Her text, Nofes on Nursing,* views the environment as all that is external to patients and discusses multiple ways in which to make the environment more healthful. Nightingale saw the nurse as being in charge of all of the activities on a unit, even permitting the entrance of any and all persons. Essentially, the nurse in Nightingale's schema was to design, maintain, manage, and control the environment. The nurse was in charge of the unit, and by extension the patient, 24 hours a day, 7 days a week. This "pan-authority" gives the nurse great power even today. It is amazing that we as nurses do not exercise more of this power over the environment and thus over patient care. Rather than focusing on the 30 minutes that the physician is with the patient, nurses need to think about how to design a more therapeutic environment for the other 231A hours of the day.
"Nursing therapeutics" thus needs to take into account all aspects of the mental/emotional environment of patients as well as the physical environment. Temperatures of patients are often taken at 5:00 AM, for example, when we know a subnormal reading is likely and that the elderly patient will arise hours before breakfast. Blood pressures and blood sugars are also low at this hour and falls may be more likely.
The emotional environment in hospitals is also unhealthy for elders. The impersonal quickened pace, the constant public address system, the sparse number of personal objects that would trigger location in time and space, and the dizzying number of persons who enter and leave the room often unannounced and uncaring, occur over the entire 24-hour period. Even in relatively physically well elders, confusion occurs when they are exposed to such an environment. It reminds one of the childhood game in which one was blindfolded, spun around, and then asked to identify objects in the room. Intensive care units are even more mentally unhealthy for elders with an impeded day/night cycle and strict control over family visitors.
The environment has come to be regarded as being of great importance to society in general, as can be seen by the discussion of the greenhouse effect and of soil contamination. But at either extreme of life, the environment is especially important; children and older adults are vulnerable to environmental effects and nursing, therefore, has the greatest responsibility for these populations.
A mentally healthy environment also contains other elements in Nightingale's view: communing with nature on a daily basis by providing a view or walk in the outside world, low-level or at least nonabrasive noise, and worry-free situations, as well as control of disturbances, such as laboratory specimen taking. The fostering of hope can be as simple as a plan for a pleasant afternoon for someone with terminal cancer. This seemingly simple attitude on the part of nurses can assist elders to adjust to the vicissitude of hospital life.
Research into the aspects of air travel has supported many of these environmental concerns with the recent modifications of sleeping and eating schedules as one travels across time zones. Research in hospitals and nursing homes regarding the need for privacy, degrees of closeness, and so forth is also needed to maintain the orientation of elders as well as their mental health. The dehumanizing of the environment and the related pandemic depression in nursing homes should be addressed. Nightingale had a vision that nursing therapeutics, or the actions taken by nurses to promote health, would be focused on the control of the environment; we need to recapture this vision today if our health-care system itself is not to be "toxic" to elders.
- 1. Nightingale F. Notes On Nursing: What it is and What it is not. New York: Dover. (Original published 1859).