Evidenced Based Practice
Group Presentation
Rick Loenser, RN
and
Mary Anne Gross, RN
Environmental
Model
 Florence Nightingale’s theoretical
framework for environment was a
detailed account of her concepts
upon ventilation, warmth, light,
diet, cleanliness, and noise
(Alligood, 2010, p. 75).
 She believed nursing was “to assist
nature in healing the patient. This
was to be accomplished by
managing the internal and external
environments in an assistive way-in
a way that was consistent with the
laws of nature” (Chinn & Kramer,
2008, p. 31).
Florence Nightingale
 First to use a theoretical foundation in nursing
 Unsanitary conditions posed health hazard (Notes on
Nursing, 1859)
 External influences can prevent or cause disease and or
death
Nightingale’s Concepts
 Person
 Patient who is acted on by nurse
 Affected by environment
 Has reparative powers
 Environment
 Foundation of theory. Included everything, physical, psychological,
and social
 Health
 Maintaining well-being by using a person’s powers
 Maintained by control of environment
 Nursing
 Provided fresh air, warmth, cleanliness, good diet, quiet to facilitate
person’s reparative process
Retrieved from http://currentnursing.com/nursing_theory/nursing_theorists.html
“It is the unqualified result of all my
experience with the sick, that second
only to their need of fresh air is their
need of light” (Nightingale, 1860).
Light Theory Application
by Rick Loenser, RN
Evidence base for the benefits
of light theory
Increasing evidence
recognizes the importance
of everyday sunshine.
“In 1863 Florence
Nightingale appealed to
hospital designers to
include wards that were
brightly lit by natural
sunlight” (Genius, 2006, p.
422).
Research supports the
benefits of sunshine to
help alleviate
symptoms of :

Depression

Cancer

Post-operative pain
(Genius, 2006, p. 422)
 Although sun exposure has been used
therapeutically throughout history, it’s use has been
doubted as of late (Genius, 2006, p. 422).
Rationale for Use of Nursing Theory
 Does Nightingale’s light theory still have applications
for today’s nursing environment?
Research supports Nightingale’s light
theory and has used the evidence to
support hospital design.
 Even though Nightingale does not mention the term,
evidence base practice, her theory is the basis for the
concepts contained within the term evidence base practice
for nursing (McDonald, 2001).
The Study
 Eighty-nine people, aged
sixty and older
 All of the individuals
diagnosed with depression
 “Forty-two of the
participants underwent
phototherapy consisting of
60 minutes of strong, pale
blue light treatment every
morning for three weeks.”
 “The remaining 47 people
underwent a placebo
treatment of dim red light
for the three-week period.”
(Ritsaert L., et. Al., 2011)
The Framework
 The framework used in this study was based
upon light therapy and its effects upon
depression.
 A light box has been used to treat seasonal
affective disorder, or SAD, but this was the
first time it had been reviewed for treating
non-seasonal depression in older patients.
(Ritsaert L., et. Al., 2011)
Research Results
 “Immediately after the phototherapy
session, people who received the bright
pale blue light had a significant (7%)
improvement in the symptoms of
depression as compared to people who
had the dim red placebo treatment”
(Ritsaert, L., et. Al., 2011).
 “ And three weeks later, there was a
21% improvement over the placebo
group” (Ritsaert L., et. Al., 2011).
 This study shows that phototherapy
might have real benefit for older people
who are living with mild depression,
especially those who can't tolerate
antidepressants.
(Ritsaert, L., et. Al., 2011)
Limitations of the Study
 Demographics of patient population
are limited to older adults
 Limited time frame for collected
data
 Small scale
 Methods for data collection were not
described to identify if consistency
was observed
 Application of the study is not
identified
Strengths of the Study
 Objective is clearly defined
 The function and the purpose of the study was
supported by findings
 Observable differences noted in the statistics
How can I use this in my practice?
 Open the curtains when it is daytime.
 Place patients near the window
 Take patients on a walk
Cleanliness Theory Application
by Mary Anne Gross, RN
Why cleanliness theory?
“Every nurse ought to
be careful to wash her
hands very frequently
during the day. If her
face too, so much the
better.”
 “the excretion, which comes from the skin,
is left there, unless removed by
washing…”
Retrieved from
http://nursingplanet.com/Nightingale/personal_cleanliness.html
 Every nurse should keep this fact constantly in
“One word as to
cleanliness merely as
cleanliness.”
mind----for, if she allow her sick to remain
unwashed she is interfering injuriously with
the natural processes of health just as
effectually as if she were to give the patient a
dose of slow poison by the mouth.”
Retrieved from
http://nursingplanet.com/Nightingale/personal_cleanliness.html
Rationale for Use of Nursing Theory

“It is classified as lower-level theory but it provided the greatest foundation of nursing education,
practice and theories.”

“As per most of the nursing theories, environmental adaptation remains the basis of holistic nursing
care.”
Retrieved from http://currentnursing.com/nursing_theory/Florence_Nightingale_theory.html

Practice
 Disease control
 Sanitation and water treatment
 Utilized by modern architecture in the prevention of "sick building syndrome" applying the
principles of ventilation and good lighting
Picture taken by Mart Anne Gross, RN
Rational for Use of Theory Cont.
 Waste disposal
 Control of room temperature


Noise management
Education
 Principles of nursing training
 Better practice result from better education
 Skills measurement through licensing by the use of testing methods, the case studies

Research
 Use of graphical representations like the polar diagrams
 Notes on nursing
Retrieved from http://slsu-coam.blogspot.com/2008/08/nightingales-environmental-theory.html
Notes on nursing picture retrieved from Florence Nightingale Museum Guidebook, 2001, p. 23
Hand Hygiene
Why Hand Hygiene?
 “ Every day, 247 people die in the USA as a result of a
health care-associated infection. This is equivalent to a
767 aircraft crashing every day or more than 90,000
deaths annually”
 “Hand Hygiene is the primary measure to reduce
health care-associated infection”
Retrieved from
http://www.centerfortransforminghealthcare.org/UserFiles/file/hand_hygiene_storyboard.pdf
The Study
Best Practices from 8 Hospitals
 Cedars-Sinai Health System – California
 Exempla Lutheran Medical Center – Colorado
 Froedtert Hospital – Wisconsin
 The Johns Hopkins Hospital – Maryland
 Memorial Hermann The Woodlands – Texas
 Trinity Health-St. Joseph Mercy Hospital – Michigan
 Virtua-Memorial – New Jersey
 Wake Forest University Baptist Medical Center – North
Carolina
Retrieved from
http://www.centerfortransforminghealthcare.org/UserFiles/file/hand_hygiene_storyboard.pdf
 Each organization set up one or more hand hygiene




projects for each unit or area of care.
Staff were selected to be observers – to secretly observe
peers and to record hand hygiene performance.
Data from the observers were typed into the Targeted
Solutions Tool (TST) to measure and track actual staff
performance.
After 10 days of data collection, staff could start to see
how they were doing.
The TST used three types of charts to track progress and
target problem areas.
Retrieved from
http://www.centerfortransforminghealthcare.org/UserFiles/file/hand_hygiene_storyboard.pdf
Data Collections
Target
Observers & Just-in-Time Coaches
 After two weeks, the organization began to implement
solutions that were targeted to the barriers they had
identified through data collection and measurement.
 Observers continued to observe and collect data and justin-time coaches began coaching and supporting staff as
they began to change behaviors and improve hand
hygiene.
 The entire process took between
to
weeks,
on the organization’s resources and experience.
 Continuous improvement was measured and tracked
through the TST.
Retrieved from http://www.centerfortransforminghealthcare.org/UserFiles/file/hand_hygiene_storyboard.pdf
P Chart of Compliance
This is a statistical process control chart, also
called a proportion chart or P chart, which shows
hand hygiene compliance rates on a typical unit.
UCL – Upper control limits
Each point on the blue line represents the day’s
compliance. The points on the line that fall
outside of the control limit lines are represented
by a red dot, signifying that the process has
changed.
In this sample chart, the average compliance and
point-to-point lines have shifted up in the
direction of improved performance.
Mean – Represents the proportion or overall
average compliance rate. The mean may be
recalculated every time data are entered into the
database
LCL – Lower control limits. The control limits
reflect variations in the compliance rates over
time. Typically, 95 percent of the data falls within
the control
Retrieved from
http://www.centerfortransforminghealthcare.org/UserFiles/file/hand_hygiene_storyboard.pdf
Research Results:
Identifying Causes, Targeting Solutions
Causes
Solutions
 Date provide a framework for a
 Hand Hygiene compliance data are
not collected or reported accurately
or frequently
systematic approach for improvement
 Utilize a sound measurement system to
determine the real score in time
 Scrutinize and question the data
 Measure the specific, high impact
causes of hand hygiene failures in your
facility and target solutions to those
cause
__________________________________
__________________________________
 Ineffective placement of
 Provide easy access to hand hygiene
dispensers or sinks
equipment and dispensers
Retrieved from
http://www.centerfortransforminghealthcare.org/
UserFiles/file/hand_hygiene_storyboard.pdf
Causes
 Safety culture does not stress hand
Solutions

Make hand washing a habit-as automatic as
looking both ways when you cross the street
or fastening your seat belt when you get in
the car

Commitment of leadership to achieve hand
hygiene compliance of 90+ percent

Serve as a role model by participating proper
hand hygiene

Hold everyone accountable and responsibledoctors, nurses, food service staff,
housekeepers, chaplains, technicians,
therapists
hygiene at all levels
___________________________________
 Hands full
________________________________________

Create of place for everything: for example,
a health care worker with full hands needs a
dedicated space where he can place items
while washing hands
Retrieved from
http://www.centerfortransforminghealthcare.org/
UserFiles/file/hand_hygiene_storyboard.pdf
www.picturesof.net/pages/110112-181964997053.html
More Causes
 Lack of accountability and just-in-time coaching
 Ineffective or insufficient education
 Wearing gloves interferes with process
 Perception that hand hygiene is not needed if wearing gloves
 Health care workers forget
 Distractions
Retrieved from
http://www.centerfortransforminghealthcare.org/UserFiles/file/hand_hygiene_storyboard.pdf
Limitations of the Study
 Since the study was very structured and targeted to
specific hospitals, there were very limited limitations
to the study, if any.
 Key to Compliance:
 Hold EVERYONE accountable and responsible
 Apply progressive discipline
 Commitment of leadership to achieve 90+%
 Serve as a role model by practicing proper hand hygiene
Retrieved from
http://www.centerfortransforminghealthcare.org/UserFiles/file/hand_hygiene_storyboard.pdf
Strengths of the Study
 Performed by Joint





Commission Center
for Transforming
Healthcare
8 of the top
hospitals in the
country were
targeted
All use Lean Six
Sigma
methodologies
Used measureable
successes
Used targetable
solutions
Was sustainable
Cleanliness Theory Today
 The principles of nursing practice by Florence Nightingale
are continuously used to this very day. With the advent of
technology and with it globalization comes the threats from
the environment.

Global warming
 Industrial noise
 Air pollution
 Fad diets
 Vanity
 Nurses of today still need to:

Maintain adequate ventilation
 Promote adequate & appropriate nutrition
 Maintain normal homeostatic body temperature
 Observe basic hygiene
 Comfort measures including environmental sanitation
How can the cleanliness theory
be used in my practice?

Be proactive instead of reactive
 Assure that there is a soap dispenser near by
 Place all items in my hands down prior to entering
a patient room
 Wear gloves when process requires it
 Be accountable and responsible
 Don’t get distracted
 Don’t forget
Critical Reflection
 “Theory guides practice, but current
knowledge and practice must be
based on evidence..” (Kearney,
2008, p. 104).
 We must use research supported
evidence in our practice to help
alleviate problems that impede
health (Kearney, 2008, p. 104).
 Gather the most current knowledge
and support the research by
adjusting our practice to fit it’s
findings.
References
Alligood, M.R., & Tomey, A. M. (2010). Nursing Theorists and Their Work (7th ed.). Maryland Heights, MO: Mosby
Elsevier
Attewell, A. (2001). Florence Nightingale Museum Guidebook, LondonSE1 7EW, UK.
Chinn, P., & Kramer, M. (2008). Theory and nursing: A systematic approach. St. Louis, MO: Mosby
CSL Cartoonstock. (2011). Wash Hands cartoon 9 - search ID sat0313. Retrieved from
`
https://www.cartoonstock.com/directory/w/wash_hands.asp
Current Nursing. (2010). Florence Nightingale 1898: Notes on Nursing What It Is, and What It Is Not. Personal
Cleanliness, Chapter XI. Retrieved from
http://www.nursingplanet.com/Nightingale/personal_cleanliness.html
References Cont.
Joint Commission Center for Transforming Healthcare. (2011). Hand Hygiene: Best Practices from
Hospitals. Retrieved from http://www.hpoe.org/resources-and-tools/resources/hand-hygieneproject.pdf
Genius, S. J. (2006). Keeping Your Sunnyside Up. Can Fam Physician, 52(4), 422-423, 429-31.
Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1481673/?tool=pubmed
Kearney-Nunnery, R. (2008). Advancing Your Career: Concepts of Professional Nursing (4th ed.).
Philadelphia, PA.:F.A. Davis Company
McDonald, L. (2001). Florence Nightingale and the early origins of evidence-based nursing. Evid
Based Nurs 4, 68-69. doi:10.1136/ebn.4.3.68. Retrieved from
http://ebn.bmj.com/content/4/3/68.extract
References Cont.
Nightingale, F. (1860). Notes on Nursing: What it is and What it is not. New York, NY.: D.
Appleton and Company. Retrieved from
http://digital.library.upenn.edu/women/nightingale/nursing/nursing.html#IX
Nursing Theories. (2011). A companion to nursing theories and models: Nursing Theorists.
Retrieved from http://currentnursing.com/nursing_theory/nursing_theorists.html
Riesart, L., Eus J. W., Van Someren M., Nielen, M. A., Bernard Uitdehagg, M. J., Smit, J. H.,…
Hoogendijk, W. (2011). Bright Light Treatment in Elderly Patients With Nonseasonal Major
Depressive Disorder: A Randomized Placebo-Controlled Trial. Archives of General
Psychiatry, 68(1),61-70. Retrieved from
http://alternativemedicine.healthcommunities.com/depression/light-therapy.shtml#adjump
References Cont.
Scribd. (2011). Nursing Theories with Applications. Retrieved from
http://www.scribd.com/doc/25944745/Nursing-Theories-with-applications
Theoretical Foundations of Nursing. (2008) Nightingale’s Environmental Theory.
Retrieved from
http://slsu-coam.blogspot.com/2008/08/nightingales-environmental-theory.html