Analysis of Florence Nightingale's Environmental Theory

Elevated levels of noise might be enjoyable at a sports event or a rock concert, but not in a hospital for patients who are healing and recovering from illnesses or surgeries. The constant beeping and humming of the machines, the chatter by the medical professionals, visitors coming and going in the halls, bright lights, ringing phones, overhead paging, and televisions can impact a patient’s recovery. Many hospitals are implementing noise-reduction initiatives in the form of “quiet time” to aid patients in escaping this constant clamor which can lead to negative outcomes. Evidence based practice has shown that the reduction of audio and visual stimuli increases sleep and recovery time, creating a more pleasant hospital environment and promote healing.

Evidence-based nursing is a method delivering nursing care and making quality decisions based upon a combination of clinical knowledge and the most recent pertinent research available on the topic. Replacing traditional policies and procedures with consideration of patient preferences and an individual’s needs can help to provide high quality care, improve overall patient satisfaction, and increase patient outcomes. Nurses make a commitment to life-long learning and providing patient-centered care, which is the basis of this type of nursing care.

With the demand for healthcare being 24 hours a day, 7 days a week, hospitals are a very busy place with constant activity. As a result of evidence-based nursing, a lot of hospitals are enforcing the two-hour time blocks as a way to escape this chaos by dimming the lights, discouraging staff from conducting loud and bothersome activities such as taking vitals, and encouraging a timeout from visitors interactions. During quiet time, all departments are asked to refrain from testing and consultations which can increase the decibel level of noise on the floor.

Quiet time was implemented to be utilized in the critical care environment. The purpose of the critical care unit is to provide life-sustaining care with the most advanced technology. Along with this type of care comes a lot of unpleasant stimuli in the form of machines with bright lights and obnoxious sounds. While the technology and constant bedside monitoring by healthcare professionals is necessary, there remains significant gaps that can affect the quality of the healthcare provided and patient satisfaction.

The World Health Organization (WHO) and the Environmental Protection Agency (EPA) has suggested that hospital sound levels should not exceed 35 to 45 dB during the day and 30 to 35 dB at night. Since 1960, the mean noise level in hospitals has increased by 26% during the day (from 57 to 72 dB) and 43% at night (from 42 to 60 dB) (Halm, M., 2016). These average noise levels far exceeded the levels recommended by these agencies. It is recognized that the quality of care can be compromised by these high decibel levels and loud acoustic conditions, leading to unwanted mental and physical effects.

Unlike many other complications that arise with patients in the hospital such as catheter infections or falls, noise can potentially expose the patients to undiagnosed stressors such as sleep deprivation. Several studies have concluded that loud noises and external stimuli can cause short term impact such as difficulty concentrating, drowsiness, decreased reaction time, memory problems, anxiety, depression and mood swings. In the presence of healing, these symptoms can worsen and lead to additional physiological effects such as decreased immune function, reduced pain threshold, impaired wound healing, and increased susceptibility of infection. As an individual sleeps, there are decreases in muscle tension, blood pressure, body temperature, blood flow and heart rate, and the respiratory rate. Additionally, metabolism and stress hormones levels decline, and the immune system is activated (Salzmann, 2016). By enabling the human body to recover through the natural state of sleep, healing capability is enhanced.

From the patient’s perspective, these unwanted consequences can be a truly unpleasant experience that impairs their ability to rest comfortably and recover from their surgery or illness. From a hospital perspective, this decreases patient satisfaction score and opens the door to poor patient outcomes and increased complications. Research has shown that “noise levels exceeding 40 dBA may affect perception and judgment and interrupt complex intellectual functions that require concentration, such as problem solving” (Salzmann, 2016). This research further reported a reduction in noise levels ranged from 2 to 20 dB and sleep improved more than seventy percent (70%) after day-shift quiet times were initiated, leading to improved patient satisfaction.

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The implementation of quiet time in hospitals nationwide is comprised of many elements intended to make the inpatient hospital stay more pleasant for a patient. In addition to the elimination of unnecessary noise, another element to the quiet time protocol is dimming the overhead corridor lights and turning off lights in patient’s rooms. External outdoor lighting through the windows are the only source of lighting during this time. This reduction is an in effort to reduce this visual form of noxious stimuli.

The human body is naturally equipped a circadian rhythm driven by the circadian pacemaker in the anterior hypothalamus of the brain. This rhythm functions as an individual’s inner clock and is a rhythmic cycle of one’s behavioral, physical, and mental cycles that responds primarily to light and darkness in the environment. Circadian rhythms, light, and sleep are interconnected codependent. Light stimulates the immune system by regulating the pineal neuro hormone melatonin, initiates the absorption of vitamin D and has been reported to reduce the number of hospital days in patients suffering from bipolar disorder. (Engwall, et al., 2015) The health, wellbeing, and recovery of patients can be affected by the patient’s ability to get quality sleep and coinciding with the circadian rhythm. By darkening the unit, it serves as a strong visual cue to be quiet, creating a more relaxing atmosphere stimulating the natural hormones and vitamins in one’s body.

The importance of the relationship between rest and healing dates back over 150 years to nursing theorist Florence Nightingale. Florence Nightingale was the founder of the “Environmental Theory” which focused on the integration of body, mind and spirit in the effort for optimize healing, and believed that “the role of the nurse is to put the patient in the best possible condition for nature to act so healing can occur”. (Halm, 2016) The components of this theory addressed areas such as lighting, noise, air, ventilation, cleanliness, and variety. As stated by Nightingale, “Unnecessary noise is the most cruel absence of care which can be inflicted either on sick or well”. (Zborowsky, 2014) Nightingale challenged nurses to create environments where optimal health could be achieved.

In the mid 1900’s, another prominent nursing theorist, Virginia Henderson, embraced the concept that the fundamental and biophysical components of basic human needs were sleep and rest. This was later referred to as the Need Theory. She believed that one’s environment can affect a person’s physical and mental wellbeing and the importance of the promotion of rest to recover. Well known past century theorists such as Florence Nightingale and Virginia Henderson have shaped the path for nurses to assist their patients in the road to recovery by applying best practice methods that include advanced application of theory and evidence based research as the foundation of their nursing process.

Many hospitals have put the theories evolved from Nightingale and Henderson to the test with the implementation of the quiet time initiative. An article posted by the Journal of Nursing Care Quality featured the “Quiet Time Bundle,” citing that introducing these types of interventions into the hospital setting has improved patient satisfaction and increased the quality of sleep by (10%) percent post implementation. Twenty-seven percent (27%) of the patients in the study stated that they were still awakened during quiet time hours by noises in the halls of external from their rooms, such as carts, slamming doors, and loud conversations. (McGough et al., 2018) While this is still a significant number of concerns, the trend is heading downward and showing promise to the initiative.

In 2005, the Centers for Medicare & Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ) has linked patient satisfaction scores to Medicare reimbursement. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is driven by three main goals: 1) to motivate hospitals to improve their quality of care with regard to patient satisfaction, 2) to provide transparent public reporting of survey results, and 3) to allow consumers to objectively compare hospitals. ('Is there a Relationship between Patient Satisfaction and Favorable Surgical Outcomes?,' n.d.) Mandatory public reporting of these scores by hospitals, which includes questions regarding the rating the overall quietness of the facility, allowed for full reimbursement for these services.

Evidence based practice will continue to shape the way that nursing care is performed and received. Florence Nightingale’s Environmental Theory, coupled with Henderson’s Need Theory have helped shape and create the Quiet Time model as it is today. With the ever-changing technology in the modern day, there are more equipment, lights and sounds to add into the hospital mix, which may positively and negatively affect their ultimate care and recovery. Focusing on these unwanted complications, greater patient outcomes can be achieved.

References:

1. Engwall, M., Fridh, I., Johansson, L., Bergbom, I., & Lindahl, B. (2015). Lighting, sleep and circadian rhythm: An intervention study in the intensive care unit. Intensive & Critical Care Nursing, 31(6), 325–335. https://doi-org.casper.idm.oclc.org/10.1016/j.iccn.2015.07.001
2. Halm, M. (2016). Making Time for Quiet. American Journal of Critical Care, 25(6), 552–555.
3. Is there a relationship between patient satisfaction and favorable surgical outcomes? (n.d.). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4548286/
4. McGough, N. N. H., Keane, T., Uppal, A., Dumlao, M., Rutherford, W., Kellogg, K., Fields, W. (2018). Noise reduction in progressive care units. Journal of Nursing Care Quality, 33(2), 166–172. https://doi-org.casper.idm.oclc.org/10.1097/NCQ.0000000000000275
5. Salzmann, E. M., Lagerqvist, L., & Pousette, S. (2016). Keep calm and have a good night: nurses’ strategies to promote inpatients’ sleep in the hospital environment. Scandinavian Journal of Caring Sciences, 30(2), 356–364.
6. Ward-Smith, P. (2015). Quiet at Night: Implementing a Nightingale principle. Urologic Nursing, 35(1), 45.
7. 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.