Journal Reading (Peplau and the Psychodynamic Nursing)

Remembering Hildegard Peplau
By Richard Lakeman

On the 17th of March 1999, HildegardPeplau died at the age of 89, ending a nursing career, which spanned over fifty years. Peplau is often recognised as the ‘mother of psychiatric nursing’ but her ideas have influenced all fields of nursing. In 1948 Peplau completed her seminal work, ‘Interpersonal Relations in Nursing’. However, it wasn’t published until 1952 because at the time it was too revolutionary for a nurse to publish a book without a medical practitioner as a co-author. This work which has been published in nine languages, has perhaps done more to facilitate the development of nursing from an occupation to a profession than any other. Sills (1998, p.171) described Peplau as “…a woman of uncommon intellect, socialized outside the traditional 1940s model of nursing in the United States, who developed a paradigm of professionalism…. that has permeated every aspect of her long and distinguished career.”

Even if a nurse has never read any of the hundreds of articles or books, which cite and develop Peplau’s ideas, it is likely that she or he, will still have been influenced by them. Peplau suggested that nurses can and do make a difference to people in the context of interpersonal relationships, which have a discernible pattern, predictable phases and during which the nurse assumes roles such as counsellor, leader or teacher.

Some may recognise many of her ideas as being similar to those developed in role theory, cognitive behavioural therapy, symbolic interactionism, or reflecting ‘common sense’. A number of studies suggest that Peplau's theory remains a common frame of reference for most psychiatric nurses (Hirschmann, 1989). Some selected ideas from the works of Peplau (1952, p16) described nursing as "a significant, therapeutic, interpersonal process. It functions co-operatively with other human processes that make health possible for individuals in communities .... Nursing is an educative instrument, a maturing force, that aims to promote forward movement of personality in the direction of creative, constructive, productive, personal and community living". Lack of growth, for whatever reason, implies impaired health in the individual and basic human needs must be met if a healthy state is to be achieved and maintained (Stuart & Sundeen, 1987, p 46).

A number of assumptions are implicit in Peplau's original and latter writings (Forchuk, 1991). For example, the relationship of nurse and patient is influential in the outcome for the patient; People may assume a number of roles and have the capacity for empathy in relationships (Torres, 1986, p 171); People tend to behave in ways which have worked in the past when faced with a crisis (Forchuk, 1991); Anxiety and tension arise from unmet or conflicting needs, and the energy which arises may be harnessed into positive means for defining, understanding and meeting the problem at hand.

The nurse patient relationship is characterised by a number of overlapping phases with a number of therapeutic tasks or goals to be accomplished. During each phase the patient expresses needs which find expression and require intervention in unique ways.

Orientation Phase

The phase of the relationship, when the nurse and patient first meet is known as the orientation phase. This is a time when the patient and nurse come to know each other as people and each other’s expectations and roles are understood. The patient at this time needs to recognise and understand their difficulty and the need for help, be assisted to plan to use the professional services offered, and harness the energy derived from felt needs (Peplau, 1952, p 19). It may be expected that the patient will test limits in order to establish the integrity of the nurse. The tasks of this phase are to build trust, rapport, establish a therapeutic environment, assess the patients strengths and weakness and establish a mode of communication acceptable to both patient and nurse (Shives, 1994, p 91). When the patient can begin to identify problems the relationship progresses to the working phase.

Working Phase

The working phase incorporates the identification and exploitation sub-phases and the relationship may fluctuate back and forth as new problems are identified. During the identification phase trust begins to develop and the patient begins to respond selectively to persons who seem to offer help. The patient begins to identify with the nurse and identify problems, which can be worked on. The meaning behind feelings and behaviour of the nurse and patient are explored. Peplau (1952, p31) states that when a nurse permits patients to express what they feel, and still get all of the nursing that is needed, then patients can undergo illness as an experience that reorients feelings and strengthens positive forces in the personality. The tasks of this phase are to develop clarity about the patient's preconceptions and expectations of nurses and nursing, develop acceptance of each other, explore feelings, identify problems and respond to people who can offer help. In particular the nurse assists in the expression of needs and feelings, assists during stress, shows acceptance and provides information. The nurse and patient may make plans for the future but the implementation of the plan signifies the beginning of the exploitation phase of the working relationship. During the exploitation phase the patient realistically exploits all of the services available to them on the basis of self interest and need (Peplau, 1952, p 37). The nurse assists the patient in their efforts to strike a balance between the needs for dependence and independence. The plan of action is implemented and evaluated. The patient may display a change in manner of communicating, as new skills in interpersonal relationships and problem solving are developed (Forchuk & Brown, 1989, p 32). The nurse continues to assess and assists in meeting new needs as they emerge.

Resolution Phase

The resolution phase involves the gradual freeing from identification with helping persons, and the generation and strengthening of ability to stand alone, eventually leading to the mutual termination of the relationship (Peplau, 1952, p 39). The patient abandons old needs and aspires to new goals. She or he continues to apply new problem solving skills and maintains changes in style of communication and interaction. Resolution includes planning for alternative sources of support, problem prevention, and the patient’s integration of the illness experience.

Roles of the Nurse

The nurse may assume different roles within the relationship. The first role assumed by both the nurse and patient is stranger. This role requires respect and positive interest on the part of the nurse. The nurse may function as a resource person, providing specific answers to questions usually formulated with relation to a larger problem. As teacher the nurse assists the patient as a learner to grow and learn from experience. As leader the nurse may assist the patient as follower in a democratically implemented nursing process (Stuart & Sundeen, 1987, p 46). The nurse may be cast into surrogate roles by patients based on their significant past relationships. Considerable importance is also assigned to the role of the nurse as counsellor which is viewed as helping the patient integrate the facts and feelings associated with an episode of illness into his or her total life experience. Nurses may assume many other roles but in the context of the interpersonal relationship all aim to assist the patient to meet the goals of therapy, need satisfaction and growth (Stuart & Sundeen, 1987, p45).

Communication

Peplau (1952) expanded on a number of concepts drawn from developmental, psychoanalytical and behavioural theory in order to assist the nurse in understanding behaviour. Peplau (1952, p 290) defined communication as an interpersonal process involving the selection of symbols or concepts that go some way towards developing a common understanding. Anxiety is present in all individuals to some degree and is cognitively triggered by real or imagined, internal or external threats to an individuals security (Forchuk, 1991). The ability to empathise with the patient, and self-understanding are necessary requisites of the nurse as therapist. Stuart and Sundeen (1987) describe Peplau's concepts as belonging to a school of thought called the interpersonal view of behavioural deviations which hold that behaviour evolves within the context of interpersonal relations. A common belief within this theory is that by experiencing a healthy relationship with the therapist, the patient can learn to have more satisfying interpersonal relationships in general. Closeness within the relationship is seen as necessary as it builds trust, empathy, enhances self-esteem and fosters growth towards healthy behaviour. The process of therapy involves re-educating the patient in more successful ways of relating.

Nursing’s debt to Peplau

This brief and selective summary cannot do justice to Peplau’s ideas, which have been developed, expanded and put into practice over the last fifty years. It is my hope that more people will continue to access Peplau’s original work, which will highlight that she was primarily a pragmatist rather than an academic theorist. It captures the essence of what nursing is and can become, lending it a timeless quality. Peplau developed knowledge with practical import on learning, anxiety, hallucinations, interpersonal concepts, individual, family and group therapy. She articulated a framework for partnership and recovery, which continue to have significance for contemporary practice.

Peplau developed and taught in the first graduate programme in psychiatric nursing in the United States, assisted in the development of the first graduate programme in Europe and was instrumental in developing the role of ‘nurse specialist’. She was an advisor to the World Health Organisation, a member of the International Council of Nurses, a fellow of the Academy of Sigma Theta Tau, and has been awarded some of nursing highest honours. Few students struggling to complete academic studies would be failed to be impressed by Peplau’s credentials, which include no less than seven doctoral degrees!

Peplau (1987) viewed psychiatric nursing as a viable, complimentary and necessary alternative to psychiatric-medical treatments. She encouraged nurses to be proud of the development of nursing and challenged us to remember that… Somewhere, somehow, at some time in the past, courageous nurses determined these skills, learned them, fought for the right to use them, refined them, and taught them to other nurses. All nurses have an obligation to remember that part of nursing’s past, and to keep their own skills in pace with new opportunities for nursing into the next century. (Peplau, 1989, p.32), Peplau was one such courageous woman who has left us a legacy of practical knowledge to enable the survival and continued development of nursing. We are forever in her debt.

References

Forchuk, C. & Brown, B. (1989). Establishing a nurse-client relationship. Journal of

Psychosocial Nursing, 27(2), p 30-34.

Forchuk, C. (1991). Peplau’s theory: Concepts and their relations. Nursing Science

Quarterly, 4(2), p 54-60.

Hirschmann, M. (1989). Psychiatric and mental health nurses’ beliefs about therapeutic

paradox. Journal of Child Psychiatric Nursing, 2(1), p 7-13.

Marriner-Tomey, A. (1994). Nursing Theorists and Their Work (3rd Ed). St Louis, USA:

Mosby.

Peplau, H.E. (1952). Interpersonal Relations in Nursing. New York: G.P. Putnam’s Sons.

Peplau, H. E. (1987). Psychiatric skills: Tomorrow's world. Nursing Times, 83(4), 29-32.

Shives, L.R. (1994). Basic Concepts of Psychiatric-Mental Health Nursing (3rd Ed).

Philadelphia: J.B. Lippincott Company.

Sills, G. M. (1998). Peplau and professionalism: the emergence of the paradigm of

professionalization. Journal of Psychiatric and mental Health Nursing, 5(4), 167-171.

Stuart, G.W. & Sundeen, S.J. (1987). Principles and Practice of Psychiatric Nursing (3rd

Ed). St. Louis, USA: C.V. Mosby Co.

Torres, G. (1986). Theoretical Foundations of Nursing. USA: Appleton-Century-Crofts.

Note: this article is posted for the TFN students in requirement for journal reading. No content of this article is written by the user of the blog site.

Peplau's Psychodynamic Nursing

Psychodynamic Nursing

Theoretical Sources

- borrowed from behavioral science—psychological model

Use of Empirical Evidence

Maslow – people are motivated to attain self-actualization

Miller – personality theory, adjustment mechanisms, psychotherapy and principles of social learning

Pavlov’s – stimulus-response model influenced the principles of Miller’s social learning

Sullivan – the pioneer of modern psychiatry and includes cultural and social determiners to Freud’s interpersonal relationship model

MAJOR CONCEPTS AND DEFINITIONS

Psychodynamic nursing describe the dynamic relationship between a nurse and a patient.

Psychodynamic nursing is being able to understand one’s own behavior to help others identify felt difficulties, and to apply principles of human relations to the problems that arise at all levels of experience.

Peplau challenged psychiatric nursing to thrive in the new millennium in four central areas:

- the nurse-patient relationship

- engagement in evidence-based practice

- competence in information technology

- leadership in shifting the health care paradigm to community-based delivery.

NURSE-PATIENT RELATIONSHIP

(Interpersonal Relations Theory)

She described four phases of this relationship:

1. Orientation - in which the person and the nurse mutually identify the person's problem
2. Identification - in which the person identifies with the nurse, thereby accepting help
3. Exploitation - in which the person makes use of the nurse's help
4. Resolution - in which the person accepts new goals and frees herself or himself from the relationship.

Orientation Phase

1. When the nurse and patient first meet is known as the orientation phase.

2. This is a time when the patient and nurse come to know each other as people and each other’s expectations and roles are understood.

3. The patient at this time needs to recognize and understand their difficulty and the need for help, be assisted to plan to use the professional services offered, and harness the energy derived from felt needs.

4. It may be expected that the patient will test limits in order to establish the integrity of the nurse.

5. The tasks of this phase are to build trust, rapport, establish a therapeutic environment, assess the patient’s strengths and weakness and establish a mode of communication acceptable to both patient and nurse.

6. When the patient can begin to identify problems the relationship progresses to the working phase.

Identification Phase

1. Trust begins to develop and the patient begins to respond selectively to persons who seem to offer help.

2. The patient begins to identify with the nurse and identify problems, which can be worked on.

3. The meaning behind feelings and behavior of the nurse and patient are explored. Peplau states that when a nurse permits patients to express what they feel, and still get all of the nursing that is needed, then patients can undergo illness as an experience that reorients feelings and strengthens positive forces in the personality.

4. The tasks of this phase are to develop clarity about the patient's preconceptions and expectations of nurses and nursing, develop acceptance of each other, explore feelings, identify problems and respond to people who can offer help.

5. In particular the nurse assists in the expression of needs and feelings, assists during stress, shows acceptance and provides information.

6. The nurse and patient may make plans for the future but the implementation of the plan signifies the beginning of the exploitation phase of the working relationship.

Exploitation Phase

1. The patient realistically exploits all of the services available to them on the basis of self interest and need.

2. The nurse assists the patient in their efforts to strike a balance between the needs for dependence and independence.

3. The plan of action is implemented and evaluated. The patient may display a change in manner of communicating, as new skills in interpersonal relationships and problem solving are developed.

4. The nurse continues to assess and assists in meeting new needs as they emerge.

Resolution Phase

1. The resolution phase involves the gradual freeing from identification with helping persons, and the generation and strengthening of ability to stand alone, eventually leading to the mutual termination of the relationship.

2. The patient abandons old needs and aspires to new goals.

3. She or he continues to apply new problem solving skills and maintains changes in style of communication and interaction.

4. Resolution includes planning for alternative sources of support, problem prevention, and the patient’s integration of the illness experience.

Psychological Mothering:

1. The patient is accepted unconditionally to satisfy his needs.
2. There is recognition of and in response to the patient’s readiness for growth and his initiative.
3. Power in the relationships shifts to the patient as the patient is able to delay gratification and to invest in goal achievement.

NURSING ROLES

1. Stranger Role: Receives the client the same way one meets a stranger in other life situations; provides an accepting climate that builds trust. Accepting the patient objectively.

2. Resource Person Role: Answers questions, interprets clinical treatment data, gives information. Interpreting the medical plan to the patient.

3. Teaching Role: Gives instructions and provides training; involves analysis and synthesis of the learner's experience. Offering information and helping the patient to learn.

Peplau separates teaching into two categories : Instructional—which consists largely of giving information and is the form explained in educational literature. Experiential— which is using the experience of the learner as a basis from which learning products are developed.

4. Counseling Role: Helps client understand and integrate the meaning of current life circumstances; provides guidance and encouragement to make changes. Working with the patient on current problems.

5. Surrogate Role: Helps client clarify domains of dependence, interdependence, and independence and acts on client’s behalf as advocate. Figuratively standing in for a person in the patient's life.

6. Active Leadership Role: Helps client assume maximum responsibility for meeting treatment goals in a mutually satisfying way. Working with the patient democratically.

MAJOR ASSUMPTIONS

Peplau identifies two explicit assumptions :

1. The kind of person the nurse becomes makes a substantial difference in what each patient will learn as he receives nursing care.

2. Fostering personality development toward maturity is a function of nursing and nursing education. Nursing uses principles and methods that guide the process toward resolution of interpersonal problems.

NURSING METAPARADIGM

Nursing

Nursing described as a significant, therapeutic, interpersonal process.

Person

Peplau defines person in terms of man. Man is an organism that lives in an unstable equilibrium.

Health

Peplau defines health as a word symbol that implies forward movement of personality and other ongoing human processes in the direction of creative, constructive, productive, personal, and community living.

Environment

Peplau implicitly defines the environment in terms of existing forces outside the organism and in the context of culture, from which mores, customs, and beliefs are acquired.

Theoretical Assertions

Interpersonal Relations in Nursing

• Patient-nurse relationship
• Awareness of feelings
• Use of experiential learning method

Logical Form

- inductive approach

- empirical generalizations

- observes empirical events and generalizes from specific to all similar events

Application and Importance of the Theory

PRACTICE:

1. Integration of scientific disciplines in formulating paradigm of psychiatric nursing.
2. Strengthen nurse-patient relationship.
3. The start of psychiatric nursing.
4. Used for counseling women undergoing depression.

EDUCATION:

1. Interpersonal Relations in Nursing—used as a manual of instruction to nursing students.
2. Foundation of psychiatric nursing education.

RESEARCH:

1. Different studies on the nursing phenomena.
2. Improvement of the social system.
3. Stress management program.
4. Formation of behavior scale.
5. Therapeutic behavior of the nurses.

Analysis of the Theory

SIMPLICITY

1. The major theory that is interpersonal relations is easily understood.
2. Assumptions and key concepts were clearly given, explained, broken down and outlined.
3. Demonstrated clearly and identified properly the four phases of nurse-patient relationship and interpersonal model.
4. Applied effectively in the nursing profession.
5. It is consistent and semantic.

GENERALITY

1. Applicable to all nurses in any setting.
2. Used only in the situations that communication can occur.
3. It is impossible in working with senile, comatose or newborn patients. (one-sided relationship)

EMPIRICAL PRECISION

1. Based on reality.
2. Could be tested and observed using pure observation.
3. Theoretical area and empirical data are validated and verified.

DERIVABLE CONSEQUENCES

1. Widens the perception of nursing profession.
2. Broaden the scope of nursing practice.
3. Touched the lives of many.

References
Octaviano, E.F. & Balita, C.E. (2008). Theoretical Foundations of Nursing: The Philippine
Perspective, 77–86. Philippines: Ultimate Learning Series.
Tomey, A.M. & Alligood, M.R. (2002). Nursing Theorists and Their Work. 5th ed. Missouri:
Mosby, 379–388.

The Life of Hildegard Peplau

The Life of Hildegard Elizabeth "Hilda" Peplau

(1909 - 1999)

References
Octaviano, E.F. & Balita, C.E. (2008). Theoretical Foundations of Nursing: The Philippine
Perspective, 77–86. Philippines: Ultimate Learning Series.
Tomey, A.M. & Alligood, M.R. (2002). Nursing Theorists and Their Work. 5th ed. Missouri:
Mosby, 379–388.

Journal Reading (Environmental Theory)

Nightingale in Scutari: Her Legacy Reexamined

Christopher J. Gill and Gillian C. Gill

Nearly a century after the death of Florence Nightingale (1820–1910), historians continue to debate her legacy. We discuss her seminal work during the Crimean War (1854–1856), the nature of these interventions during the war, and her continued impact today. We argue that Florence Nightingale’s influence today extends beyond her undeniable impact on the field of modern nursing to the areas of infection control, hospital epidemiology, and hospice care.

Florence Nightingale (1820–1910) was a heroine to the British soldiers she cared for during the Crimean War (1854–1856) and a gadfly on the rumps of British parliamentarians who led Britain into that pointless conflict but left its troops poorly supported and needlessly vulnerable to disease. Medical men in her day and historians ever since have tended to dismiss the importance of Nightingale’s legacy [1–3]. Yet a careful study of Nightingale’s work during and after the Crimean War shows that she was rightly hailed as a legend during her lifetime; played a key role in the areas of public health policy, medical statistics, hospital design and management, and patient care; and deserves a lasting place in the pantheon of medical pioneers [4].

THE CRIMEAN WAR AND THE BRITISH ARMY HOSPITALS IN
SCUTARI, TURKEY

To understand the significance of Florence Nightingale’s work, one needs to grasp the miserable conditions in the Crimean war zone and at the hospitals at the British Army’s base at Scutari. Mortality rates in the armies that participated in the Crimean War were horrific: ∼1 in 5 men sent to Crimea died there. Notably, infections killed far more soldiers than did bullets, saber thrusts, or shells. In contrast, the US Army’s crude mortality rate in Vietnam was 2.6% [6].

In fairness, the British field surgeons did a credible job of treating war wounds through amputation and debridement [8]. Their patients were typically young and healthy before their injuries, and if infection could be avoided through prompt trauma management, the soldier had a reasonable chance of survival. Unfortunately, the surgeons could do little to treat the myriad causes of fever, human-made and otherwise, present in their environment. The Crimean War occurred 20 years before Pasteur and Koch promulgated the germ theory and a full century before the first antibiotics were created, and with the singular exception of quinine therapy for malaria, doctors had few remedies to manage infectious diseases. Thus, soldiers described as having medical illnesses were packed onto transport ships in shockingly squalid conditions and were ferried across the Black Sea to Scutari, a trip many did not survive. Records from the transport ship Shooting Star document that 47 of 130 patients died during one 13-day transit from Balaklava to Scutari [9]. In a real sense, the Scutari hospitals served more as so-called fever wards than true military hospitals and existed largely to segregate patients with fever from their healthy compatriots. Soldiers were not sent to Scutari to be healed so much as to die.

Doctors of the day recognized several variations of fever, including typhoid, relapsing fever, and the intermittent quotidian, quartan, and tertian fevers of malaria. During the war, some fevers acquired the appellations “Crimean Fever” or “Varna fever,” which was named after the Bulgarian coastal town where the British Army was first based. But such distinctions were rarely applied in Scutari. Most patients received a diagnosis of febris continua communis, also known as “low fever,” a wastebasket diagnosis used primarily to distinguish
this fever from the “high fever” associated with typhus [8]. The extreme crowding on the wards was ideal for spreading typhus, typhoid, dysentery, and respiratory infections; one account noted that beds were spaced 0.5 m apart (figure 2A) [8]. As Sarah Terrot, one of Nightingale’s nurses, recounted, “one poor fellow neglected by the orderlies because he was dying…was very dirty, covered with wounds, and devoured by lice. I pointed this out to the orderlies, whose only excuse was, ‘It’s not worthwhile to clean him: he’s not long for this world.’ The men in bed on each side of him told me his state was such that lice swarmed from him to them” [10].

Intestinal infections were rampant and devastating. Whereas only 29% of patients at Scutari were admitted for treatment of bowel disease or fever, dysentery contributed to nearly 50% of deaths [8]. At least 3 outbreaks of cholera occurred during the war: between April and September 1855, a total of 2368 patientswith cholera were admitted to one of the Scutari hospitals, of whom 1423 (60%) died [9]. For these patients, tincture of opium was the best treatment medical science had to offer. As described by one British surgeon, “I might sum up my account by saying that everything was tried and that nothing succeeded. At least I can say that I never cured a case, and I never saw a case cured” [11]. Remarkably, even those patients admittedwith conditions described as rheumatic had mortality rates as high as 10% [8]. The changing seasons merely shifted the spectrum of diseases seen in Scutari: summer brought malaria and cholera; in the winter, more patients succumbed to gangrene after frostbite (also known as “gelatio”).

Horrible as this situation may have been, it was far from unique in the history of warfare. What was unusual was the degree to which news of the squalor in which the British troops died at Balaklava and at Scutari was documented by London Times correspondents (by telegraph!), making this the first war in which the army medical corps was flatly accused of negligence. These reports scandalized the nation and nearly toppledLord Aberdeen’s government in Parliament—particularlywhen it became known that the French army was doing a far better job of supplying and caring for its troops than was the British army. It was in this environment and under considerable public and political pressure that Minister at War Sidney Herbert, on the basis of his appraisement of her managerial skills and experience, wrote an impassioned appeal to Florence Nightingale, asking her to lead a team of nurses to Crimea. Ironically,Nightingale had already written her parliamentary allies proposing precisely the same thing. And so it was that, early in November 1854, Nightingale found herself and her 38 nurses in Turkey, gazing at the massive walls of Barracks Hospital (Scutari). Famously, she is quoted as saying that “the strongest will be wanted at the wash tub.”

NIGHTINGALE IN SCUTARI

A, Popularized illustration, first printed in the Illustrated London News in 1855, of Florence Nightingale touring the wards of Barracks Hospital (copyright held and used with permission by the Florence Nightingale Museum [London, United Kingdom]). B, Photograph of the actual paper concertina lantern made for and used by Nightingale in 1855 (used with the courtesy of the Director of the National Army Museum [London]). The popular depictions of Nightingale with an open flame lantern reflect the near absence of accurate portraits and the complete absence of photographs of her during the period of the Crimean War.

Florence Nightingale’s time in Scutari enabled her to prove a point. Her experiences working on English fever wards and while volunteering as a nurse at the Middlesex Hospital in London during the Cholera outbreak of 1854 had convinced her that the so-called heroic medicine of the day, which was based on infusions of arsenic, mercury, opiates, and bleeding, hastened the deaths of many more patients than it saved [12]. Nightingale believed that, by keeping patients well-fed, warm, comfortable, and above all clean, nursing could solve many problems that 19th century medicine could not. Treatment of soldiers in Scutari provided an opportunity to validate this theory on an unprecedented scale. To this task, Nightingale brought her skills as a nurse. But she also brought prodigious managerial skills, an obsession with meticulous record keeping, and a deep faith in the Sanitarian movement. Florence Nightingale was an early disciple of the Sanitarian Edwin Chadwick, the main proponent of the British Public Health Act of 1848 [13], and although she presumably had no concept of bacteria or viruses, she clearly understood contagion. She saw a clear relationship between the diseases killing her patients and the filth in which they lay, the air they breathed, the water they drank, and the food they ate. To Nightingale, the greatest tragedy of the Crimean War was the British Army’s failure, through bureaucratic inertia, to protect the soldiers’ health or to assist in their recovery. In her words, “The 3 things which all butdestroyed the army in Crimea were ignorance, incapacity, and useless rules” [14].

Her interventions, considered at the time to be revolutionary, seem in hindsight to be acts of common sense. She and her nurses washed and bathed the soldiers, laundered their linens, gave them clean beds to lie in, and fed them, while working and lobbying to improve the overall hygiene of the wards. She helped establish a rational system for receiving and triaging the injured soldiers. As the wounded soldiers disembarked, they were stripped of their blood- and offal-soaked uniforms, and their wounds were bathed. To prevent cross-contamination between soldiers, Nightingale insisted that a fresh, clean cloth be used for each soldier, rather than the same cloth for multiple patients. She set up huge boilers to destroy lice and found honest washerwomen who would not steal the linens. She shamed hospital orderlies into removing buckets of human waste, to clean up the raw sewage that polluted the wards, and to unplug latrine pipes. At her behest, new windows capable of opening were installed to air out the wards. She established a separate kitchen in Barracks Hospital, which was supported by her own finances, to prepare soups, beef teas, jellies, cereals, and other easily digestible foods to supplement the army’s meager rations. In response to rampant petty corruption that was siphoning off medical supplies, she established a parallel supply system for critical materials and food, and she proved that the official supplies were being stolen by sending her representatives into the Turkish markets to buy back the purloined goods. When faced with the imminent arrival of hundreds of additional patients, at her expense, Nightingale organized a team of 200 Turkish workers to replace the floor in Barracks Hospital, which, having been destroyed by a fire, was an ideal habitat for fleas, flies, and lice. And, significantly, she kept meticulous records of everything she saw or did.

For these actions, she earned the deep enmity of army bureaucrats. In the aftermath of recriminations following the Crimean War, the army released a massive 1637-page report about the medical challenges in Scutari that makes not a single mention of Nightingale or her nurses [9]. The army surgeons resented the power she wielded and the implication that they were somehow culpable in the deaths of their patients. Dr.Duncan Menzies, the Chief Medical Officer at Barracks Hospital in 1854, did his best to thwart Miss Nightingale, owing
to the fact that her documentation of the supply shortages in Scutari flatly contradicted his own reports that the army “had everything—Nothing was wanted” [15]. Despite all that—or
perhaps because of it—she earned the deep adoration of the rank-and-file soldiers. Soldiers still died in Scutari. The difference was that they now knew that someone was looking out for them.

NIGHTINGALE’S LEGACY REEXAMINED

The effects of Nightingale’s reforms were striking. One of the early “fever casualties” brought to Scutari described these reforms as follows: “Everything changed for the better. The sick were not kept waiting in the passages but went at once to bed, were washed, and had clean linen and were attended as well as in England” [16]. Critics of Florence Nightingale rightly
point out that the profound decreases in the mortality rate during the latter months of 1855 could not have resulted solely from improvements in nursing (table 2). But this merely underscores the fact that the improved survival rate had less to do with the outstanding individual care she and her nurses provided and far more to do with the structural changes in the procurement of supplies and the improved sanitation that occurred under her influence. In hindsight, these interventions likely served to critically alter the conditions that favored the spread through the wards of typhus, tuberculosis, dysentery, cholera, typhoid, and other infectious diseases that were decimating the soldiers.

Several contemporary historians have attempted to portray Nightingale as little more than a manager with no taste or talent for patient care [1, 2], but such characterizations are both untrue and unkind. Her own letters to friends, family, and government officials, as well as the private and published testimony of other nurses and British Army surgeons who served during the war, clearly establish that she was one of the handful of women permitted by army doctors to do wound care, that she was fully involved in what we now call first aid and triage, and that she preferentially took on the care of patients with infectious diseases who were determined by doctors, correctly, to be beyond medical help and who were therefore avoided [4]. As her aunt Mai Smith wrote home from Scutari in January 1856, the happiest hours Nightingale spent were those she spent with the patients [15].

For her work in Scutari and her subsequent teachings [17, 18], Florence Nightingale will forever be linked with modern nursing—and rightly so. However, we believe that 3 areas of contemporary medicine were also deeply influenced by her.

The first area of influence is hospital infection control. Although the CrimeanWar settled nothing in terms of geopolitics, it served as the backdrop for a second struggle between the Sanitarian movement and the medical dogma of the day, which the Sanitarians at least won decisively. Nightingale cannot claim credit for originating the Sanitarian theories, but the impact of her reforms in Scutari were so obvious and well publicized that the treatment of hospitalized and infected patients was forever changed. In her words, “In the present (so-called) enlightened time, sound principles of Hygiene [sic] are by no means widely spread even among the civil medical profession. To this circumstance it appears mainly to be owing that the belief in contagion as an unavoidable cause of death from epidemic disease is still so prevalent” [14]. Many of our current health care practices, such as isolation of patients with antibioticresistant pathogens, avoidance of cross-contamination, routine cleansing of all patient areas, aseptic preparation of foods, ventilation of wards, and disposal of human and medical wastes, trace their origins to practices enacted by Nightingale at Scutari.


The second field influenced by Florence Nightingale is hospital epidemiology. Nightingale was a skilled statistician who was greatly influenced by the work of Adolphe Quetelet (1796–
1874), the leading statistician of her day [19]. She considered his book Essaie de Physique Sociale to be a revelation of the will of God. In annotations to her copy of Quetelet’s book, she wrote that “all Sciences of Observations depend upon Statistical methods—without these, are blind empiricism. Make your facts comparable before deducing causes. In complete, pell-mell observations arranged so as to support theory; insufficient number of observations; this is what one sees” [20]. The mortality diagrams that she invented for her report about the CrimeanWar remain models of elegance today (figure 3). However, her intellectual contributions to the field were arguably less significant than her ability to demonstrate the power of applied descriptive statistics in practice. One of her most famous achievements was
to prove that the majority of soldiers in the Crimean War died not of war wounds but of fever, cholera, diarrhea, dysentery, and scurvy, all of which are preventable conditions [14].

Finally, we would argue that hospice medicine owes Nightingale a particular debt. Long before Kubler-Ross’ theories about death with dignity [21], Florence Nightingale practiced it. As a nurse engaged in direct treatment of patients, Nightingale saved perhaps dozens of soldier’s lives, but by her own accounts, she closed the eyes of hundreds. One of the duties
she assigned herself was to write letters to the families of patients who were dead or dying and, particularly, patients who were illiterate. In these letters, she explained the circumstances of illness and death, and she often included small packets of the dead soldiers’ personnel effects. Her nightly tours of the 6.4 km of wards at Barracks Hospital started as a routine, became a ritual, and ended as a covenant between her and the men—and they understood its meaning precisely. As one soldier wrote, “What a comfort it was to see her pass even. She would speak to one, and nod and smile to many more; but she could not do it all you know. We lay there by hundreds; but we could kiss her shadow as it fell and lay our heads on the pillow again content” [22]. It is no surprise that the image of Florence Nightingale that continues to inspire today is that of her touring the wards alone at night by the light of a Turkish lamp (figure 2). In the lyrics of a soldier’s ballad, penned while
the war was still being waged:

On a dark lonely night on Crimea’s dread shores
There’d been bloodshed and strife on the morning before;
The dead and the dying lay bleeding around,
Some crying for help—there was none to be found
Now God in His mercy He pitied their cries,
And the soldiers so cheerful in the morning do rise.
So, forward my lads, may your hearts never fail
You are cheered by the presence of a sweet Nightingale.
Her heart it means good for no bounty she’ll take,
She’d lay down her life for the poor soldier’s sake;
She prays for the dying, she gives peace to the brave,
She feels that a soldier has a soul to be saved.
The wounded they lover [sic] her as it has been seen,
She’s the soldier’s preserver, they call her their Queen.
May heaven give her strength and her heart never fail.
One of Heaven’s best gifts is Miss Nightingale.

References
1. Royle T. Crimea: the great Crimean War, 1854–1856. New York: Saint Martin’s Press, 2000.
2. Lambert A, Badsey S. The war correspondents: the Crimean War. Stroud, United Kingdom: Alan Sutton Publishing, 1994.
3. Smith FB. Florence Nightingale: reputation and power. London: Croom Helm, 1982.
4. Gill G. Nightingales: the extraordinary upbringing and curious life of Miss Florence Nightingale. New York: Random House, 2004.
5. Garrison FH. Notes on the history of military medicine. Washington, DC: Association of Military Surgeons, 1922.
6. Neel S. Vietnam studies medical support: 1965–1970.Washington, DC: Department of the Army, 1991.
7. Duberly FI. Journal kept during the Russian war: from the departure of the army from England in April 1854, to the fall of Sebastopol. London: Elibron Classics, 2000. First published 1856 by Longman.
8. Shepherd J. The Crimean doctors: a history of the British medical services in the Crimean War. Vol. 2. Liverpool, United Kingdom: Liverpool University Press, 1991.
9. Medical and surgical history of the British Army which served in Turkey and the Crimea during the war against Russia in the years 1854–1856. London: Harrison, 1858.
10. Terrot SA. Nurse Sarah Anne with Florence Nightingale at Scutari. Robert Richardson, ed. London: John Murray, 1977.
11. Bakewell RH. Notes on the diseases most commonly treated at the Scutari hospitals. Medical Times and Gazette 1855; 2:441–2.
12. Cameron D, Jones IG. John Snow, the Broad Street pump and modern epidemiology. Int J Epidemiol 1983; 12:393–6.
13. Hamlin C, Sheard S. Revolutions in public health: 1848, and 1998. BMJ 1998; 317:587–91.
14. Nightingale F. A contribution to the sanitary history of the British army during the late war with Russia. London: Harrison and Sons, 1859.
15. Goldie SM. Florence Nightingale: letters from the Crimea, 1854–1856. Manchester, United Kingdom: Manchester University Press, 1997.
16. Robinson R. Copy of manuscript found at 10 South Street (January, 1860), attributed to Robert Robinson. London: British Library Archives, 1860.
17. Nightingale F. Introductory notes on lying-in institutions together with a proposal for organizing an institution for training midwives and midwifery nurses. London: Longmans, Green, and Co., 1871.
18. Nightingale F. Notes on nursing: what it is and what it is not. London: Harrison and Sons, 1860.
19. Dossey BM. Florence Nightingale: mystic, visionary, healer. Springhouse, PA: Springhouse, 2000.
20. Diamond M, Stone M. Nightingale on Quetelet II, the marginalia. JR Stat Soc 1981; 144:181–2.
21. Kubler-Ross E, Wessler S, Avioli LV. On death and dying. JAMA 1972; 221:174–9.
22. Woodham-Smith C. The reason why: the story of the fatal charge of the light brigade. London: Penguin Books, 1958.

Note: this article is posted for the TFN students in requirement for journal reading. No content of this article is written by the user of the blog site.

Nightingale's Environmental Theory

The Environmental Theory

Theoretical Sources

Education: Nightingale is a very good mathematician (a nurse statistician) and a philosopher.
Her aunt Mai describes her as "a woman with great mind."

Literature: Her political inclinations were from the ideologies of Stanley Herbert (family friend).
Dicken's novel "The Adventures of Martin Chuzzlewit", a novel with a that portrays a victorian drunken, untrained and inexpert nurse causes an stigma and bad impressions about nurses. The novel greatly affects her beliefs about being a nurse and pursue the battle to change the negative stigma about nurses.

Intellectuals: Political leaders like John Stuart Mill, Benjamin Jowett, Edwin Chadwick and Harriet Marinue greatly affects and influence her beliefs of changing things as she viewed as unacceptable to society.

Religious Beliefs: For Nightingale, an action for the benefit fo others is called "God's Calling". As stated in her diary, "God spoke to me in silence and he called me to services" - DUM VIVIMUS, SERVIMUS.

Use of Empirical Evidence
She uses the polar diagram (statistical diagram) in her reports, books and letters.
She is a very good researcher and a great statistician.

According to Palmer, Nightingale has a very excellent research skills, she is good in recording, communicating, ordering, coding, conceptualizing, inferring, analyzing and synthesizing. Her focus is on the observation of social phenomena. She highlighted the use of observation and the performance of tasks in the nursing education.

Major Concepts and Definitions
Environment - concepts of ventilation, warmth, light, diet, cleanliness and noise. She focus o the physical aspect of environment.

She believed that "Healthy surroundings were necessary for proper nursing care."

5 essential components of healthy environment:
1. pure air
2. pure water
3. efficient drainage
4. cleanliness
5. light

Concerns of Environmental Theory
1. Proper ventilation focus on the architectural aspect of the hospital.
2. Light has quite as real and tangible effects to the body. Her nursing intervention includes direct exposure to sunlight.
3. Cleanliness and sanitation. She assumes that dirty environment was the source of infection and rejected the "germ theory". Her nursing interventions focus on proper handling and disposal of bodily secretions and sewage, frequent bathing for patients and nurses, clean clothing and handwashing.
4. Warmth, quiet and diet environment. She introduce the manipulation of the environment for patient's adaptation such as fire, opening the windows and repositioning the room seasonally, etc.
5. Unnecessary noise is not healthy for recuperating patients.
6. Dietary intake.
7. Petty management proposed the avoidance of psychological harm, no upsetting news. Strictly war issues and concerns should not be discussed inside the hospital. She includes the use of small pets of psychological therapy.

Nursing Metaparadigm

Nursing
Nursing is very essential for everybody's well-being. Notes on nursing focus on the implementation and rendering efficient and effective nursing care.

Person
The patient is the focus of the environmental theory. The nurse should perform the task for the patient and control environment for easy recovery. She practice nurse-patient passive relationship.

Health
Health is the being well and using every power that the person has to the fullest extent. A healthy body can recuperate and undergo reparative process. Environmental control uplifts maintenance of health.

Environment
People would benefit form the environment.

Theoretical Assertions
Prevention of interruption is very vital in the reparative process of the patient. Her focus is on nursing education that required even more training.

Nursing Practice is the application of common sense, observation, perseverance and ingenuity.

"If the person wants to recuperate, he needs to cooperate with the nurse."

Disease came from the organic materials from the patient and environment not on the germ theory. She totally disagree and rejected the germ theory.

Sanitation means the manipulation of the environment to prevent diseases.

Nursing is the commitment to the nursing works.

She gives a little focus on the interpersonal relationship and nurse caring behavior.

She believed that the nurse should be moral agents. "Think and act like a nurse."

Professional relationships, principles of confidentiality and care for the poor to improve health and social condition were the focus of her nursing care.

Logical Form
She used inductive reasoning from her experiences and observation with is address with logical thinking and philosophy.

Importance of Environmental Theory

Practice
1. Disease control
2. Sanitation and water treatment
3. Utilized by modern architecture in the prevention of "sick building syndrome" applying the principles of ventilation and good lighting.
4. Waste disposal
5. Control of room temperature.
6. Noise management.

Education
1. Principles of nursing training. Better practice result from better education.
2. Skills measurement through licensing by the use of testing methods, the case studies.

Research
1. Use of graphical representations like the polar diagrams.
2. Notes on nursing.

Evaluation of the Environmental Theory
Hardy evaluated the environmental theory as a grand theory because it explains the totality of the behavior. It is classified as lower-level theory but it provided the greates foundation of nursing education, practice and theories.

The Analysis

Simplicity: The theory is simply explained as the nurse, patient and environment interacts with each other. There are dangers in the environment and benefits from the good environment. The roles of environmental management to patient recovery is greatly emphasized. Manipulating the environment to prevent diseases. Nurse-patient relationship focus on cooperation and collaboration. Her care focus on eating patterns and food preferences of the patients, provision of comfort, protection from emotional distress and conservation of energy.

Generality: The universality of the concepts provide general guidelines and is still applicable and relevant today.

Empirical Precision: The theory is stated completely and presented facts. She uses quantitative research method. She focus on observation and experiences rather than systematic empirical research.

Derivable Consequences: Measures of independence and accuracy of care. Nurse-patient relationship towards wellness, environmental manipulation and psychological care.


References
Octaviano, E.F. & Balita, C.E. (2008). Theoretical Foundations of Nursing: The Philippine
Perspective, 63–72. Philippines: Ultimate Learning Series.

Tomey, A.M. & Alligood, M.R. (2002). Nursing Theorists and Their Work. 5th ed. Missouri:
Mosby, 65–75.

The Life of Florence Nightingale

The Life of Florence Smith Nightingale
(1820-1910)