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✅ Discussion:The basic
story of Florence Nightingale is familiar to most nurses. This week we learned
more about Nightingale’s life and work. Select at least one piece of the
Nightingale legacy that was new to you and tell us how this changed your
understanding of this great woman and her contributions to nursing.Please feel free to use any or all of the enclosed references. The only required reference is from Judd & Sitzman.…ReferencesBiography
of Florence Nightingale. (2019). Retrieved from…Judd, D.
and Sitzman, K. (2014) A History of American Nursing: Trends and Eras. Jones
and Bartlett Learning. Burlington, MA.McDonald,
L. (2014). Florence Nightingale, statistics and the Crimean War. Journal of the Royal Statistical Society:
Series A (Statistics in Society), 177(3), 569–586.…Zborowsky,
T. (2014). The Legacy of Florence Nightingale’s Environmental Theory: Nursing
Research Focusing on the Impact of Healthcare Environments. Health Environments Research & Design
Journal (HERD) (Vendome Group LLC), 7(4), 19–34.…


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The Legacy of Florence Nightingale’s
Environmental Theory:
Nursing Research Focusing on the
Impact of Healthcare Environments
Terri Zborowsky, PhD, EDAC
OBJECTIVE: The purpose of this paper is to explore nursing research
that is focused on the impact of healthcare environments and that has
resonance with the aspects of Florence Nightingale’s environmental
BACKGROUND: Nurses have a unique ability to apply their observational
skills to understand the role of the designed environment to enable healing in their patients. This affords nurses the opportunity to engage in
research studies that have immediate impact on the act of nursing.
METHODS: Descriptive statistics were performed on 67 healthcare
design-related research articles from 25 nursing journals to discover the
topical areas of interest of nursing research today. Data were also analyzed to reveal the research designs, research methods, and research
settings. These data are part of an ongoing study.
AUTHOR AFFILIATIONS: Terri Zborowsky is a Research Associate at The
Center for Health Design; a Principal at Zborowsky Healthcare Design Consulting; and Research Chair at the Nursing Institute for Healthcare Design.
CORRESPONDING AUTHOR: Terri Zborowsky, [email protected];
(651) 724-0081.
RESULTS: Descriptive statistics reveal that topics and settings most frequently cited are in keeping with the current healthcare foci of patient
care quality and safety in acute and intensive care environments.
Research designs and methods most frequently cited are in keeping with
the early progression of a knowledge area.
CONCLUSIONS: A few assertions can be made as a result of this study.
First, education is important to continue the knowledge development in
this area. Second, multiple method research studies should continue
to be considered as important to healthcare research. Finally, bedside
nurses are in the best position possible to begin to help us all, through
research, understand how the design environment impacts patients during the act of nursing.
KEYWORDS: Evidence-based design, literature review, nursing
ACKNOWLEDGMENTS: Part of the funding for the article review process was
provided by The Center for Health Design.
PREFERRED CITATION: Zborowsky, T. (2014). The legacy of Florence Nightingale’s environmental theory: Nursing research focusing on the impact of
healthcare environments. Health Environments Research & Design Journal,
7(4), 19–34.
SUMMER 2014 • VOL. 7 NO. 4, pp. 19–34
lorence Nightingale was one of the first nurses to document the impact
of the built environment on patients. In addition to writing about sanitation, infection rates, and ventilation, Nightingale understood that environmental aspects such as color, noise, and light, along with the nurse’s presence,
significantly contributed to health outcomes. Dossey (2005) has summarized
Nightingale’s comments on the defects of hospital construction that compromised health, including:

Arrangement of the bed along the dead wall and more than two rows of
beds between the opposite windows.

Defective means of natural ventilation and warming; windows only on
one side, or a closed corridor connecting the wards.

Defective height of wards and excessive width of wards between the
opposite windows.

Defective ward furniture.

Defective hospital kitchens and laundries.

Defective condition of water closets.

Defects of sewerage.

Use of absorbent materials for walls and ceilings, and poor washing of
hospital floors.

Selection of bad sites and bad local climates for hospitals and erecting of
hospitals in towns.

Defective accommodation for nursing and discipline.
It is clear that Nightingale was well aware of the impact the built environment
had on patients—she knew this from direct observation. In fact, all of her assertions were from her acute observations of patient or community outcomes and
their surroundings. Nightingale’s environmental theory can be viewed as a systems model that focuses on the “client” in the center, surrounded by aspects of
the environment all in balance. If one element is out of balance, then the client
is stressed, and it is up to the nurse to do what is needed to bring back balance to
the client’s surrounding environment to relieve the stress (Lobo, 2011).
Nurses have been the primary caregivers of the sick, infirmed, and the injured.
While doctors and allied practitioners assist in patient diagnosis and treatment,
nurses have always been at the bedside of the patient, delivering the care prescribed, whether the care is provided in an infirmary, hospital, or in the patient’s
home. Since Nightingales’ documentation of her “bedside’ experiences, the role
of the nurse has evolved and changed. Nursing has evolved from a vocation to
a professional career. Nurses today can be educated in a variety of specialties.
Nurse practitioners diagnose and treat their own patients. Nurses play an important role in healthcare leadership as Chief Nursing Officers or Chief Executive
Officers, often putting in place the policies needed to provide quality patient
care. Other nurses specialize in research, both in academia as well as in clinical
settings. Yet today nurses remain the most likely of healthcare professionals to be
at the patient’s side delivering the care needed. It is in the very act of nursing that
an intimate relationship is created, one that puts the nurse in a unique position.
Similar to Nightingale, nurses today see the influence of the surrounding environment on the patient’s ability to heal. This makes nurses uniquely able to apply
their observation skills to understanding the role of the designed environment
to enable healing in their patients. These types of observations afford nurses the
opportunity to contribute greatly to this growing body of knowledge.
The purpose of this article is to explore the role that nurses have played in the
development of research studies that resonate with aspects of Nightingale’s environmental theory. The particular aspects of interest are those from the built
or ambient environment, termed the “designed environment” for this article.
Nightingale (1860) listed these aspects as:






This article uses data from an ongoing study to explore these and other variables of interest in current nursing research journals. To provide context for
this research, a brief review of nurses in healthcare design and related literature
is included. This article also includes recommendations to advance a research
agenda for bedside nurses.
Few government healthcare reports have garnered public attention like the Institute of Medicine’s To Err Is Human: Building a Safer Healthcare System (2000).
The report was a comprehensive look at medical errors and the quality of healthcare in the U.S. and as a result disclosed the failure of this healthcare system
to protect the very people it should, its patients. The disclosures in the report
shocked many in the public realm, but to those who worked in the system, many
of them nurses, it served as an acknowledgement of issues of which they were
already aware. However, nurses understood assigning blame on human error
alone was not going to solve the larger systemic issues healthcare organizations
faced (Tri-Council of Nurses, 2000). As with most dark clouds, however, there
was a silver lining. The report sparked a series of follow-up reports that explored
the problems underlying the dismal statistics and provided solutions. For nurses
this meant discussions would focus on understanding how their work environment, as part of the larger system, affected the quality of patient care.
In both the original To Err Is Human report and the subsequent report, Crossing the Quality Chasm: A New Health System for the 21st Century (Institute of
Medicine, 2001), the overall concept of nurses’ work environment was discussed
SUMMER 2014 • VOL. 7 NO. 4, pp. 19–34
as it related directly to patient safety and quality care. However, not until the
2004 report, Keeping Patients Safe: Transforming the Work Environment of Nurses
(Institute of Medicine, 2004) were the various parts unravelled and the physical aspects of nurses work environment discussed in depth. Chapter 6, “Work
and Workspace Design to Prevent and Mitigate Errors” dealt specifically with
the “evidence on the design of nurses’ work hours, work processes, and workspaces, primarily as they relate to patient safety, but also with respect to efficiency” (IOM, 2004, p. 227). After a thorough review of nursing work issues such
as medication errors, fatigue, hand washing, distractions, supply management,
acuity adaptable patient rooms among other issues, several recommendations
were made, including:

Nursing leadership should be provided with resources that enable them
to design the nursing work environment and care processes to reduce
errors, and should concentrate on errors associated with:
— Surveillance of patient health status.
— Patient transfers and other patient hand-offs.
— Complex patient care processes.
— Non-value added activities performed by nurses, such as locating and
obtaining supplies, looking for personnel, completing redundant and
unnecessary documentation, and compensating for poor communication systems.

Hand washing and medication administration should be addressed
(IOM, 2004, p. 13).
Chapter 6 and the recommendations revealed an important fact: Physical aspects
of nurses’ work environment significantly impact their ability to perform their
job and, as a result, impact patient care outcomes. Keeping Patients Safe revealed
how using quality improvement tools such as Lean or Six Sigma could help redesign these work environments to decrease the chances of error and increase value
added time for the nurse. Nurses’ time is better spent at the bedside, providing
the care and education needed to improve patient outcomes.
Sadly, 10 years later, many of the same problems remain. Nurses face an increasingly complex patient population with diminishing resources available to them.
When building projects are underway and the opportunity exists to engage
nurses in the design and planning of these work environments, rarely is this
opportunity to make the changes so badly needed utilized. As Gregory (2009)
noted in her editorial, “Nobody Asked Me: Why Nurses Should Take an Interest in Workplace Design,” nurses have not been asked to be at the table during
the design process. As a result of the disconnect she witnessed, Gregory helped
launch the Nursing Institute for Healthcare Design (NIHD) with the vision
to help educate and empower nurses to bring their “bedside” knowledge to the
table when the opportunity to design their workspaces occurs. “We challenge
nurses to learn about what other nurses are doing to influence hospital design,
to research design trends, and to speak up, using their experience and problem-solving skills to improve their work surroundings” (Gregory, 2009, p. 11).
Within healthcare systems, nurses remain strong advocates for their patients and
family members; they remain at their bedside providing the care that is needed,
and they remain ever vigilant, observing and documenting what they see, hear,
and feel. In 2010, the Robert Wood Johnson Foundation (RWJF) published
“Addressing the Quality and Safety Gap—Part III: The Impact of the Built
Environment on Patient Outcomes and the Role of Nurses in Designing Health
Care Facilities” (Robert Wood Johnson Foundation, 2010). It noted, “[N]urses
at all levels and in every setting have a critical role to play on multidisciplinary
teams charged with assessing, planning, and designing new and replacement
facilities” (p. 1). The report goes on to discuss the role of research findings, specifically evidence-based design (EBD), to provide the framework from which to
make design decisions during the design process. This is particularly true when
considering the importance of integrating architecture, information technology,
clinical processes, and workplace culture. What this document did so well was
to highlight how nurses can explore the aspects of the designed environment
that affect the quality of patient care and safety. As noted by Kerm Henriksen,
PhD, the human factors advisor for patient safety at the Agency for Healthcare
Research and Quality, “Nursing is the backbone for what goes on in hospitals.
Nurses have a lot of practical knowledge and can help identify design threats to
patient safety and quality of care” (RWJF, 2010, p. 2).
Figure 1. Aligning Infrastructure, Leadership, and Processes: A Multidisciplinary Model.
Leadership and
s ea
ar c
r ch
Strategic Goals:
Improved Patient,
Staff, and Resource
Clinical and
Source: Adapted from Evidence-Based Design: Application in the Military Health System,
E. Malone, J. R. Mann-Dooks, & J. Strauss (Noblis, 2007, p. 12). Used with permission.
SUMMER 2014 • VOL. 7 NO. 4, pp. 19–34
Malone, Mann-Dooks, and Strauss (2010) presented a framework for understanding how healthcare leaders can solve clinical problems utilizing research in
the process. Malone, herself a nurse and former CEO and commander emeritus
of DeWitt Army Community Hospital at Fort Belvoir, noted that coordination
in this area is often missing. “[W]e have these wonderful stovepipes of innovation but very little integration because architects, IT experts, and clinicians tend
to work in separate silos.” (Malone, Mann-Dooks, & Strauss, 2010, p. 3). Their
model provides a conceptual framework to examine the interplay among physical, technological, and human factors, as well as the need for more multidisciplinary research.
Finally, Lamb and Zimring (2010) offered some pedagogical solutions. Together,
with a group of educators from around the country, they identified interprofessional competencies for systems integrators—leaders capable of bringing together experts from different disciplines, including nursing. “The real challenge is to
integrate knowledge from different professional disciplines to create better and
safer health care environments.” (Lamb & Zimring, 2010, p. 8). Six domains were
identified for teaching:
1. Science of healthcare design—applying and extending evidence-based
2. Healthcare systems and environments—describing and influencing the
context in which services are planned, delivered, and evaluated;
3. Patient- and family-centered care—engaging patients in their own care
and mobilizing and leveraging support systems;
4. Teamwork—facilitating collaboration and communication among different stakeholders;
5. Professional cultures—identifying and capitalizing on expertise of
designers, architects, engineers, clinicians, and so on; and
6. Innovation—thinking creatively to solve problems.
In March 2014, RWJF published “Ten Years After Keeping Patients Safe: Have
Nurses’ Work Environments Been Transformed?” This paper revisited some of
the recommendations in the Institute of Medicine’s report for averting harm,
highlighting both progress and persistent gaps in transforming nurses’ work
environments, and showcased research, policies, and tools with the potential
to advance this transformation. This RWJF document fell short, however, in
addressing the role of the built environment in helping to overcome the quality
gap. The discussion about improving nurse work environments should be focused
on people, process, and place as interrelated concepts. Kreitzer and Zborowsky
(2009) used these concepts to explore the creation of “Optimal Healing Environments.” Examining the relationship between people and process is not enough;
the designed environment must be included in the discussion. Previous literature reviews in this field of knowledge have stressed the impact that the designed
environment has on staff efficacy, satisfaction, and safety, as well as patient outcomes, including physiological, behavioral, and psychological (Rubin, Owens,
& Golden, 1998; Ulrich, Zimring, Quan, Joseph, & Choudhary, 2004; Ulrich
et al., 2008). It is time to look more closely at the legacy of Nightingale and the
role nurses have played in conducting nursing research, studies that reveal the
impact of the designed environment on their patients and on the act of nursing.
Nurse Research on the Impact of Healthcare Environments
Outside of Florence Nightingale’s work, there is little documentation of the role
nurse researchers might play in this knowledge domain, although it is clear that
nurses have been publishing research on the impact of the design environment
on nurses’ ability to conduct their work safely and efficiently, as well as on patient
outcomes. In the past, nurses may not have had the design vocabulary to explain
their studies within the healthcare design domain. These two knowledge areas,
healthcare and health design, had not frequently crossed paths. It was not until
the Institute of Medicine’s initial healthcare quality report (1999) that nursing
researchers and others started to rigorously explore all aspects of healthcare—
people, process, and place—for help in understanding how to fix the quality gap.
Bedside nurses were on the frontlines of the discussion. Not just observers of
this phenomena, they were actors as well. They were, in essence, studying their
own experiences—how the designed environment impacted their patients and
enabled them to provide the very best care. Nurses feel the effects of a lack of
proper air temperature. They see the work-arounds created because of poor spatial adjacencies and they understand how it feels to make patient decisions while
standing in a corridor that might have decibel level peaks similar to a freeway.
Many nurses observed these effects, but it was only through conducting research
that they were able to explore how to make needed change.
Nursing journals have been around since the early 20th century. The American
Journal of Nursing, first published in 1900, is still in print. These journals have
served to document the research and opinions of nurses through the years. At
some point, articles began to examine the role of the designed environment in
care delivery. Many articles published in this genre through the years appear to
be quality improvement strategies. So what can we learn from further examination of these studies? What might this research offer to us as practitioners
of nursing and/or design? What might the research tell us about Nightingale’s
environmental theory—is it relevant today? The rest of this article will explore
answers to these questions. Using a literature review approach, it will identify
how variables in Nightingale’s environmental theory are explained or explored
in studies published in nursing journals. The literature review below examines
selected nursing journals. It is part of a larger study to be published at a …
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