Florence Nightingale and subsequent nurse theorists wrote about the role of environment as a factor in human health to varying degrees. Environment has been alluded to and described by different nurse theorists as physical space, the social environment, the psychological environment or the spiritual environment. Further, several theorists have defined environment along multiple dimensions. Nightingale described the nurses role in optimizing the environment for healing, while others, such as Sister Callista Roy write about the environment as something clients must "adapt to"as part of the healing process. This paper seeks to explore the phenomenon of environment in nursing practice, and suggest considerations for expanding nursing knowledge in the realm of the impact of environment on human health. Advances in technology, man-made chemicals and the changing social fabric of the human experience begs further consideration for nurses to become more informed about the environment as a determinant of human health and what steps nurses can take to improve health by advocating for and adjusting environmental conditions.

Florence Nightingale's hallmark book, Notes on Nursing, directs the reader through many pages of text describing what nursing is and what it is not. She offers specific descriptions and guidance about optimizing environmental factors to improve patient comfort and facilitate health and healing. She discusses air quality, water quality, noise, light, and diet and nutrition. These fundamental essentials of the patient experience may be below the detectable limit of what many nurses today consider "nursing." In many ways, Florence followed current management ideals for "highly effective people" written about in the 1990's by Dr. Stephen Covey. She focused on "putting first things first." Before progressing to elaborate theories or plans for care, she focused on ensuring that the basic environmental setting for care delivery was suitable. Her work correlates well with Maslow's Theory on the Hierarchy of Needs, concurring that basic needs must first be met before further development or advancement (or healing) can occur.

Nightingale's attention to environment has added significance to the role environmental conditions play in human health status. We now have more than 80,000 synthetic chemicals available in the commercial marketplace (Steingraber, 1997), few of which are tested for health effects in humans, and even fewer tested for health effects in the developing fetus. We now spend as much as 90% of our lives in indoor environments (US EPA 1996), settings over which there is little or no federal regulation or standards for air quality. Asthma has been cited as the leading cause of absenteeism from school and work in America (American Lung Association 1998). Nightingale was so adamant about the importance of indoor air quality and ventilation that she coined it the "first cannon of nursing."

The community where she practiced, Europe in the 1800's was plagued with poor air quality from the heavy use of coal as a fuel for home heating. Her concern was on indoor as well as outdoor air quality. Nightingale wrote about the need for pure and clean water to promote health and healing. Water quality continues to be a problem internationally. Nurses are often taught about the importance of hydration for patients, but we are taught little about how to protect and secure a clean water source. Recent federal legislation in the United States, has prompted the Consumer Right to Know Legislation about clean water, and public drinking water systems that service more than 500 families must publish annual consumer confidence reports (CCR's) which list features of the water composition, including chemical and biological contaminants such as lead, arsenic, and cryptosporidium. Nurses of the present and the future and their patients would be well served if environmental knowledge and understanding were more commonplace in basic nursing education.

Nursing theory has evolved on a number of levels in the past fifty years. While it is true that Florence Nightingale is commonly recognized and accepted as the founder of modern nursing, there is some question as to whether or not she had an actual theory of nursing. Dr. Louise Selanders (1998) took Nightingale's writings and outlined them in a theoretical format, teasing out her philosophy, her principles, and creating diagrams which depict the Nightingale model. The model demonstrates Nightingales' recognition of the spiritual nature of beings, the environmental, biological, psychological and social aspects of care. Absent from the diagrammatic representation, however, is Nightingale's integration of data collection, use of statistics, and mathematical data in evaluation and decision making. Many of Nightingale's theories of environment have been informally ‘tested" out by occupational health professionals and industrial hygienists for years. Studies have been done of populations in buildings with poor air quality, which indicate a correlation between respiratory symptoms and poor air quality. In Massachusetts, occupational asthma is a reportable illness on the OSHA 200 log. The leading industry for reported cases of occupational asthma is hospitals (MA Nurses Association). This finding is primarily related to latex powder in the environment that has sensitized and permanently disabled dozens of nurses at the Brigham and Womens' Hospital in Boston, MA.

Other nurse theorists wrote about the role of environment either directly or indirectly. It is fair to say that thus far, no other nurse theorist has taken such a strong focus on the environment in health and healing, and specified the importance of nursing's attention to environmental factors. Nightingale was very specific in her recommendations and charged nurses with attending to environmental factors as Nightingale. It seems that nurses have become increasingly task oriented and narrowed their focus from the environment to the patient, and in later times, to the technology supporting the patient. Nurse theorists such as Jean Watson have called for a renaissance of appreciation for Nightingale's model and writings. Ms. Watson, as did Nightingale, underscores an emphasis on the importance of environment, and the characteristics of the physical space in which caregiving is rendered.

Sister Callista Roy developed the Roy Adaptation Model for Nursing in 1980. Her theory has been applied to health teaching about osteoporosis (Doyle, Rajacich, AAOHN Journal November 1991) and breastfeeding (Sjoden, Journal of Advanced Nursing, 1993). Her model emphasizes the importance of adaptation to situations to facilitate healing. In many cases, the Roy model makes sense. However, "adaptation" might not be the best route for humans in light of environmental conditions. Adaptation to unfavorable conditions, such as poor air quality or toxic substances in a workplace might lead to cancer or asthma or other adverse health impacts. Nightingale wrote about adjusting environmental conditions to facilitate health and healing. She did not write about patients adapting to environmental conditions, but rather advocated for nurses intervening to improve environmental conditions. There are situations where adaptation might best be expressed by leaving a situation or changing a situation, or by the nurse intervening to change the environment.

Margaret Newman's Theory describes health as expanding consciousness in situations where absence of disease or disability is not possible. Newman refers to "pattern" as a characteristic of wholeness that reveals the meaning of life. She continues by explaining that pattern is a dynamic relatedness with one's environment, both human and non-human. She explains that nurses have a responsibility to stay in partnership with clients as their patterns are disturbed by illness or other disruptive events. In this way, she describes the nurse-client relationship as a necessary constant in the environment. While Newman does not write specifically about attributes of the physical environment she acknowledges environment as a factor. Individuals faced with the need to optimize health in situations where absence of disease or disability are not possible must overcome and adapt to environmental factors which presented little challenge previously, developing new patterns for navigating relationships and the physical environment. The concept of pattern recognition as it relates to environment brings an indirect focus, or blurs the emphasis on the environmental conditions (e.g., air, water) versus man-made environmental barriers or conditions, as factors in health and healing. Considering interactions with the physical environment as a series of "patterns" to be recognized, which take on different meaning depending on one's health status, can facilitate the design of appropriate care. Environment takes on new meanings for individuals who have compromised health. Environment which was previously been a "silent partner" in one's life, can suddenly present numerous challenges and become a significant component of healing.

Madeline Leininger is best known for her work related to cultural competency in nursing. Leininger talks about cultural care and the need to be sensitive to the role of culture in health and healing. Cultural care and sensitivity have strong environmental components. While Leininger does not specify environment in great detail, she alludes to it in her writings on culture. Cultures and environment worldwide differ greatly. Food, language, dress, physical gestures, objects in the environment, light, darkness, sound, smell all take on different meaning in different cultures. Contrast the care that can be delivered in different settings for different cultures. In my brief exposure to healthcare in different parts of the world, I understand how important the role of culture and environment can be to one's healing and health status. Environmental factors from décor, to type of linens used, to availability of nourishment, to sound, gestures of caregivers, and more, are all factors that can influence care. An example to illustrate this is the story of my Cambodian friend who was hospitalized in a US hospital for GI bleeding. A series of events including her admission procedure, questioning, and foods that were served left her feeling like the healthcare setting and the practitioners were "unfriendly." She was not made to feel comfortable in the environment where care was being delivered, primarily due to a lack of sensitivity to her culture. Considering culture as an environmental factor can impact one's experience in healthcare. Culturally sensitive care providers can create an environment where patients feel accepted and their cultural norms are respected and honored. In this way, Leiningers' work around culture has environmental relevance and is an important feature in nursing care.

The middle range theory of Vigilance (Carr, 1998) provides a unique opportunity to consider the continual presence of a caring family member in the environment as a nursing phenomenon. While the theory looks at vigilance and the experience for family members, it provides the opportunity to consider vigilance as an environmental factor. Consider the change in the environment when you are in a room by yourself, and then when someone you love enters that room. Consider the difference between having someone who knows and cares about you present nearly continuously and being alone in a room. The environment is transformed by that person's presence, even if they are silent. Their very presence influences the behavior of everyone that enters the room. It can influence it positively or negatively, depending on the circumstances. Nonetheless, their presence is a factor of the environment. By their presence they can change the healthcare experience. It may be by providing additional touch and physical contact for the patient, by humming a song, by wearing a familiar scent (fragrance or perfume), by praying for their loved one, by communicating with caregivers, by providing useful information about the patients usual preferences, or merely humanizing the patient, letting caregivers know that this person has value and worth in the eyes of another person, despite the present condition. Vigilance is an environmental component which can impact other "environmental factors" including physical environment (vigilant members are able to open windows, provide nourishment), psychological environment (person is not alone, ever), spiritual environment (provide the sense that someone can feel connected and loved), and cultural environment (can carry on traditions, prayers, and bring culturally important aspects into care).

Environment as a phenomenon in nursing is imbedded in the philosophical assumptions and principles of Parse's Human Becoming Theory. Parse states, "The human is coexisting while co-constituting rhythmical patterns with the universe" and " Becoming is a rhythmically co-constituting human-universe process." Parse's acknowledgment of the "universe" and "rhythmical patterns" acknowledges that humans do not live in a vacuum, but rather coexist in the universe and relate to environmental conditions. While the crux of her theory focuses on human becoming, the underpinnings of "becoming" have a physiological basis, which is related to one's relationship with the environment. While Parse does not specifically focus in the environment, but rather on the past, present and future experiences, cultural forces, and continual evolution and becoming, environment is a "given" for the processes she describes. For example, environmental conditions are integrated into the human experience, and influence thoughts, feelings, decisions, and the quality of relationships. Parse describes this as universal conditions, and the human response to such conditions. An example of this could be the effect of extreme weather conditions such as a hurricane or flood. In such situations, human response to the universe is impacted dramatically. On another level, far subtler, is the physiological human response to chronic low levels of certain toxic substances. Subtle, yet a detectable changes in physiology and health (example exposure to lead dust) can impair health, and ultimately the human "becoming" experience. (Needleman's work re; lead exposed children and aggressive tendencies demonstrated that a history of exposure to lead in childhood is linked to aggressive behavior in later years.)

Benner describes how nurses develop competence and grow in optimal clinical environments. She describes how an expert nurse can create an environment to foster professional development in other nurses. Nurses supporting nurses creates a positive clinical environment and good morale. Expert nurses are able to appreciate their effect on the environment around them. The evolution of expert skills in nursing alters the academic environment for students, leading faculty to create different types of learning opportunities in different environments. As nursing programs evolve to incorporate environmental health skills, Benner's model offers new areas for exploration in nursing. What does a nurse with "expert" environmental health skills offer? How does a nurse acquire expert environmental health skills? What is the difference between an expert environmental health nurse and an occupational health nurse? Benner's theory doesn't specifically cull out environment as a focus, however the concept of the evolution of nursing competency from novice to expert influences the workings and ambiance of the clinical environment, and this is a phenomenon to be acknowledged. The concept of integrating new knowledge (environmental health nursing) into clinical nursing domain creates the need for understanding the criteria for defining an expert nurse with environmental health skills.

A variety of nursing theories have been developed in the past fifty years, many using the Florence Nightingale's work as foundational. In a metaphoric sense, Florence Nightingales work can be viewed as the base root and trunk of a tree, and modern theorists as branches from that tree leading into various areas of nursing practice. Theories have been defined as grand and middle range, depending on their scope of focus. Nightingale's theory of environment provides basic fundamentals for nursing practice, and has achieved universality.

Questions about the entry level for nursing practice continue to be asked within the nursing community. Benner's work on the evolution from novice to expert nurse further clarifies nurses' professional progress and competence development. When one considers Florence Nightingale's life and educational background prior to her official entry into nursing, her experience makes the case for the benefits the nursing profession can gain from a more broad-base education for nurses. Florence's father insisted on introducing his daughters to mathematics, sciences, foreign languages and history. He encouraged them to be well versed in a variety of areas, including philosophy and religious studies. Florence was able to draw from this rich educational background throughout her career, and her knowledge in such areas is reflected in her writings. Given the current juncture in human history, the nursing profession would be well served by evaluating the educational preparation Nightingale received, and parody the breadth of that education in the preparation for nurses today. Further, adding courses focused on the environment, indoor air quality, ergonomics, water quality, and industrial hygiene topics would prepare nurses to advocate for and optimize environmental conditions. This is particularly relevant in light of the research by Dr. David Pimentel of Cornell University, who has identified the fact that more than 40% of deaths worldwide are caused by environmental pollution and degradation. Nurses interested in health promotion and disease prevention must be well-versed in environmental studies to work effectively.

There is a movement in nursing today which represents a renaissance for Florence Nightingale's environmental message. This movement is manifested by the development of several environmental groups within nursing, by individual nurses introducing environmental resolutions within their organizations, by the American Nurses Association adopting a resolution to eliminate toxic pollution from healthcare, so that all nurses can practice nursing without adding a toxic burden to the communities they serve. The International Council of Nurses representing nurses from 118 nations worldwide has adopted a similar resolution that addresses the toxicity of medical wastes globally. The Kellogg Foundation has funded an initiative by the University of Maryland College of Nursing to integrate Environmental Health into nursing curriculum at 435 schools of nursing in the 17 Southern states in the USA. Nurse leaders such as Dr. Barbara Sattler, Dr. Eleanor Schuster, Dr. Barbara Dossey, Dr. Louise Selanders, and Dr. Jean Watson all are calling for nursing to have a greater appreciation for the environment as a domain of nursing practice. Hollie Shaner has used Nightingale's model of to develop an Environmentally Responsible Clinical Practice Model, featured in the text: Exploring Our Environmental Connections by NLN Press. These are a few examples of the emerging trend toward reintegration of environment as central to nursing practice. The ongoing relevance of Nightingale's work continues to expand and provide a utilitarian function for nursing theory, especially given the current crisis in the health care setting. Those nurses who are becoming educated on environmental issues bring unique skills and understanding to the healthcare environment. Florence set the stage in her writings for nurses to be involved at all levels and all capacities in providing optimal health care settings and care.

In closing, the environment as a phenomenon in nursing is represented in the works of many nursing theorists, either directly or indirectly. Environment as a phenomenon in nursing will continue to have importance as new environments are inhabited by humans. Environment as a nursing phenomenon will have importance as our existing environments are rapidly being biogeochemically transformed by technology, innovation, and an ever-increasing human population load.

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