The Importance of the Patient Care Environment: Ventilation

The Importance of the Patient Care Environment: Ventilation

Joy Stepinski, MSN, RN-BC

September 1, 2025

Many years ago, I took advantage of a layover in London. I decided to tour Westminster Abbey and marvel at Big Ben. Across the Thames River stood St. Thomas Hospital, where I discovered the Florence Nightingale Museum. Florence Nightingale is often referred to as the mother of modern-day nursing. The museum displayed a lantern she carried, along with an exhibit about her time caring for soldiers during the Crimean War. Her principles of nursing practice, related to infections, are still highly regarded today. Her environmental theory remains a topic of discussion among nurses, influencing the transformation of patient care.

Nightingale emphasized that the environment influenced healing. The core principles of the Environmental Theory, or canons, include ventilation, clean water, proper nutrition, natural light, minimal noise, and clean bedding [1]. These canons highlight the close relationship among the patient, environment, health, and nurse. Today, nursing practice continues to focus on the patient environment. Nurses are trained to reduce clutter, ensure cleanliness, promote quiet by decreasing noise, and control lighting based on the patient's illness and needs.

The first canon that Nightingale discusses in her book Notes on Nursing [1] is ventilation. She writes, “the first essential to the patient is… to keep the air he breathes as pure as the external air, without chilling him” (p. 8). When rooms are closed, without access to fresh air, the indoor environment becomes stagnant and musty. As a result, unwanted germs may grow.

Ventilation in the human body is a vital physiological process of moving air into and out of the lungs. Without the ability to breathe, living beings cannot survive. Not only is breathing a fundamental physiological need, but it is also a complex process that is coordinated by the brain and the respiratory muscles. With each breath, oxygen is replenished throughout the body, required for cells to function. Carbon dioxide is released from the body, helping to balance the pH level within the blood [2].

Poor ventilation is often associated with buildings, such as long-term care facilities. In nursing homes, ventilation is not necessarily regulated. Residents typically spend most of their days indoors without access to fresh air and sunlight. One European study [3] suggested a relationship between air pollutants and poor respiratory outcomes among residents, including cough and feelings of breathlessness. Listed air pollutants were formaldehyde, ozone, and nitrogen dioxide.

In Peru, 70 naturally ventilated clinical rooms were compared with 12 mechanically ventilated rooms [4]. The facilities had a high number of infectious patients. In a calculated model, the investigators predicted that 39% of those exposed to untreated tuberculosis would become infected in mechanically ventilated rooms. A slightly reduced 33% would become infected in modern, naturally ventilated spaces. In conclusion, natural ventilation was a cost-effective way to reduce the transmission of infections. Interestingly, the best method was the natural ventilation of pre-1950 buildings with high ceilings and large windows (11%).

A Singapore study investigated the effects of ventilation among children in 104 child care centers. Ventilation strategies included natural ventilation, air conditioning, mechanical ventilation, and a combination of natural and air-conditioned rooms [5]. Open windows were used in natural ventilation, while fans were used in mechanical ventilation. The study results showed that children experienced less asthma, allergy, and respiratory symptoms in centers that were naturally ventilated.

During the recent outbreak of SARS-CoV-2, ventilation was a hot topic of discussion. Scientists theorized that the virus was spread by respiratory microdroplets that were suspended in the air. Recommendations included avoiding recirculated air that was not properly filtered and instead, opening windows and doors to increase air flow within buildings [6].

Natural air is not only important for physical health, but also for mental well-being. Fresh air, particularly in areas rich in vegetation, offers numerous benefits. Plants are like air filters, removing pollutants and releasing oxygen [7}. Physiologically, fresh air is linked with improved respiratory health, mental clarity, and energy. Emotionally, research shows that ecotherapy, which offers the therapeutic benefits of outside air, leads to reduced stress and improved mood. The deep breathing of fresh air promotes mindfulness.

Nightingale emphasized the importance of opening windows to heal the sick. She relayed that people do not catch colds if they are warmed properly in bed with fresh air entering, even at night. The wisdom of natural ventilation continues today. Fresh air is shown to decrease infection, improve respiratory health, and boost emotional well-being. In the words of Florence Nightingale [1], “Always air your room, then, from the outside air, if possible. Windows are made to open; doors are made to shut” (p.12).

References:

1.      Nightingale, F. (1947). Notes on nursing. https://archive.org/details/notesnursingwhat00nigh/page/8/mode/2up?view=theater 

2.      Brinkman, J. E., Toro, F., & Sharma, S. (2022). Physiology, Respiratory Drive. 2022. StatPearls. Treasure Island (FL): Stat Pearls Publishing. https://www.ncbi.nlm.nih.gov/sites/books/NBK482414/ 

3.      Bentayeb, M., Norback, D., Bednarek, M., Bernard, A., Cai, G., Cerrai, S., ... & Annesi-Maesano, I. (2015). Indoor air quality, ventilation and respiratory health in elderly residents living in nursing homes in Europe. European Respiratory Journal, 45(5), 1228-1238. https://doi.org/10.1183/09031936.00082414

4.      Escombe, A. R., Oeser, C. C., Gilman, R. H., Navincopa, M., Ticona, E., Pan, W., ... & Evans, C. A. (2007). Natural ventilation for the prevention of airborne contagion. PLoS Medicine, 4(2), e68. https://doi.org/10.1371/journal.pmed.0040068

5.      Zuraimi, M. S., Tham, K. W., Chew, F. T., & Ooi, P. L. (2007). The effect of ventilation strategies of child care centers on indoor air quality and respiratory health of children in Singapore. Indoor Air, 17(4), 317-327. https://doi.org/10.1111/j.1600-0668.2007.00480.x

6.      Morawska, L., & Milton, D. K. It is time to address airborne transmission of coronavirus disease 2019 (COVID-19) Clinical Infectious Diseases, 71(9), 2311 – 2313.  https://doi.org/10.1093/cid/ciaa939

7.      Kakarla, U. (2025). The Role of Natural Light and Fresh Air in Ecotherapy. Cuestiones de Fisioterapia, 54(2), 4718-4723.