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1. Bibliography: Environment Theory For Nursing Practice
Bibliography: Environment Theory For Nursing Practice ON Bibliography: Environment
Theory For Nursing PracticeThe 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.https://www.florence-nightingale.co.uk/resources/b…ReferencesBiography of
Florence Nightingale. (2019). Retrieved from https://www.florence-
nightingale.co.uk/resources/b…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. https://doi-
org.chamberlainuniversity.idm.oclc.org…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. https://doi-
org.chamberlainuniversity.idm.oclc.org…Bibliography: Environment Theory For Nursing
Practice attachment_1attachment_2attachment_3Unformatted Attachment
PreviewFLORENCE NIGHTINGALE AND IMPACT OF HEALTHCARE ENVIRONMENTS
RESEARCH The Legacy of Florence Nightingale’s Environmental Theory: Nursing Research
Focusing on the Impact of Healthcare Environments Terri Zborowsky, PhD, EDAC
ABSTRACT 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 theory. 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

2. Design. CORRESPONDING AUTHOR: Terri Zborowsky, Terri.zborowsky@gmail.com; (651)
724-0081. © 2014 VENDOME GROUP LLC 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.
HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL?? 19 RESEARCH SUMMER 2014
• Bibliography: Environment Theory For Nursing PracticeVOL. 7 NO. 4, pp. 19–34 F 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

3. 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
20???WWW.HERDJOURNAL.COM © 2014 VENDOME GROUP LLC FLORENCE NIGHTINGALE
AND IMPACT OF HEALTHCARE ENVIRONMENTS RESEARCH 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: • Noise • Light • Air
• Ventilation • Cleanliness • Variety 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. Bibliography: Environment Theory For Nursing PracticeThis article also
includes recommendations to advance a research agenda for bedside nurses. Overview 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 © 2014
VENDOME GROUP LLC HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL?? 21
RESEARCH 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

4. 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). 22???WWW.HERDJOURNAL.COM © 2014 VENDOME GROUP LLC FLORENCE
NIGHTINGALE AND IMPACT OF HEALTHCARE ENVIRONMENTS RESEARCH 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. Bibliography:
Environment Theory For Nursing PracticeIn 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

5. 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.
Transformational Leadership and Culture h s ea Re ar c Research se r ch Re Infrastructure:
Building, Technology, Furniture, Equipment Strategic Goals: Improved Patient, Staff, and
Resource Outcomes Reengineered Clinical and Administrative Processes 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. © 2014 VENDOME
GROUP LLC HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL?? 23 RESEARCH
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 research; 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

6. 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 24??? Bibliography: Environment
Theory For Nursing PracticeWWW.HERDJOURNAL.COM © 2014 VENDOME GROUP LLC
FLORENCE NIGHTINGALE AND IMPACT OF HEALTHCARE ENVIRONMENTS RESEARCH 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 …Bibliography: Environment Theory
For Nursing Practice