critical thinking exercises on nightingale's environmental philosophy

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Nightingale’s Philosophy in Nursing Practice

Chapter 5 Nightingale’s Philosophy in Nursing Practice Kim Bolton I use the word nursing for want of a better. It has been limited to signify little more than the administration of medicine and application of poultices. It ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet—all at the least expense of vital power to the patient. ( Nightingale, 1969, p. 8 ) History and Background Nightingale was born in 1820 in Florence, Italy. Her parents were very wealthy and often traveled abroad. Nightingale was beautiful and was expected to behave like every other Victorian lady, filling her time before marriage with music, reading, embroidery, and learning how to be the perfect hostess ( Brown, 1988 ). Nightingale had other ideas. She had felt different from those around her even at a young age, and by the time she was 17, believed she was called by God into His service ( Woodham-Smith, 1951 ). She had great compassion and sympathy for people of all types, and as she grew older, she believed she had been called to help mankind. She desired to help the truly poor but suffered in silence for years because it was improper for someone of her upbringing to involve herself with actual physical work ( Brown, 1988 ). At the age of 24, Nightingale decided she needed to help the suffering masses and wished to work in a hospital. This was met with opposition from her family, and they fought about it for years before finally allowing her to go to Kaiserworth, Germany, to learn nursing from the Institution of Deaconesses ( Brown, 1988 ; Woodham-Smith, 1951 ). She studied there for 3 months and then returned to the service of her family. It was another 2 years before she was allowed to practice nursing ( Brown, 1988 ; Woodham-Smith, 1951 ). She developed what we have come to refer to as her nursing theory after her travel to Scutari to care for wounded soldiers during the Crimean War. Her writings, which included philosophy and directives, were developed from a need to define nursing and reform hospital environments rather than for the purpose of providing nursing new knowledge. Nightingale worked endlessly during her lifetime to introduce many types of reform, in areas as diverse as the British military and the environment of England ( Brown, 1988 ; Woodham-Smith, 1951 ). Because of her work in nursing and nursing education, she is known as the founder of modern nursing ( Dennis & Prescott, 1985 ; Henry, Woods, & Nagelkerk, 1990 ). She started a school of nursing at St. Thomas Hospital in England and wrote many manuscripts about hospital reform and nursing care ( Brown, 1988 ; Woodham-Smith, 1951 ). Nightingale (1969) clarified that “nursing knowledge is distinct from medical knowledge” (p. 3 ). Overview of Nightingale’s Environmental Philosophy Nightingale’s philosophy is environmentally oriented. This is evidenced by her many writings and her book Notes on Nursing: What It Is and What It Is Not ( Nightingale, 1969 ). She believed that the environment of the patient should be altered to allow nature to act on the patient ( McKenna, 1997 ; Nightingale, 1969 ). Her work focuses mostly on the patient and the environment but also includes the nurse and health. For instance, it was the nurse’s duty to alter the patient’s environment so that nature could act on the patient and repair health. The components of Nightingale’s philosophy, which is now recognized as theory in this theory era, are the following: •  Environment: Environment can be defined as anything that can be manipulated to place a patient in the best possible condition for nature to act ( Selanders, 1998 ). This theory has both physical and psychological components. The physical components of the environment refer to ventilation, warmth, light, nutrition, medicine, stimulation, room temperature, and activity ( Lobo, 2011 ; Nightingale, 1969 ; Reed & Zurakowski, 1996 ; Selanders, 1998 ). The psychological components include avoiding chattering hopes and advices and providing variety ( Lobo, 2011 ; Nightingale, 1969 ). •  Person: Although most of Nightingale’s writings refer to the person as the one who is receiving care, she did believe that the person is a dynamic and complex being. Reed and Zurakowski (1996) state, “Nightingale envisioned the person as comprising physical, intellectual, emotional, social, and spiritual components” (p. 33 ). •  Health: Nightingale (1954b) wrote, “Health is not only to be well, but to be able to use well every power we have” (p. 357 ). From this statement we can infer that she believed in prevention and health promotion in addition to nursing patients from illness to health. •  Nursing: Nightingale believed nursing to be a spiritual calling. Nurses were to assist nature that was healing the patient ( Chinn & Kramer, 2011 ; Nightingale, 1969 ; Reed & Zurakowski, 1996 ; Selanders, 1998 ). She defined different types of nursing as nursing proper (nursing the sick), general nursing (health promotion), and midwifery nursing ( Reed & Zurakowski, 1996 ; Selanders, 1998 ). Nightingale saw nursing as the “science of environmental management” ( Whall, 1996, p. 23 ). Nurses were to use common sense, observation, and ingenuity to allow nature to effectively repair the patient ( Pfettscher, 2010 ). Although the model seems linear, it has been observed that the nurse initiates mutuality of care and outcome between the nurse and the patient ( Selanders, 1998 ). Nightingale assumed that the patient wanted to be healthy and would cooperate with and assist the nurse to allow nature to help the patient ( Pfettscher, 2010 ). Using Nightingale’s philosophy in practice today fits well with the use of the nursing process. The nurse assesses the patient situation, identifies a need, implements a plan of care, reevaluates the situation, and finally changes the plan to better serve the patient. This is done as often as necessary until the main goal of nursing (improved health state) is accomplished. At each phase of the process, documentation occurs to allow other caregivers to follow the plan of care ( Selanders, 1998 ). Critical Thinking Using Nightingale’s Theoretical Philosophy The term critical thinking was not in use in Nightingale’s day; however, she expected nurses to use their powers of observation in caring for patients. In her book Notes on Nursing: What It Is and What It Is Not (1969), she developed a whole section on observation of the sick. She wanted her nurses “to be clear thinkers and independent in their judgments” ( Reed & Zurakowski, 1996, p. 47 ). She advocated for nurses to have educational backgrounds and knowledge that were different from those of physicians ( Nightingale, 1969 ; Reed & Zurakowski, 1996 ; Selanders, 1998 ). She believed in and rallied for nursing education to be a combination of clinical experience and classroom learning. Nightingale states, “Neither can [nursing] be taught by lectures or by books, though these are valuable accessories, if used as such; otherwise what is in the book stays in the book” ( Nightingale, 1954b, p. 355 ). Using critical thinking for the application of Nightingale’s environmental theory requires use of her 13 canons ( Selanders, 1998 ) and the nursing process. Table 5-1 illustrates the interaction of the nurse and the patient with the use of Nightingale’s environmental theory. TABLE 5-1 Critical Thinking with Nightingale’s Theory Nightingale’s Canons ( Nightingale, 1969 ; Selanders, 1998 ) Nursing Process and Thought Ventilation and warmth Assess the client’s body temperature, room temperature, and room for fresh air (or adequate ventilation) and foul odors. Develop a plan to keep the room airy and free of odor while maintaining the client’s body temperature. Light Assess the room for adequate light. Sunlight works best. Develop and implement adequate light in the client’s room without placing the client in direct light. Cleanliness of rooms and walls Assess the room for dampness, darkness, and dust or mildew. Keep the room free from dust, dirt, mildew, and dampness. Health of houses Assess the surrounding environment for pure air, pure water, drainage, cleanliness, and light. Examples include removing garbage or garments from the area, removing any standing water (or ensuring that water drains away from the area), and ensuring that air and water are clean and free from odor and that there is plenty of light. Noise Assess the noise level in the client’s room and surrounding area. Attempt to keep noise level to a minimum, and refrain from whispering outside the door. Bed and bedding Assess the bed and bedding for dampness, wrinkles, and soiling, and check the bed for height. Keep the bed dry, wrinkle-free, and at the lowest height to ensure the client’s comfort. Personal cleanliness Attempt to keep the client dry and clean at all times. Frequent assessment of the client’s skin is needed to maintain adequate skin moisture. Variety Attempt to stimulate variety in the room and with the client. This is accomplished with cards, flowers, pictures, books, or puzzles. Encourage friends and relatives to engage the client in some sort of stimulating conversation. Chattering hopes and advices Avoid talking without reason or giving advice that is without fact. Continue to talk to the client as a person, and continue to stimulate the client’s mind. Avoid personal talk. Taking food Assess the diet of the client. Take note of the amount of food and drink ingested by the client at every meal or snack. What food Continue with the assessment of the diet to include type of food and drink the client likes or dislikes. Attempt to ensure that the client always has some food or drink available that he or she enjoys. Petty management Petty management ensures continuity of care. Documentation of the plan of care and all evaluation will ensure others give the same care to the client in your absence. Observation of the sick Observe everything about your client. Record all observations. Observations should be factual and not merely opinions. Continue to observe the client’s surrounding environment, and make alterations in the plan of care when needed. Although the 13 canons are central to Nightingale’s theory, they are not all-inclusive. She believed that the person was a holistic individual and thus had a spiritual dimension. She believed nursing was a spiritual calling, and with that belief she assumed that nurses could help those clients who were in spiritual distress ( Nightingale, 1954a , 1969 ). This is an assumption because of the time period in which Nightingale lived; it was expected that Christians would help other Christians. She identified nursing of the sick (nursing proper) and nursing of the well (nursing general) ( Nightingale, 1969 ). She believed the two to be almost identical, with the outcome being the major difference. Because Nightingale believed in nursing well persons—or health promotion—it is logical that she assumed her nurses would complete some health teaching as they were caring for the sick or for those who were already well. The use of Nightingale’s theory, the 13 canons, as well as health promotion and spiritual distress is illustrated in the following two case applications. CASE HISTORY OF DEBBIE Debbie is a 29-year-old woman who was recently admitted to the oncology nursing unit for evaluation after sensing pelvic “fullness” and noticing a watery, foul-smelling vaginal discharge. A Papanicolaou smear revealed class V cervical cancer. She was found to have a stage II squamous cell carcinoma of the cervix and underwent a radical hysterectomy with bilateral salpingo-oophorectomy. Her past health history revealed that physical examinations had been infrequent. She also reported that she had not performed breast self-examination. She is 5 feet, 4 inches tall and weighs 89 pounds. Her usual weight is approximately 110 pounds. She has smoked approximately two packs of cigarettes a day for the past 16 years. She is gravida 2, para 2. Her first pregnancy was at age 16, and her second was at age 18. Since that time she has taken oral contraceptives on a regular basis. Debbie completed the eighth grade. She is married and lives with her husband and her two children in her mother’s home, which she describes as less than sanitary. Her husband is unemployed. She describes him as emotionally distant and abusive at times. She has done well following surgery except for being unable to completely empty her urinary bladder. She is having continued postoperative pain and nausea. It will be necessary for her to perform intermittent self-catheterization at home. Her medications are (1) an antibiotic, (2) an analgesic as needed for pain, and (3) an antiemetic as needed for nausea. In addition, she will be receiving radiation therapy on an outpatient basis. Debbie is extremely tearful. She expresses great concern over her future and the future of her two children. She believes that this illness is a punishment for her past life.

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Nightingale's Environment Theory

As the founder of modern nursing, Florence Nightingale’s Environment Theory changed the face of nursing practice. She served as a nurse during the Crimean War, at which time she observed a correlation between the patients who died and their environmental conditions. As a result of her observations, the Environment Theory of nursing was born. Nightingale explained this theory in her book, Notes on Nursing: What it is, What it is Not . The model of nursing that developed from Nightingale, who is considered the first nursing theorist, contains elements that have not changed since the establishment of the modern nursing profession. Though this theory was pioneering at the time it was created, the principles it applies are timeless.

There are seven assumptions made in the Environment Theory, which focuses on taking care of the patient’s environment in order to reach health goals and cure illness. These assumptions are:

• natural laws
• mankind can achieve perfection
• nursing is a calling
• nursing is an art and a science
• nursing is achieved through environmental alteration
• nursing requires a specific educational base
• nursing is distinct and separate from medicine

The focus of nursing in this model is to alter the patient’s environment in order to affect change in his or her health. The environmental factors that affect health, as identified in the theory, are: fresh air, pure water, sufficient food supplies, efficient drainage, cleanliness of the patient and environment, and light (particularly direct sunlight). If any of these areas is lacking, the patient may experience diminished health. A nurse’s role in a patient’s recovery is to alter the environment in order to gradually create the optimal conditions for the patient’s body to heal itself. In some cases, this would mean minimal noise and in other cases could mean a specific diet. All of these areas can be manipulated to help the patient meet his or her health goals and get healthy.

The Environment Theory of nursing is a patient-care theory. That is, it focuses on the care of the patient rather than the nursing process , the relationship between patient and nurse, or the individual nurse. In this way, the model must be adapted to fit the needs of individual patients. The environmental factors affect different patients unique to their situations and illnesses, and the nurse must address these factors on a case-by-case basis in order to make sure the factors are altered in a way that best cares for an individual patient and his or her needs.

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The ten major concepts of the Environment Theory, also identified as Nightingale’s Canons, are:

• Ventilation and warming
• Light and noise
• Cleanliness of the area
• Health of houses
• Bed and bedding
• Personal cleanliness
• Offering hope and advice
• Observation

According to Nightingale, nursing is separate from medicine. The goal of nursing is to put the patient in the best possible condition in order for nature to act. Nursing is “the activities that promote health which occur in any caregiving situation.” Health is “not only to be well, but to be able to use well every power we have.” Nightingale’s theory addresses disease on a literal level, explaining it as the absence of comfort.

The environment paradigm in Nightingale’s model is understandably the most important aspect. Her observations taught her that unsanitary environments contribute greatly to ill health, and that the environment can be altered in order to improve conditions for a patient and allow healing to occur.

Nightingale’s Modern Nursing Theory also impacted nursing education. She was the first to suggest that nurses be specifically educated and trained for their positions in healthcare. This allowed there to be standards of care in the field of nursing, which helped improve overall care of patients.

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Florence Nightingale's theory and her contributions to holistic critical thinking in nursing

Affiliations.

• 1 Universidade Federal de Santa Catarina. Florianópolis, Santa Catarina, Brazil.
• 2 Universidade Federal do Rio Grande do Sul. Porto Alegre, Rio Grande do Sul, Brazil.
• 3 Lovisenberg Diakonale Høgskole. Oslo, Noruega.
• PMID: 33950115
• DOI: 10.1590/0034-7167-2020-0139

Objective: to reflect on Florence Nightingale's legacy and describe her contributions to critical holistic thinking in nursing.

Methods: this is a theoretical reflection, for which scientific productions on Florence Nightingale's environmental theory, as published in national and international journals, were based.

Results: Florence Nightingale's philosophy and teachings emphasize that the nurse must use her brain, heart and hands to create healing environments to care for the patient's body, mind and spirit. Nursing, since the time of Nightingale, has been building the holistic paradigm, in all schools of thought, with a view to a humanistic approach to the human being in their indivisible relationship with the environment.

Final considerations: Florence's contributions to holistic critical thinking in nursing are evident, constituting nurses' differential in clinical practice.

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Objective: to reflect on Florence Nightingale's legacy and describe her contributions to critical holistic thinking in nursing. Methods: this is a theoretical reflection, for which scientific productions on Florence Nightingale's environmental theory, as published in national and international journals, were based. Results: Florence Nightingale's philosophy and teachings emphasize that the nurse must use her brain, heart and hands to create healing environments to care for the patient's body, mind and spirit. Nursing, since the time of Nightingale, has been building the holistic paradigm, in all schools of thought, with a view to a humanistic approach to the human being in their indivisible relationship with the environment. Final considerations: Florence's contributions to holistic critical thinking in nursing are evident, constituting nurses' differential in clinical practice.

Descriptors: Critical Thinking; Nursing Theory; History of Nursing; Nursing Care; Nursing.

Objetivo: refletir sobre o legado de Florence Nightingale e descrever suas contribuiçoes para o pensamento crítico holístico na enfermagem. Métodos: trata-se de uma reflexâo teórica, para a qual serviram de base produçoes científicas sobre a teoria ambientalista de Florence Nightingale, publicadas em periódicos nacionais e internacionais. Resultados: a filosofia e os ensinamentos de Florence Nightingale enfatizam que a enfermeira deve usar o cerebro, o coraçâo e as mâos na criaçâo de ambientes de cura, para cuidar do corpo do paciente, de sua mente e de seu espirito. A enfermagem, desde a época de Nightingale, vem construindo o paradigma holístico, em todas as escolas de pensamento, com vistas a uma abordagem humanística do ser humano em sua indivisível relaçâo com o ambiente. Consideraçoes finais: as contribuiçoes de Florence ao pensamento crítico holístico na enfermagem sao evidentes, constituindo o diferencial do enfermeiro na prática clínica.

Descritores: Pensamento Crítico; Teoria de Enfermagem; História da Enfermagem; Cuidados de Enfermagem; Enfermagem.

Objetivo: reflexionar sobre el legado de Florence Nightingale y describir sus contribuciones al pensamiento crítico holístico en enfermería. Métodos: se trata de una reflexión teórica, para la cual se basaron producciones científicas sobre la teoría ambiental de Florence Nightingale, publicadas en revistas nacionales e internacionales. Resultados: la filosofía y las enseñanzas de Florence Nightingale enfatizan que la enfermera debe usar su cerebro, corazón y manos para crear ambientes curativos para cuidar el cuerpo, la mente y el espíritu del paciente. La enfermería, desde la época de Nightingale, ha ido construyendo el paradigma holístico, en todas las escuelas de pensamiento, con miras a un acercamiento humanista al ser humano en su relación indivisible con el medio ambiente. Consideraciones finales: las contribuciones de Florence al pensamiento crítico holístico en enfermería son evidentes, constituyendo el diferencial de la enfermera en la práctica clínica.

Descriptores: Pensamiento; Teoría de Enfermería; Historia de la Enfermería; Atención de Enfermería; Enfermería.

INTRODUCTION

The year 2020 marks the bicentenary of the birth of Florence Nightingale, the forerunner of modern nursing, i.e., the ideal time to analyze and reflect on her contributions and the impact on nursing professionalization. Based on Dewey's premise, "The past is key to understanding the present". This theoretical reflection proposes to describe Florence's contributions to holistic critical thinking in nursing(1).

Nightingale left a legacy of teachings and cornerstones that underpin the profession to this day. Her idealism runs through the historical trajectory of nursing through the records left, as current as 200 years ago. The alignment of current trends with Nightingale's theory and philosophy is impressive.

Florence's contributions are prominent in international literature, especially when her fundamental principle is discussed in her writings, i.e., healing (healing process or healing act), representing the gathering of all aspects of the body, mind and spirit, to achieve and maintain the integration of a balance, which denotes holistic nursing care(2-4). Nightingale, in the distinction between therapy and healing, explains that therapy can always be instituted, but healing is not always possible. Removing the signs and symptoms of a disease does not heal the disease, and involves only one dimension of care, the physical dimension, leaving the spiritual dimension in the background(5-8).

In this sense, it is important to highlight that Nightingale introduced, in the context of care, colors, light, music, pets, exercise, flowers as aspects to be emphasized in a favorable environment in search of healing, reaffirming the bases of environmental theory and the premise that the environment influences people's health(5).

It is stated that, in order to become a nurse sensitive to holism, it requires the understanding, in the care encounter in which it is present, of all the facets presented by patients. This genuine presence requires nurses to first understand all aspects of themselves®; in other words, it is paramount, in the care process, that nurses also understand themselves in their entirety to, from that, be able to understand patients in all their needs, be they physiological or spiritual.

In this way, spirituality in nursing is one of the pillars of holistic nursing, with emphasis on characteristics such as: harmony, balance and interaction in a functional totality of its aspects; qualities and potential of individuals and/or collectivity; person-centered or community-centered care, focusing on it as an indivisible unit and in constant interaction with the environment; comprehensive attention to the individual's and/or the community's basic human needs, addressing biopsychosocial and spiritual aspects; use of technology applied to human health; development of natural methods in order to improve their health(6-7).

Currently, nurses are being challenged to boost Florence's ideals through critical thinking, aiming to provide humane and competent care based on the best scientific evidence against the backdrop of unprecedented changes, which have occurred worldwide, requiring nurses to be able for critical and holistic thinking in clinical decisionmaking and care management in different contexts of practice. Thus, it is important to highlight the fundamental concepts of the course proposed by Nightingale in the 1850s. Her precepts, created with wisdom and from an expanded world view, revolutionary for the time, echo through the decades, influencing science nurses until today and that show their contributions to the constitution of nurses' holistic critical thinking®.

This study aimed to reflect on Florence Nightingale's legacy and describe her contributions to critical holistic thinking in nursing.

This is a theoretical reflection article, for which scientific productions on Florence Nightingale's environmental theory, published in national and international journals, were based. For this, a search was carried out in national and international databases, with the objective of selecting published studies on the contributions of Florence's environmental theory to holistic critical thinking in nursing.

Moreover, bibliographic references were used for the theoretical basis about critical thinking and Florence Nightingale's theory. Based on the selected scientific productions, a careful reading was carried out in order to identify and synthesize the main contributions of environmental theory, being organized and presented in three sections: Florence Nightingale's legacy: central principles and concepts of environmental theory; Florence Nightingale: repercussions of her teachings for modern nursing; Holistic nursing and nurses' holistic critical thinking.

Florence Nightingale's legacy: central principles and concepts of environmental theory

Nightingale's life trajectory was immersed in complexity, partially revealed in her 14,000 letters and 100 books, reports, and bulletins. The precursor of nursing believed that nursing was her call from God, her curious and passionate mind for nursing and her relentless desire to transform opened doors challenging the social context, in which she encountered persistent opposition, as she was always a visionary and courageous woman. Furthermore, she advocated that patients receive civilized care, regardless of the social situation experienced®.

Faced with this premise, this reflection article seeks to provoke the reader to reflect on Florence's trajectory, examining her legacy with the following question: does Nightingale's theory and principles contribute to the development of nurses' holistic critical thinking today? The answer is affirmative, since, in this context, holistic nursing is based on nursing knowledge, theories, research, doing mediated by experience, intuition and creativity. Additionally, "it includes as a function and objective of nursing care and contribute to the healing of people in their entirety from birth to death", as recommended by Florence Nightingale®.

In 1859, Florence wrote Notes on Hospital, and, in 1860, Notes on Nursing. These compendiums explained hygiene standards, treatment of injuries, ventilation and other concepts necessary for building nursing science. Her standards on nutrition, sleep and exercise continue to guide health promotion to the present day(3).

The three principles of Florence's environmental theory are healing, leadership, and global action. The principle considered basic was healing, and the secondary ones, leadership and global action, were principles necessary to support healing at its deepest level. With regard to Florence's educational model, one must take into account the fact that it is based on the anticipation of care and attention to patients' needs, providing guidance for nurses to perform activities in order to meet patients' needs(8).

Florence Nightingale's environmental theory is based on five points, which she believed to be essential to obtain a healthy home, such as clean water and air, basic sanitation, cleanliness and light, as she believed that a healthy environment was fundamental for healing. In her time, she reported that noise was harmful and disturbed the rest of individuals, so the conversation of caregivers should be avoided, as well as agitation, unnecessary questions. On the other hand, Florence recommended nutritious food, beds and appropriate bedding and personal hygiene for individuals®.

In this theoretical and practical context, nursing was seen as a means of "putting the individuals' structure in such a state that they have no disease or can recover from the disease", placing individuals in a condition in which nature can preserve or recover health - preventing or curing illness or injury. Health, according to Florence, is defined as the ability of individuals to properly use all their skills and competencies in the perspective of caring for themselves and others®.

Florence defended a solid knowledge base in nursing and anchored in principles; if this were not possible, it would be like building a house with a weak foundation, i.e., it will fall. This premise becomes even more current when applied in nursing education, i.e., nurses trained with strong bases and principles will have subsidies to provide quality care, applying their critical thinking to making accurate decisions for the benefit of patients under their responsibility. Florence argued that nurses should accurately observe their patients and report the real state of health in an orderly manner to the physician®.

Based on Nightingale's principles, we can evidence her search for respect for humanity and social justice, as she defended respect for the human person regardless of social class, physical disabilities, hygiene conditions or occupation. While her family sought to include her in an elitist culture, her spirituality called her to serve ordinary people. For Nightingale, a true nurse should renounce class distinctions and always focus on the person®.

Faced with soldiers wounded in the Crimean War, she insisted that each soldier be treated with dignity and kindness, a radical departure from military custom. In light of this, we highlight the efforts of hospital institutions to provide humane and patient-centered care. We can now observe the focus on safety and meeting users' real health needs, through quality programs and through direct care provided by nurses, proposing to be closer to their patients®.

Florence Nightingale: repercussions of her teachings for modern nursing

Modern nursing has (re) invented itself; however, it has retained numerous principles of Florence's environmental theory in its scientific bases. It also incorporated new technologies, to guarantee the execution of human and singular care to human beings, always guided by the science and art inherited from Florence Nightingale, prioritizing the comfort, the technique and the environment suitable for healing patients.

Nightingale's commitment to staying with patients in times of suffering is the very basis of patient-centered care, which becomes a very current and necessary principle for the full recovery of patients®. For this, individualized care to patients' needs needs to be implemented. Currently, such care, also called nursing interventions or activities, ended up being researched and polished. They were cataloged in the form of international classification of results and interventions, based on the standardized language of nursing diagnoses, structured from the real or potential problems of individuals, who need nursing assistance.

Florence addressed the organization of care delivery with a focus on obtaining a healing; currently, we can find this determination in the Nursing Process, understood as a methodological instrument used by nurses to organize and plan nursing care and structured in five stages: research, nursing diagnoses, planning, implementation, and assessment.

Modernity has brought significant advances, which have strained the qualification of nurses' being and doing; the insertion of new care and teaching technologies has been widely implemented. In this direction, Florence's teachings have left their mark, influencing the nursing routine, as it has always emphasized the importance of nurses' commitment to care, as well as learning based on practice.

Numerous ways of doing nursing are currently presented as novelties, denoting the rescue of innovations that Florence, in her time, created and implemented, only with the difference of today taking on a new guise, such as risk stratification, prevention and control of infections, cleanliness, fresh air, comfort, considering that the environment directly affects the health of individuals through music, colors. The possibility of inserting pets or therapeutic animals are practices indicated and implemented by Florence®.

Therefore, in this process, innovating in nursing presupposes taking into account the principles and concepts learned from Nightingale, in addition to the theories proposed by countless nursing theorists. Care territories and contexts should be sought to, in this way, modify forms of care devoid of scientific knowledge and the necessary structure for quality nursing care.

Thus, memories of the past related to the origins of care science must be preserved in order to understand and modify the being and doing of nurses in the present and in the future. This is the main objective of modern nursing. In this context, we highlight the importance of holistic nursing and the development of critical thinking, so urgent today, in order to qualify teaching, research, and care(2).

One of the greatest challenges of modern nursing is to meet human needs in their entirety. These will be better identified by nurses who think and practice nursing in a holistic perspective, developing professional training focused on critical thinking in their care contexts and practices. Thus, said innovations in nursing will consist of the necessary and pressing rescue of Florence's teachings®5.

Thus, this brings us to the current world health scenario that we are experiencing with regard to the health situation in the midst of Florence's bicentennial. The scientific, human, ethical and social commitment of nursing science in times of pandemic is reaffirmed, recognizing the value of philosophy which, in turn, is even more necessary to maintain her environmental theory principles today. It should be explored in depth in the spaces of training and assistance, providing the basis for supporting nursing education and the development and practical application of critical thinking of future nurses, aiming at qualitatively intervening in human care with a view to prevention and healing diseases in general. Thus, Florence Nightingale's principles can directly reflect on the process of training and care in different contexts of teaching and care.

Holistic nursing and nurses' holistic critical thinking

Holistic nursing is based on nursing knowledge, theories, research, doing mediated by experience, as well as intuition and creativity®. In this perspective, nursing practice incorporates theory, practice and subjective aspects, as well as intuition and creativity, which are decisive in how this care model will be constituted.

Florence's legacy with regard to holistic nursing, as well as critical thinking, is evident when we analyze the historical path of meeting humanity'needs, and has been at the forefront in providing care and comfort to patients. Moreover, nursing was also concerned with health education for the population. Florence encouraged her students to consider cultural and religious diversity, as well as the values, needs and concerns of individuals in their uniqueness, without neglecting the economic and social aspects that involve care(5).

Florence's historical trajectory shows the importance of nurses capable of thinking critically and holistically to deal with situations of adversity, as was the case in the Crimean War. Florence experienced scenarios of uncertainties, adversities and care contexts for which she needed to apply her highly developed critical thinking to the feminine patterns and patterns of her time(3).

Holistic critical thinking can be defined as thinking with quality, i.e., a judgment process centered on deciding what to believe or what to do. In doing so, the critical thinker should not be negative or cynical, but reflective and balanced, requiring people to express some kind of reason or basis for whatever they are saying(9).

According to Florence's view, nurses should think critically about patient care, doing what was appropriate and necessary to help them heal, reinforcing the importance of developing in nurses the critical and holistic way of thinking in the daily life of be and do nursing(8).

Starting from this way of thinking, at that time, evidence-based practice was carried out in a very healthy way for the performance of nursing procedures and care, as research was still scarce. Even so, Florence can be considered a pioneer in conducting research on evidence-based practice and the application of critical thinking. Florence's environmental theory strongly supported nursing and also for the development of critical thinking, contributing to evidence-based nursing practice and beyond these very important aspects of nurses' training and clinical practice®^.

Like Florence, it is worth highlighting other nursing theorists, such as Watson, Horta, King and Leninger, who impacted society by considering not only the physical aspects of a human being, but also the interconnection between each individual's body, mind and spirit. It must be considered that, in the last three decades, nursing has gone from a model focused on physiological and scientific aspects to a model focused on nursing science, care and healing, seeking to consider the cultural aspects, values and beliefs connected to the act to care(10).

In Brazil, we can describe this movement as a paradigm shift from a biomedical-technicist model to a care model based on the art and science of technical-scientific and humanistic care(10). This movement boosted the emphasis on Florence Nightingale's philosophy and teachings, awakening in nurses the capacity and a need to think holistically using the brain, heart and hands in creating healing environments, in order to effectively take care of the trinomial dimensional body-mind-spirit.

Accordingly, it is possible to note a critical thinking strongly influenced by the contributions of Florence's legacy, which direct nurses towards a comprehensive and humanistic approach, in which the ability to listen and to consider a person in their entirety predominates. In this direction, nurses who develop holistic critical thinking in nursing training will have better performance by applying cognitive, behavioral and habits of the mind and, consequently, Florence Nightingale's principles and theory. In this regard, it will be possible to care for individuals as a unique human being, i.e., singular, in order to consider the needs related to the physical body (physiological aspects), the mind (emotional aspects) and the spirit (spiritual aspects)(10).

The scarcity of research published in Brazil addressing the influence of Nightingale's theory on nurses' holistic critical thinking is one of the limitations of this reflection. This denotes a knowledge gap to be filled, given the importance of this theme for nursing education and care. Concerning the contributions of this study, the possibility of impacting professional practice through knowledge and recognition of Florence's legacy for training and professional practice is highlighted, in addition to enabling students and nurses to understand Nightingale's theory.

FINAL CONSIDERATIONS

This theoretical reflection ends with evidence of the fundamental importance of the contributions of Florence Nightingale's legacy to critical thinking in nursing. Moreover, it is seen that her theory is decisive in filling the knowledge gaps related to the holistic dimension in carrying out the nursing process, aiming at accurate clinical decision-making of students and nurses. It is imperative that nurses apply Nightingale's holistic philosophy and assumptions in nursing, as patients expect compassion, in addition to specialized nurses focused on the totality of human needs.

Nightingale's legacy allows us to meet these expectations, as her philosophy includes encouraging self-care, art and nursing science, covering related theories, in addition to research and ethics. Nightingale demonstrated by example in her trajectory, spreading, in her scientific productions that her fundamental principle was to care with a focus on prevention and healing through the process that unites all the singular dimensions that constitute the whole of individuals to achieve and maintain integration and balance. Thus, to guarantee this focus on nursing training, the commitment that teaching and caring are verbs and actions to be conjugated beyond the discourse and carried out in the genuine practice of being and doing by nurses is reaffirmed.

How to cite this article:

Riegel F, Crossetti MGO, Martini JG, Nes AAG. Florence Nightingale's theory and her contributions to holistic critical thinking in nursing. Rev Bras Enferm. 2021;74(2):e20200139. doi: http://dx.doi.org/10.1590/0034-7167-2020-0139

Corresponding author:

Fernando Riegel 1?Pf

E-mail: [email protected]

EDITOR IN CHIEF: Antonio José De Almeida Filho

ASSOCIATE EDITOR: Rafael Silva

Submission: 04-26-2020 Approval: 09-27-2020

1. Dewey J. Democracy and education. New York (NY): Free Press (Reprint), 2004.

2. American Holistic Nurses Credentialing Corporation. American Holistic Nurses Association. Foundations. Competencies, and curriculum guidelines for basic to doctoral holistic nursing education[Internet]. 2017[cited 2020 Jul 5];1(1):1-55. Available from: https://www.ahncc.org/ wp-content/uploads/2018/10/Foundations-Competencies-Curricular-Guidelines.pdf

3. Nightingale F. Notes on nursing: what it is, and what it is not. Philadelphia (PA): J. B. Lippincott, 1859/1992.

4. Healing. In: Dictionary Cambridge. Gra-Bretanha, Cambridge (GB-C): Cambridge University Press; 2020.

5. Kalb KA, Conner-Von SO. Holistic Nursing Education: Teaching in a holistic way. Nurs Educ Perspect. 2019;40(3):162-64. https://doi. org/10.1097/01.NEP.0000000000000405

6. American Holistic Nurses Association (AHNA). What is Holistic Nursing. [Internet]. 2020. [cited 2020 Jul 5]. 1(1)-1-2. Available from: http:// ahna.org/about/whatis.html

7. Lopes ND, Nóbrega MML. Holismo nos modelos teóricos de enfermagem. Rev Bras Enferm. [Internet]. 1999[cited 2020 Jul 5];52(2):233-42. Available from: https://www.scielo.br/pdf/reben/v52n2/v52n2a10.pdf

8. McEwen M, Willis EM. Theoretical Basis for Nursing. 5 ed. Alphen aan den Rijn (NL): Wolters Kluwer; 2018. 624 p.

9. Facione PA, Gittens CA. Think Critically. Chapter 1. Califórnia (EUA): Pearson Education; 2016. 418 p.

10. Riegel F, Crossetti MGO, Siqueira DS. Contributions of Jean Watson's theory to holistic critical thinking of nurses. Rev Bras Enferm. 2018;71(4):2072-6. http://dx.doi.org/10.1590/0034-7167-2017-0065

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Applicability of theoretical references by nurses in primary health care: scoping review, trust and nursing, aplicabilidade de referenciais teóricos por enfermeiros na atenção primária à saúde: revisão de escopo, nursing education's dynamic history, holismo nos modelos teóricos de enfermagem, holistic nursing education: teaching in a holistic way., holism in theoretical nursing models, contributions of jean watson's theory to holistic critical thinking of nurses., trending questions (3).

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Florence Nightingale’s theory and her contributions to holistic critical thinking in nursing

• Fernando Riegel,
• Maria da Graça Oliveira Crossetti,
• Jussara Gue Martini,
• Andrea Aparecida Gonçalves Nes

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ABSTRACT Objective: to reflect on Florence Nightingale’s legacy and describe her contributions to critical holistic thinking in nursing. Methods: this is a theoretical reflection, for which scientific productions on Florence Nightingale’s environmental theory, as published in national and international journals, were based. Results: Florence Nightingale’s philosophy and teachings emphasize that the nurse must use her brain, heart and hands to create healing environments to care for the patient’s body, mind and spirit. Nursing, since the time of Nightingale, has been building the holistic paradigm, in all schools of thought, with a view to a humanistic approach to the human being in their indivisible relationship with the environment. Final considerations: Florence’s contributions to holistic critical thinking in nursing are evident, constituting nurses’ differential in clinical practice.

• Critical Thinking
• Nursing Theory
• History of Nursing
• Nursing Care

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• DOI: 10.1590/0034-7167-2020-0139
• Corpus ID: 233740719

Florence Nightingale's theory and her contributions to holistic critical thinking in nursing.

• Fernando Riegel , M. G. Crossetti , +1 author A. A. Nes
• Published in Revista Brasileira de… 2021
• Environmental Science, Philosophy, Medicine

24 Citations

Nursing professionals' education on the spiritual dimension of critical patients., what is nursing professionalism a concept analysis, spiritual self-care management for nursing professionals: a holistic approach, perspectives of clinical instructors of nursing student competences in acute and critical care, evolución de la práctica enfermera desde florence nightingale hasta la enfermería moderna, nursing education's dynamic history, interrelations between florence nightingale’s environmentalist theory and the ecosystem theory, integrality of health care from the philosophical perspective of emmanuel, applicability of theoretical references by nurses in primary health care: scoping review, trust and nursing, 10 references, contributions of jean watson's theory to holistic critical thinking of nurses..

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Notes on Nursing: What It Is, and What It Is Not

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Florence Nightingale’s theory and her contributions to holistic critical thinking in nursing

Abstract: objective: to reflect on florence nightingale’s legacy and describe her contributions to critical holistic thinking in nursing. methods: this is a theoretical reflection, for which scientific productions on florence nightingale’s environmental theory, as published in national and international journals, were based. results: florence nightingale’s philosophy and teachings emphasize that the nurse must use her brain, heart and hands to create healing environments to care for the patient’s body, mind and spirit… show more.

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Cited by 25 publication s

References 3 publication s, spiritual self-care management for nursing professionals: a holistic approach.

Among all the groups and occupations that have been affected by the global pandemic, nursing professionals stand out as having been particularly hard-pressed due to the dramatic increase in the need for their services. Given the rising tide of coronavirus disease 2019 patients who require specialized medical treatment as well as the millions of others that are lining up for vaccinations, it can be assumed that many nursing professionals have had to endure such things as longer working hours, tighter schedules, and the intensity of a work environment in which failure of care and multiple deaths are the daily fare. This article proposes that nurses can avoid such severe consequences by taking up a regime of enhanced self-care management that enables them to achieve psychophysical balance and wellness. Three practices are highlighted in this regard: prayer, meditative walking, and the mindfulness practice of body scanning. Our suggestion is that these coping strategies will be both beneficial and healthful for nursing professionals in terms of enhancing their spiritual/existential resilience and meeting their own need for consolation as they navigate in an extremely difficult and demanding work environment.

Enfermagem em saúde pública no monitoramento do near miss materno: reflexões da teoria de enfermagem/Public health nursing in the monitoring of maternal near miss: reflections of nursing theory

Objetivo: refletir, na perspectiva da Teoria de Enfermagem de Florence Nightingale, a respeito do Processo de Enfermagem no monitoramento do near miss materno. Método: trata-se de estudo reflexivo comparativo entre a análise do processo de monitoramento dos casos de near miss materno e os metaparadigmas da Teoria de Enfermagem de Florence Nightingale, aplicados a um ambiente de gestão em saúde pública e atuação do enfermeiro, a partir da análise de Teorias de Enfermagem em uma disciplina de mestrado. Resultados: na teoria de Florence são veiculados os conceitos de saúde, doença, enfermagem e ambiente. E, na trajetória da reflexão, revisitam-se os princípios elementares da profissão desenvolvidos por Florence, os quais identificam a assistência (enfermagem), a gestão (saúde/doença) e o monitoramento do near miss materno na saúde pública (ambiente). Para o monitoramento de near miss materno, identificam-se os conceitos para atuação e análise. Considerações Finais: o estudo proporcionou relacionar a perspectiva expressa na teoria de Florence Nightingale com a atuação do enfermeiro no monitoramento do near miss materno, a partir dos metaparadigmas.

The succession plan: Using competency-based curriculums to educate a new generation of nurse leaders

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Florence Nightingale’s theory and her contributions to holistic critical thinking in nursing

La teoría de florence nightingale y sus contribuciones al pensamiento crítico holístico en enfermería.

to reflect on Florence Nightingale’s legacy and describe her contributions to critical holistic thinking in nursing.

this is a theoretical reflection, for which scientific productions on Florence Nightingale’s environmental theory, as published in national and international journals, were based.

Florence Nightingale’s philosophy and teachings emphasize that the nurse must use her brain, heart and hands to create healing environments to care for the patient’s body, mind and spirit. Nursing, since the time of Nightingale, has been building the holistic paradigm, in all schools of thought, with a view to a humanistic approach to the human being in their indivisible relationship with the environment.

Final considerations:

Florence’s contributions to holistic critical thinking in nursing are evident, constituting nurses’ differential in clinical practice.

Descriptors: Critical Thinking; Nursing Theory; History of Nursing; Nursing Care; Nursing

reflexionar sobre el legado de Florence Nightingale y describir sus contribuciones al pensamiento crítico holístico en enfermería.

se trata de una reflexión teórica, para la cual se basaron producciones científicas sobre la teoría ambiental de Florence Nightingale, publicadas en revistas nacionales e internacionales.

Resultados:

la filosofía y las enseñanzas de Florence Nightingale enfatizan que la enfermera debe usar su cerebro, corazón y manos para crear ambientes curativos para cuidar el cuerpo, la mente y el espíritu del paciente. La enfermería, desde la época de Nightingale, ha ido construyendo el paradigma holístico, en todas las escuelas de pensamiento, con miras a un acercamiento humanista al ser humano en su relación indivisible con el medio ambiente.

Consideraciones finales:

las contribuciones de Florence al pensamiento crítico holístico en enfermería son evidentes, constituyendo el diferencial de la enfermera en la práctica clínica.

Descriptores: Pensamiento; Teoría de Enfermería; Historia de la Enfermería; Atención de Enfermería; Enfermería

refletir sobre o legado de Florence Nightingale e descrever suas contribuições para o pensamento crítico holístico na enfermagem.

trata-se de uma reflexão teórica, para a qual serviram de base produções científicas sobre a teoria ambientalista de Florence Nightingale, publicadas em periódicos nacionais e internacionais.

a filosofia e os ensinamentos de Florence Nightingale enfatizam que a enfermeira deve usar o cérebro, o coração e as mãos na criação de ambientes de cura, para cuidar do corpo do paciente, de sua mente e de seu espírito. A enfermagem, desde a época de Nightingale, vem construindo o paradigma holístico, em todas as escolas de pensamento, com vistas a uma abordagem humanística do ser humano em sua indivisível relação com o ambiente.

Considerações finais:

as contribuições de Florence ao pensamento crítico holístico na enfermagem são evidentes, constituindo o diferencial do enfermeiro na prática clínica.

Descritores: Pensamento Crítico; Teoria de Enfermagem; História da Enfermagem; Cuidados de Enfermagem; Enfermagem

INTRODUCTION

The year 2020 marks the bicentenary of the birth of Florence Nightingale, the forerunner of modern nursing, i.e., the ideal time to analyze and reflect on her contributions and the impact on nursing professionalization. Based on Dewey’s premise, “The past is key to understanding the present”. This theoretical reflection proposes to describe Florence’s contributions to holistic critical thinking in nursing ( 1 1 Dewey J. Democracy and education. New York (NY): Free Press (Reprint), 2004. ) .

Nightingale left a legacy of teachings and cornerstones that underpin the profession to this day. Her idealism runs through the historical trajectory of nursing through the records left, as current as 200 years ago. The alignment of current trends with Nightingale’s theory and philosophy is impressive.

Florence’s contributions are prominent in international literature, especially when her fundamental principle is discussed in her writings, i.e., healing (healing process or healing act), representing the gathering of all aspects of the body, mind and spirit, to achieve and maintain the integration of a balance, which denotes holistic nursing care ( 2 2 American Holistic Nurses Credentialing Corporation. American Holistic Nurses Association. Foundations. Competencies, and curriculum guidelines for basic to doctoral holistic nursing education[Internet]. 2017[cited 2020 Jul 5];1(1):1-55. Available from: https://www.ahncc.org/wp-content/uploads/2018/10/Foundations-Competencies-Curricular-Guidelines.pdf https://www.ahncc.org/wp-content/uploads... 3 Nightingale F. Notes on nursing: what it is, and what it is not. Philadelphia (PA): J. B. Lippincott, 1859/1992. - 4 4 Healing. In: Dictionary Cambridge. Grã-Bretanha, Cambridge (GB-C): Cambridge University Press; 2020. ) . Nightingale, in the distinction between therapy and healing, explains that therapy can always be instituted, but healing is not always possible. Removing the signs and symptoms of a disease does not heal the disease, and involves only one dimension of care, the physical dimension, leaving the spiritual dimension in the background ( 5 5 Kalb KA, Conner-Von SO. Holistic Nursing Education: Teaching in a holistic way. Nurs Educ Perspect. 2019;40(3):162-64. https://doi.org/10.1097/01.NEP.0000000000000405 https://doi.org/10.1097/01.NEP.000000000... 6 American Holistic Nurses Association (AHNA). What is Holistic Nursing. [Internet]. 2020. [cited 2020 Jul 5]. 1(1)-1-2. Available from: http://ahna.org/about/whatis.html http://ahna.org/about/whatis.html... 7 Lopes ND, Nóbrega MML. Holismo nos modelos teóricos de enfermagem. Rev Bras Enferm. [Internet]. 1999[cited 2020 Jul 5];52(2):233-42. Available from: https://www.scielo.br/pdf/reben/v52n2/v52n2a10.pdf https://www.scielo.br/pdf/reben/v52n2/v5... - 8 8 McEwen M, Willis EM. Theoretical Basis for Nursing. 5 ed. Alphen aan den Rijn (NL): Wolters Kluwer; 2018. 624 p. ) .

In this sense, it is important to highlight that Nightingale introduced, in the context of care, colors, light, music, pets, exercise, flowers as aspects to be emphasized in a favorable environment in search of healing, reaffirming the bases of environmental theory and the premise that the environment influences people’s health ( 5 5 Kalb KA, Conner-Von SO. Holistic Nursing Education: Teaching in a holistic way. Nurs Educ Perspect. 2019;40(3):162-64. https://doi.org/10.1097/01.NEP.0000000000000405 https://doi.org/10.1097/01.NEP.000000000... ) .

It is stated that, in order to become a nurse sensitive to holism, it requires the understanding, in the care encounter in which it is present, of all the facets presented by patients. This genuine presence requires nurses to first understand all aspects of themselves ( 3 3 Nightingale F. Notes on nursing: what it is, and what it is not. Philadelphia (PA): J. B. Lippincott, 1859/1992. ) ; in other words, it is paramount, in the care process, that nurses also understand themselves in their entirety to, from that, be able to understand patients in all their needs, be they physiological or spiritual.

In this way, spirituality in nursing is one of the pillars of holistic nursing, with emphasis on characteristics such as: harmony, balance and interaction in a functional totality of its aspects; qualities and potential of individuals and/or collectivity; person-centered or community-centered care, focusing on it as an indivisible unit and in constant interaction with the environment; comprehensive attention to the individual’s and/or the community’s basic human needs, addressing biopsychosocial and spiritual aspects; use of technology applied to human health; development of natural methods in order to improve their health ( 6 6 American Holistic Nurses Association (AHNA). What is Holistic Nursing. [Internet]. 2020. [cited 2020 Jul 5]. 1(1)-1-2. Available from: http://ahna.org/about/whatis.html http://ahna.org/about/whatis.html... - 7 7 Lopes ND, Nóbrega MML. Holismo nos modelos teóricos de enfermagem. Rev Bras Enferm. [Internet]. 1999[cited 2020 Jul 5];52(2):233-42. Available from: https://www.scielo.br/pdf/reben/v52n2/v52n2a10.pdf https://www.scielo.br/pdf/reben/v52n2/v5... ) .

Currently, nurses are being challenged to boost Florence’s ideals through critical thinking, aiming to provide humane and competent care based on the best scientific evidence against the backdrop of unprecedented changes, which have occurred worldwide, requiring nurses to be able for critical and holistic thinking in clinical decision-making and care management in different contexts of practice. Thus, it is important to highlight the fundamental concepts of the course proposed by Nightingale in the 1850s. Her precepts, created with wisdom and from an expanded world view, revolutionary for the time, echo through the decades, influencing science nurses until today and that show their contributions to the constitution of nurses’ holistic critical thinking ( 2 2 American Holistic Nurses Credentialing Corporation. American Holistic Nurses Association. Foundations. Competencies, and curriculum guidelines for basic to doctoral holistic nursing education[Internet]. 2017[cited 2020 Jul 5];1(1):1-55. Available from: https://www.ahncc.org/wp-content/uploads/2018/10/Foundations-Competencies-Curricular-Guidelines.pdf https://www.ahncc.org/wp-content/uploads... ) .

This study aimed to reflect on Florence Nightingale’s legacy and describe her contributions to critical holistic thinking in nursing.

This is a theoretical reflection article, for which scientific productions on Florence Nightingale’s environmental theory, published in national and international journals, were based. For this, a search was carried out in national and international databases, with the objective of selecting published studies on the contributions of Florence’s environmental theory to holistic critical thinking in nursing.

Moreover, bibliographic references were used for the theoretical basis about critical thinking and Florence Nightingale’s theory. Based on the selected scientific productions, a careful reading was carried out in order to identify and synthesize the main contributions of environmental theory, being organized and presented in three sections: Florence Nightingale’s legacy: central principles and concepts of environmental theory ; Florence Nightingale: repercussions of her teachings for modern nursing ; Holistic nursing and nurses’ holistic critical thinking .

Florence Nightingale’s legacy: central principles and concepts of environmental theory

Nightingale’s life trajectory was immersed in complexity, partially revealed in her 14,000 letters and 100 books, reports, and bulletins. The precursor of nursing believed that nursing was her call from God, her curious and passionate mind for nursing and her relentless desire to transform opened doors challenging the social context, in which she encountered persistent opposition, as she was always a visionary and courageous woman. Furthermore, she advocated that patients receive civilized care, regardless of the social situation experienced ( 5 5 Kalb KA, Conner-Von SO. Holistic Nursing Education: Teaching in a holistic way. Nurs Educ Perspect. 2019;40(3):162-64. https://doi.org/10.1097/01.NEP.0000000000000405 https://doi.org/10.1097/01.NEP.000000000... ) .

Faced with this premise, this reflection article seeks to provoke the reader to reflect on Florence’s trajectory, examining her legacy with the following question: does Nightingale’s theory and principles contribute to the development of nurses’ holistic critical thinking today? The answer is affirmative, since, in this context, holistic nursing is based on nursing knowledge, theories, research, doing mediated by experience, intuition and creativity. Additionally, “it includes as a function and objective of nursing care and contribute to the healing of people in their entirety from birth to death”, as recommended by Florence Nightingale ( 6 6 American Holistic Nurses Association (AHNA). What is Holistic Nursing. [Internet]. 2020. [cited 2020 Jul 5]. 1(1)-1-2. Available from: http://ahna.org/about/whatis.html http://ahna.org/about/whatis.html... ) .

In 1859, Florence wrote Notes on Hospital, and, in 1860, Notes on Nursing. These compendiums explained hygiene standards, treatment of injuries, ventilation and other concepts necessary for building nursing science. Her standards on nutrition, sleep and exercise continue to guide health promotion to the present day ( 3 3 Nightingale F. Notes on nursing: what it is, and what it is not. Philadelphia (PA): J. B. Lippincott, 1859/1992. ) .

The three principles of Florence’s environmental theory are healing, leadership, and global action. The principle considered basic was healing, and the secondary ones, leadership and global action, were principles necessary to support healing at its deepest level. With regard to Florence’s educational model, one must take into account the fact that it is based on the anticipation of care and attention to patients’ needs, providing guidance for nurses to perform activities in order to meet patients’ needs ( 8 8 McEwen M, Willis EM. Theoretical Basis for Nursing. 5 ed. Alphen aan den Rijn (NL): Wolters Kluwer; 2018. 624 p. ) .

Florence Nightingale’s environmental theory is based on five points, which she believed to be essential to obtain a healthy home, such as clean water and air, basic sanitation, cleanliness and light, as she believed that a healthy environment was fundamental for healing. In her time, she reported that noise was harmful and disturbed the rest of individuals, so the conversation of caregivers should be avoided, as well as agitation, unnecessary questions. On the other hand, Florence recommended nutritious food, beds and appropriate bedding and personal hygiene for individuals ( 8 8 McEwen M, Willis EM. Theoretical Basis for Nursing. 5 ed. Alphen aan den Rijn (NL): Wolters Kluwer; 2018. 624 p. ) .

In this theoretical and practical context, nursing was seen as a means of “putting the individuals’ structure in such a state that they have no disease or can recover from the disease”, placing individuals in a condition in which nature can preserve or recover health - preventing or curing illness or injury. Health, according to Florence, is defined as the ability of individuals to properly use all their skills and competencies in the perspective of caring for themselves and others ( 3 3 Nightingale F. Notes on nursing: what it is, and what it is not. Philadelphia (PA): J. B. Lippincott, 1859/1992. ) .

Florence defended a solid knowledge base in nursing and anchored in principles; if this were not possible, it would be like building a house with a weak foundation, i.e., it will fall. This premise becomes even more current when applied in nursing education, i.e., nurses trained with strong bases and principles will have subsidies to provide quality care, applying their critical thinking to making accurate decisions for the benefit of patients under their responsibility. Florence argued that nurses should accurately observe their patients and report the real state of health in an orderly manner to the physician ( 5 5 Kalb KA, Conner-Von SO. Holistic Nursing Education: Teaching in a holistic way. Nurs Educ Perspect. 2019;40(3):162-64. https://doi.org/10.1097/01.NEP.0000000000000405 https://doi.org/10.1097/01.NEP.000000000... ) .

Based on Nightingale’s principles, we can evidence her search for respect for humanity and social justice, as she defended respect for the human person regardless of social class, physical disabilities, hygiene conditions or occupation. While her family sought to include her in an elitist culture, her spirituality called her to serve ordinary people. For Nightingale, a true nurse should renounce class distinctions and always focus on the person ( 2 2 American Holistic Nurses Credentialing Corporation. American Holistic Nurses Association. Foundations. Competencies, and curriculum guidelines for basic to doctoral holistic nursing education[Internet]. 2017[cited 2020 Jul 5];1(1):1-55. Available from: https://www.ahncc.org/wp-content/uploads/2018/10/Foundations-Competencies-Curricular-Guidelines.pdf https://www.ahncc.org/wp-content/uploads... ) .

Faced with soldiers wounded in the Crimean War, she insisted that each soldier be treated with dignity and kindness, a radical departure from military custom. In light of this, we highlight the efforts of hospital institutions to provide humane and patient-centered care. We can now observe the focus on safety and meeting users’ real health needs, through quality programs and through direct care provided by nurses, proposing to be closer to their patients ( 5 5 Kalb KA, Conner-Von SO. Holistic Nursing Education: Teaching in a holistic way. Nurs Educ Perspect. 2019;40(3):162-64. https://doi.org/10.1097/01.NEP.0000000000000405 https://doi.org/10.1097/01.NEP.000000000... ) .

Florence Nightingale: repercussions of her teachings for modern nursing

Modern nursing has (re) invented itself; however, it has retained numerous principles of Florence’s environmental theory in its scientific bases. It also incorporated new technologies, to guarantee the execution of human and singular care to human beings, always guided by the science and art inherited from Florence Nightingale, prioritizing the comfort, the technique and the environment suitable for healing patients.

Nightingale’s commitment to staying with patients in times of suffering is the very basis of patient-centered care, which becomes a very current and necessary principle for the full recovery of patients ( 5 5 Kalb KA, Conner-Von SO. Holistic Nursing Education: Teaching in a holistic way. Nurs Educ Perspect. 2019;40(3):162-64. https://doi.org/10.1097/01.NEP.0000000000000405 https://doi.org/10.1097/01.NEP.000000000... ) . For this, individualized care to patients’ needs needs to be implemented. Currently, such care, also called nursing interventions or activities, ended up being researched and polished. They were cataloged in the form of international classification of results and interventions, based on the standardized language of nursing diagnoses, structured from the real or potential problems of individuals, who need nursing assistance.

Florence addressed the organization of care delivery with a focus on obtaining a healing; currently, we can find this determination in the Nursing Process, understood as a methodological instrument used by nurses to organize and plan nursing care and structured in five stages: research, nursing diagnoses, planning, implementation, and assessment.

Modernity has brought significant advances, which have strained the qualification of nurses’ being and doing; the insertion of new care and teaching technologies has been widely implemented. In this direction, Florence’s teachings have left their mark, influencing the nursing routine, as it has always emphasized the importance of nurses’ commitment to care, as well as learning based on practice.

Numerous ways of doing nursing are currently presented as novelties, denoting the rescue of innovations that Florence, in her time, created and implemented, only with the difference of today taking on a new guise, such as risk stratification, prevention and control of infections, cleanliness, fresh air, comfort, considering that the environment directly affects the health of individuals through music, colors. The possibility of inserting pets or therapeutic animals are practices indicated and implemented by Florence ( 8 8 McEwen M, Willis EM. Theoretical Basis for Nursing. 5 ed. Alphen aan den Rijn (NL): Wolters Kluwer; 2018. 624 p. ) .

Therefore, in this process, innovating in nursing presupposes taking into account the principles and concepts learned from Nightingale, in addition to the theories proposed by countless nursing theorists. Care territories and contexts should be sought to, in this way, modify forms of care devoid of scientific knowledge and the necessary structure for quality nursing care.

Thus, memories of the past related to the origins of care science must be preserved in order to understand and modify the being and doing of nurses in the present and in the future. This is the main objective of modern nursing. In this context, we highlight the importance of holistic nursing and the development of critical thinking, so urgent today, in order to qualify teaching, research, and care ( 2 2 American Holistic Nurses Credentialing Corporation. American Holistic Nurses Association. Foundations. Competencies, and curriculum guidelines for basic to doctoral holistic nursing education[Internet]. 2017[cited 2020 Jul 5];1(1):1-55. Available from: https://www.ahncc.org/wp-content/uploads/2018/10/Foundations-Competencies-Curricular-Guidelines.pdf https://www.ahncc.org/wp-content/uploads... ) .

One of the greatest challenges of modern nursing is to meet human needs in their entirety. These will be better identified by nurses who think and practice nursing in a holistic perspective, developing professional training focused on critical thinking in their care contexts and practices. Thus, said innovations in nursing will consist of the necessary and pressing rescue of Florence’s teachings ( 2 2 American Holistic Nurses Credentialing Corporation. American Holistic Nurses Association. Foundations. Competencies, and curriculum guidelines for basic to doctoral holistic nursing education[Internet]. 2017[cited 2020 Jul 5];1(1):1-55. Available from: https://www.ahncc.org/wp-content/uploads/2018/10/Foundations-Competencies-Curricular-Guidelines.pdf https://www.ahncc.org/wp-content/uploads... - 3 3 Nightingale F. Notes on nursing: what it is, and what it is not. Philadelphia (PA): J. B. Lippincott, 1859/1992. ) .

Thus, this brings us to the current world health scenario that we are experiencing with regard to the health situation in the midst of Florence’s bicentennial. The scientific, human, ethical and social commitment of nursing science in times of pandemic is reaffirmed, recognizing the value of philosophy which, in turn, is even more necessary to maintain her environmental theory principles today. It should be explored in depth in the spaces of training and assistance, providing the basis for supporting nursing education and the development and practical application of critical thinking of future nurses, aiming at qualitatively intervening in human care with a view to prevention and healing diseases in general. Thus, Florence Nightingale’s principles can directly reflect on the process of training and care in different contexts of teaching and care.

Holistic nursing and nurses’ holistic critical thinking

Holistic nursing is based on nursing knowledge, theories, research, doing mediated by experience, as well as intuition and creativity ( 6 6 American Holistic Nurses Association (AHNA). What is Holistic Nursing. [Internet]. 2020. [cited 2020 Jul 5]. 1(1)-1-2. Available from: http://ahna.org/about/whatis.html http://ahna.org/about/whatis.html... ) . In this perspective, nursing practice incorporates theory, practice and subjective aspects, as well as intuition and creativity, which are decisive in how this care model will be constituted.

Florence’s legacy with regard to holistic nursing, as well as critical thinking, is evident when we analyze the historical path of meeting humanity’ needs, and has been at the forefront in providing care and comfort to patients. Moreover, nursing was also concerned with health education for the population. Florence encouraged her students to consider cultural and religious diversity, as well as the values, needs and concerns of individuals in their uniqueness, without neglecting the economic and social aspects that involve care ( 5 5 Kalb KA, Conner-Von SO. Holistic Nursing Education: Teaching in a holistic way. Nurs Educ Perspect. 2019;40(3):162-64. https://doi.org/10.1097/01.NEP.0000000000000405 https://doi.org/10.1097/01.NEP.000000000... ) .

Florence’s historical trajectory shows the importance of nurses capable of thinking critically and holistically to deal with situations of adversity, as was the case in the Crimean War. Florence experienced scenarios of uncertainties, adversities and care contexts for which she needed to apply her highly developed critical thinking to the feminine patterns and patterns of her time ( 3 3 Nightingale F. Notes on nursing: what it is, and what it is not. Philadelphia (PA): J. B. Lippincott, 1859/1992. ) .

Holistic critical thinking can be defined as thinking with quality, i.e., a judgment process centered on deciding what to believe or what to do. In doing so, the critical thinker should not be negative or cynical, but reflective and balanced, requiring people to express some kind of reason or basis for whatever they are saying ( 9 9 Facione PA, Gittens CA. Think Critically. Chapter 1. Califórnia (EUA): Pearson Education; 2016. 418 p. ) .

According to Florence’s view, nurses should think critically about patient care, doing what was appropriate and necessary to help them heal, reinforcing the importance of developing in nurses the critical and holistic way of thinking in the daily life of be and do nursing ( 8 8 McEwen M, Willis EM. Theoretical Basis for Nursing. 5 ed. Alphen aan den Rijn (NL): Wolters Kluwer; 2018. 624 p. ) .

Starting from this way of thinking, at that time, evidence-based practice was carried out in a very healthy way for the performance of nursing procedures and care, as research was still scarce. Even so, Florence can be considered a pioneer in conducting research on evidence-based practice and the application of critical thinking. Florence’s environmental theory strongly supported nursing and also for the development of critical thinking, contributing to evidence-based nursing practice and beyond these very important aspects of nurses’ training and clinical practice ( 5 5 Kalb KA, Conner-Von SO. Holistic Nursing Education: Teaching in a holistic way. Nurs Educ Perspect. 2019;40(3):162-64. https://doi.org/10.1097/01.NEP.0000000000000405 https://doi.org/10.1097/01.NEP.000000000... , 8 8 McEwen M, Willis EM. Theoretical Basis for Nursing. 5 ed. Alphen aan den Rijn (NL): Wolters Kluwer; 2018. 624 p. ) .

Like Florence, it is worth highlighting other nursing theorists, such as Watson, Horta, King and Leninger, who impacted society by considering not only the physical aspects of a human being, but also the interconnection between each individual’s body, mind and spirit. It must be considered that, in the last three decades, nursing has gone from a model focused on physiological and scientific aspects to a model focused on nursing science, care and healing, seeking to consider the cultural aspects, values and beliefs connected to the act to care ( 10 10 Riegel F, Crossetti MGO, Siqueira DS. Contributions of Jean Watson's theory to holistic critical thinking of nurses. Rev Bras Enferm. 2018;71(4):2072-6. http://dx.doi.org/10.1590/0034-7167-2017-0065 http://dx.doi.org/10.1590/0034-7167-2017... ) .

In Brazil, we can describe this movement as a paradigm shift from a biomedical-technicist model to a care model based on the art and science of technical-scientific and humanistic care ( 10 10 Riegel F, Crossetti MGO, Siqueira DS. Contributions of Jean Watson's theory to holistic critical thinking of nurses. Rev Bras Enferm. 2018;71(4):2072-6. http://dx.doi.org/10.1590/0034-7167-2017-0065 http://dx.doi.org/10.1590/0034-7167-2017... ) . This movement boosted the emphasis on Florence Nightingale’s philosophy and teachings, awakening in nurses the capacity and a need to think holistically using the brain, heart and hands in creating healing environments, in order to effectively take care of the trinomial dimensional body-mind-spirit.

Accordingly, it is possible to note a critical thinking strongly influenced by the contributions of Florence’s legacy, which direct nurses towards a comprehensive and humanistic approach, in which the ability to listen and to consider a person in their entirety predominates. In this direction, nurses who develop holistic critical thinking in nursing training will have better performance by applying cognitive, behavioral and habits of the mind and, consequently, Florence Nightingale’s principles and theory. In this regard, it will be possible to care for individuals as a unique human being, i.e., singular, in order to consider the needs related to the physical body (physiological aspects), the mind (emotional aspects) and the spirit (spiritual aspects) ( 10 10 Riegel F, Crossetti MGO, Siqueira DS. Contributions of Jean Watson's theory to holistic critical thinking of nurses. Rev Bras Enferm. 2018;71(4):2072-6. http://dx.doi.org/10.1590/0034-7167-2017-0065 http://dx.doi.org/10.1590/0034-7167-2017... ) .

The scarcity of research published in Brazil addressing the influence of Nightingale’s theory on nurses’ holistic critical thinking is one of the limitations of this reflection. This denotes a knowledge gap to be filled, given the importance of this theme for nursing education and care. Concerning the contributions of this study, the possibility of impacting professional practice through knowledge and recognition of Florence’s legacy for training and professional practice is highlighted, in addition to enabling students and nurses to understand Nightingale’s theory.

FINAL CONSIDERATIONS

This theoretical reflection ends with evidence of the fundamental importance of the contributions of Florence Nightingale’s legacy to critical thinking in nursing. Moreover, it is seen that her theory is decisive in filling the knowledge gaps related to the holistic dimension in carrying out the nursing process, aiming at accurate clinical decision-making of students and nurses. It is imperative that nurses apply Nightingale’s holistic philosophy and assumptions in nursing, as patients expect compassion, in addition to specialized nurses focused on the totality of human needs.

Nightingale’s legacy allows us to meet these expectations, as her philosophy includes encouraging self-care, art and nursing science, covering related theories, in addition to research and ethics. Nightingale demonstrated by example in her trajectory, spreading, in her scientific productions that her fundamental principle was to care with a focus on prevention and healing through the process that unites all the singular dimensions that constitute the whole of individuals to achieve and maintain integration and balance. Thus, to guarantee this focus on nursing training, the commitment that teaching and caring are verbs and actions to be conjugated beyond the discourse and carried out in the genuine practice of being and doing by nurses is reaffirmed.

• 1 Dewey J. Democracy and education. New York (NY): Free Press (Reprint), 2004.
• 2 American Holistic Nurses Credentialing Corporation. American Holistic Nurses Association. Foundations. Competencies, and curriculum guidelines for basic to doctoral holistic nursing education[Internet]. 2017[cited 2020 Jul 5];1(1):1-55. Available from: https://www.ahncc.org/wp-content/uploads/2018/10/Foundations-Competencies-Curricular-Guidelines.pdf » https://www.ahncc.org/wp-content/uploads/2018/10/Foundations-Competencies-Curricular-Guidelines.pdf
• 3 Nightingale F. Notes on nursing: what it is, and what it is not. Philadelphia (PA): J. B. Lippincott, 1859/1992.
• 4 Healing. In: Dictionary Cambridge. Grã-Bretanha, Cambridge (GB-C): Cambridge University Press; 2020.
• 5 Kalb KA, Conner-Von SO. Holistic Nursing Education: Teaching in a holistic way. Nurs Educ Perspect. 2019;40(3):162-64. https://doi.org/10.1097/01.NEP.0000000000000405 » https://doi.org/10.1097/01.NEP.0000000000000405
• 6 American Holistic Nurses Association (AHNA). What is Holistic Nursing. [Internet]. 2020. [cited 2020 Jul 5]. 1(1)-1-2. Available from: http://ahna.org/about/whatis.html » http://ahna.org/about/whatis.html
• 7 Lopes ND, Nóbrega MML. Holismo nos modelos teóricos de enfermagem. Rev Bras Enferm. [Internet]. 1999[cited 2020 Jul 5];52(2):233-42. Available from: https://www.scielo.br/pdf/reben/v52n2/v52n2a10.pdf » https://www.scielo.br/pdf/reben/v52n2/v52n2a10.pdf
• 8 McEwen M, Willis EM. Theoretical Basis for Nursing. 5 ed. Alphen aan den Rijn (NL): Wolters Kluwer; 2018. 624 p.
• 9 Facione PA, Gittens CA. Think Critically. Chapter 1. Califórnia (EUA): Pearson Education; 2016. 418 p.
• 10 Riegel F, Crossetti MGO, Siqueira DS. Contributions of Jean Watson's theory to holistic critical thinking of nurses. Rev Bras Enferm. 2018;71(4):2072-6. http://dx.doi.org/10.1590/0034-7167-2017-0065 » http://dx.doi.org/10.1590/0034-7167-2017-0065

Publication Dates

• Publication in this collection 03 May 2021
• Date of issue 2021
• Received 26 Apr 2020
• Accepted 27 Sept 2020

• https://orcid.org/0000-0002-3688-419X
• https://orcid.org/0000-0002-9748-4077
• https://orcid.org/0000-0003-2629-293X
• https://orcid.org/0000-0003-0684-1401
• Corresponding author: Fernando Riegel. E-mail: [email protected]
• EDITOR IN CHIEF: Antonio José De Almeida Filho
• ASSOCIATE EDITOR: Rafael Silva

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