Reframing the environment domain of the nursing metaparadigm: Exploring space, place, and technology

Abstract

Metaparadigms differentiate disciplines in terms of how each discipline develops its knowledge and its scholarship. Four domains comprise the nursing metaparadigm: environment, person, health, and nursing. Of these domains, the environment domain is the least identified. Relating this domain to the broader substantive meaning of the geographical-landscape setting of nursing encounters requires further explanation. Through a discursive process, the article positions “space and place” by referencing the nursing environment. The article aims to clarify and explain the expanding reach of the environment domain, extending its definition while recognizing its range of influence in nursing and healthcare. Distinguishing the nursing environment as a well-established domain of the nursing metaparadigm makes nursing practice more visible, valuable, and relevant. Characterized by its impact on discipline-related knowledge development guiding professional practice, the environment domain assumes an integral “space and place” in human healthcare practice.

Background

The metaparadigm of any discipline provides a framework for developing scholarships distinct in their respective fields. It is foundational to the scientific activities necessary for advancing a profession. Fawcett (2000) declared that nurses’ perceptions of the domains of the nursing metaparadigm and their awareness of professional concepts influence professional development. Furthermore, understanding the domains of the nursing metaparadigm prevents the creation of obstacles in establishing pathways to professional identity (Lee & Fawcett, 2013). Clarifying metaparadigms and their fundamental theses facilitates a deeper understanding of professional attitudes and a better appreciation of the scope of scientific studies, particularly in nursing (Kim, 2000).

The metaparadigm of nursing is integral to the work of nursing scholars. Fawcett (1984) identified four domains of the nursing metaparadigm, namely the domains of person, environment, health, and nursing. These domains are the central attributes of nurses' work and have become the standard basis for using and evaluating nursing models and theories. However, even with its remaining heuristic status, Fawcett's (1984) metaparadigm of nursing has remained uncertain in practice, continually facing skepticism and subtle opposition from scholars of nursing, who argue that the nature of the nursing metaparadigm might have “stunted” the growth of nursing knowledge development, rather than promoting the development of the discipline. All four domains of the nursing metaparadigm must be addressed in nursing scholarship for the product to be considered “nursing” knowledge in the hope that nursing moves beyond the uncertainty stage toward the clarity of its discipline-related knowledge and professional development (Morse, 2016).

While the nursing care environment remains a critical feature of nursing practice, it has not received the appropriate recognition, value, and importance compared to the domains of person, health, and nursing. In its distinctiveness as a domain of nursing, the environment has been assumed to mean the setting of nursing, referring to the geographical landscape reference and state, which is the “space and place” of the healthcare practice arena.

However, the essence of the environment domain also includes the external and internal elements relating to persons who are nursed that remain integral elements of the immediate context with which the individual milieu adapts to capacities within the social, political, and economic forces (Chopoorian, 1986; Kleffel, 1996). Nonetheless, Fawcett's (1984) descriptions of the environment domain recognized the rigid, static, and natural characteristics of healthcare practice, as well as the fluid, changeable, and constructed phenomenon within it. The environment domain of the nursing metaparadigm is generally seen to be rigid and inflexible, at best, whereas it should illuminate the value and importance of the domain, contributing to the adaptability and appropriateness of nursing care practice as that critical element of the nursing care situation. When the environment is seen as possessing such a status, it assumes a valuable position as a domain of the nursing metaparadigm, assumed as a solution to the uncertainties of nursing, and as integral to human healthcare practice.

The concept and its underlying meaning have not been well described or clarified (Holopainen et al., 2014). Multiple and commonplace meanings in the everyday language of professional nursing refer to the environment of participation in professional groups and positions, the environment framing nursing research methodology, and its inherent connections to the natural physical world of the nurse and nursed in nursing practice. Andrews and Moon (2005) explained that the nursing environment is a critically valued domain of the nursing metaparadigm that involves the economic, social, and cultural milieu of professional nursing activities.

Current literature indicates a gap in the comprehensive exploration of the environment domain within nursing research and practice. The environment’s role in shaping patient care, influencing professional development, and integrating with other metaparadigm domains needs further clarification and emphasis (Holopainen et al., 2014). Andrews and Moon (2005) also underscore that the nursing environment encompasses economic, social, and cultural dimensions that are often neglected. Addressing this gap is essential for advancing nursing knowledge and ensuring that the environment domain is appropriately valued as a critical component of nursing scholarship. By expanding the understanding of the environment domain and its implications, nursing can move toward a more holistic and effective practice that aligns with the evolving needs of patients and the healthcare system.

Purpose

This study aims to reframe the nursing environment as a dynamic construct shaped by economic, social, cultural, and technological factors. By exploring modern views on “space” and “place,” it seeks to broaden the traditional understanding to include the growing role of virtual technologies in practice settings. However, the research is limited by its dependence on existing literature and theoretical frameworks, lacking empirical data collection, which restricts its ability to provide concrete evidence. As a result, the implications of this reconceptualization for nursing practice, education, and administration will need to be investigated in future research.

Methods

The literature search for this discourse spanned from 1984 to 2024. This period encompasses the foundational work that established the nursing metaparadigm, particularly Fawcett’s seminal contributions, and extends to current discussions and critiques of the environment domain within the nursing field. Keywords used in the search included “metaparadigm of nursing,” “nursing environment domain,” “nursing practice and environment,” “virtual reality in nursing,” “technology in nursing education,” “sacred space in nursing,” “healthcare setting and context,” “nursing knowledge development,” “nursing theories and models,” and “environmental impact on patient care.” These terms helped identify relevant studies and articles that address both historical perspectives and contemporary advancements in nursing.

Foundational literature in this review includes Fawcett's (1984) influential works, starting with her 1984 book that introduced the four domains of the nursing metaparadigm: person, environment, health, and nursing. This foundational text established the basis for understanding the central attributes of nursing practice and theory (Fawcett, 1984). Fawcett’s subsequent 2000 publication further explores how nurses’ perceptions of these domains influence professional development and the creation of professional identity (Fawcett, 2000). Additionally, Kim’s article highlights the importance of clarifying the metaparadigm to enhance the understanding and application of nursing knowledge (Kim, 2000).

Contemporary literature reflects ongoing discussions and critiques of the environment domain. Holopainen et al. (2014) examine the evolving understanding of the environment domain, emphasizing its significance in nursing practice and suggesting a need for a more dynamic view of this domain. Andrews and Moon (2005) underscore the importance of considering broader socio-economic and cultural contexts in nursing research, further supporting the need for a comprehensive view of the environment domain. Recent studies also explore the integration of technology into nursing practice, such as Liszio and Masuch's (2019) review of virtual reality (VR)’s impact on reducing patient stress and enhancing care. Fraser's (2021) systematic review of VR for mental health conditions provides additional evidence of the effectiveness of technology in managing patient care. In light of the current difficulties and adjustments in nursing practice, Huang et al. (2020) conclude by discussing ways to protect healthcare workers during the COVID-19 pandemic, including using technology to reduce hazards.

This comprehensive review of historical and recent literature ensures that the discourse on the nursing metaparadigm, especially the environment domain, is well-supported by relevant evidence. This approach not only addresses the gaps in understanding but also highlights the evolving nature of nursing knowledge and practice.

Results

Definitions of Environment in Nursing Theories

The nursing metaparadigm serves as a foundational platform for nurse scholars, offering a common perspective around which nursing theories and scientific works are structured. Recognizing the metaparadigm of nursing as a discipline and a profession, its domains are interpreted uniquely by various scholars, particularly in nursing; therefore, these domains, which are often conceptualized in ambiguous and frequently conflicting ways, require clarification. Thorne et al. (1998) argued that while Fawcett's (1984) identification and description of domains in the metaparadigm of nursing aimed to impress “unity within the nursing discipline, instead led to divisiveness, hindering effective communication among nurses” (Thorne et al., 1998, p. 1265).

The environment, as a domain of the metaparadigm of nursing, has been defined, and Table 1 presents these definitions, highlighting the differences.

Table 1.

Definitions of the environment domain in the context of selected nursing theories

Theories	Definition of the Environment
Nightingale’s Environmental Theory (Nightingale, 1859)	The environment reflects a community health model in which all that surrounds human beings is regarded as essential to their health state.
Roy’s Adaptation Model (Roy, 1974)	The environment is defined as the conditions, circumstances, and influences that affect human beings’ development and behavior as an adaptive system. The environment is a stimulus or input that requires a person to adapt. These stimuli can be positive or negative.
Watson’s Theory of Human Caring (Watson, 1979)	The environment depends upon the society that provides the values that determine how one should conduct oneself and what goals one should strive toward. Caring (and nursing) have existed in every society. Every society has had some people who have cared for others. A caring attitude is not transmitted from generation to generation by genes. The culture of the profession transmits it as a unique way of coping with its environment.
King’s Theory of Goal Attainment (King, 1971)	The environment is the ground for human interaction. It is both external to and internal to the individual.
Orem’s Theory of Self-Care (Orem, 1991)	The environment has physical, chemical, and biological features. It includes the family, culture, and community.

From these definitions, it is evident that the nursing environment is influenced by the economic, social, and cultural conditions in which nurses operate. Andrews and Moon (2005) recognized the complexity of the environment, noting that theorists define it across a spectrum of philosophical and theoretical traditions, from positivism to phenomenology. They identified three perspectives on the environment: first, as everything “external” to nurses and their practices; second, as an interaction between internal and external elements; and third, as an inseparable relationship of both, leading to more abstract theoretical explorations. They argued for significant reform in the traditional approaches to nursing environments found in existing models and research.

This critical reconceptualization of the environment domain is essential for nursing to remain integral in enhancing human health and well-being. Thorne et al. (1998) contended that a comprehensive definition of the environment encompassing a wide range of nursing roles, client contexts, and social mandates would offer substantial advantages. By adopting an expanded and fluid view of the environment, nursing can better address contemporary challenges faced by nurses and those they care for, facilitating the integration of nursing’s individual and societal mandates and promoting innovative theoretical approaches that advance practice and inquiry.

Nursing Encounters and Space Exemplifying Nursing Environment

“Space” is a literal distance between two objects, and as described in Merriam-Webster (2019), it is “the distance from other people or things needed to remain comfortable” and is “an opportunity for privacy or to have time to oneself.” As such, it refers to a continuous area or expanse that is free, available, or unoccupied—the dimensions of height, depth, and width within which all things exist and move. As a verb, it refers to positioning (two or more items) at a distance from one another. Its etymology is traced back to a noun from Middle English, the Anglo-French word espace, and from Latin spatium, meaning area, room, and interval of space or time.

In nursing, the domain of the environment relates to the broader geographical landscape space at which the nurse-nursed interactions occur, conceptually emphasizing the “space and place” in which nursing encounters occur (Locsin, 2017; Tanioka, 2017). The term “encounter” is frequently used in nursing practice to describe nurse-nursed interactions, highlighting the importance of the encounter as an integral event that reflects the location where all nursing occurs. Nursing encounters are frequently characterized as presence (Parse, 1997) and as caring moments (Watson, 1999). Locsin (2017) has “placed” these encounters as occurring within the Universal Technological Domain (UTD).

Parse (1997) has described being authentically present in the “now moment” as the influencing occurrence in nurse-person interactions. The caring moment (Watson, 1999) is an instance of consciousness and possibilities in which genuine manifestations and closeness between two human beings are necessary for a nursing caring encounter. This caring moment provides inner strength, aiding the development of inner peace in the human being. From the external milieu, encounters of unlimited numbers occur, in which individuals cross interactive paths regularly. These clear contacts with specific aims lead to spiritual encounters, where the nurse and the nursed primarily appreciate and understand each other as participative and engaging human beings (Holopainen et al., 2014). The nurse and nursed are the essential protagonists in the nursing encounters within the environment domain of nursing.

Contemporary forms of “space” are currently featured in nursing care practices, including descriptions of situations in which safety, care quality, treatment outcomes, financial expenditures, and service usage are all linked together as opportunities illuminating persons’ nursing care experiences. Nursing care contributes to the fulfillment of basic physical, relational, and psychosocial life requirements, often jeopardized by diseases. A good example is represented during the COVID-19 pandemic (Sugg et al., 2021), in which demands critical nursing in a nursing-designed environment were dictated by nursing ingenuity, imagination, innovation, and creativity grounded in nursing knowledge to deliver quality human health and well-being effectively.

Recent studies such as those by Douglas and Douglas (2004) have drawn attention to the relationship between the healthcare environment and patient care outcomes. The hospital-built environment has been linked in more than 600 studies to crucial factors such as patient satisfaction, stress relief, and overall quality health outcomes (Heath, 2016). While providers work actively to maintain patients’ cultural identity as it influences and affirms their healthcare, nurses and healthcare practitioners need to be more conscious and responsive to the new “space” that effectively harmonizes new practices within the “environments” of care (VanHeuvelen, 2019). For example, in the case of the disease experience of patients during the COVID-19 pandemic, the signs and symptoms posed significant challenges in their living environment and tested the creativity and innovation skills of healthcare practitioners.

Labeling nurses as superheroes in their environment of practice (Mohammed et al., 2021) has taken nursing to new heights. For example, the emergence of adaptive ways to prevent transmission of the SARS-CoV-2 featured nurses’ ingenuity, prompting the re-envisioning of the nursing environment. The adaptation of preventive suits because ready-made personal protective equipment (PPE) was in short supply serves as an example. Redesigning plastic garbage bags and disposable hooded raincoats as “PPE-like” garb became essential to healthcare as barriers to infection, allowing nursing encounters to continue and sustaining nurse-nursed interactions well for the duration of the pandemic. This made nursing encounters safer, countering the unpopular impersonal “social distancing” protocol of wedging spaces between persons – rationalizing the protocol, which assumed that those infected with the virus were less likely to spread it if they kept their “social” distance. Miller and Ben-Joseph (2021) explained that the social distancing protocol made people realize the need to be more vigilant in following safe physical “space and place” guidelines, as asymptomatic individuals may very well be harboring and spreading the organisms.

In nursing practice, the measure of social distancing has affected communication and relations between nurses and between the nurse and the one nursed (Ferrari et al., 2021). Holopainen et al. (2014) expressed the essentiality of the “space of togetherness” in nursing, an attribute in the caring encounter between the nurse and the nursed. Regardless, in this nursing encounter, situations of vulnerability are experienced by the nurse and nursed, such as those resulting in loss of intimacy and manifest suffering, which would require adjusting and limiting social interactions and appreciating and accepting meaningful living.

However, the demand for the nursing workforce in increasingly space and technology-defined practice environments has risen significantly during the COVID-19 pandemic. Hospitals are often overwhelmed with highly infective people, exhausting hospital bed capacities (Grimm, 2021). The government-imposed protocols and guidelines to reduce the spread of the disease, including ‘lockdown’ and quarantine measures, forced people to remain in their homes and stay isolated, reimagining quarantine views (Arde et al., 2022). The influence of quarantine and isolation created significant innovative nursing care practices as expected outcomes of care had to consider limited space, social isolation, lockdown, and quarantines as people sought new patterns and ways of living.

Human beings, as natural social beings, were restricted from social outings and interactions with other human beings. Eventually, demands for creative ways to access health and welfare processes and treatments emerged. The practice of virtual healthcare consultations facilitated access to primary care for many people throughout the COVID-19 pandemic (Mold et al., 2021). Fearful of hospital visits, friends of infected persons with COVID-19 were mindful and cautious of the possibility of being infected, creating increased consciousness about the importance of testing. Nonetheless, persons with medical emergencies avoided going to the hospital because of the fear of contracting the dreaded COVID-19, leading to increased morbidity and mortality. Not surprisingly, the perception of the hospital has changed from an environment of safety and shelter to one of danger and fear (Wong et al., 2020).

Framing Nursing Practices through Space, Place, and Distancing

The principle of Synchronicity in the Human–Space–Time (HST) theory of nursing (SynHSTTNE) is advanced as foundational to nursing praxis, the theoretically based nursing practice encounter (Lim-Saco et al., 2018). As such, diverse practices impact nursing care based on nursing knowledge and processes focused on life principles of freedom, equitability, interconnectivity, and human transcendence. The ability to go beyond the limitations of human factors, space-time influences, and human transcendence has propelled globalized nursing practice within the Universal Technological Domain (UTD) (Locsin, 2017). Nursing unfolds in unitarily developing patterns that uphold the wholeness of persons through nursing engagement processes in the HST consciousness. Essentially, synchronicity exists through the meaningful connectedness of human health experiences and the consciousness of human, environment, and time elements. The dynamic nature of human health experiences in crisis, disease, illness, near-death, or poverty challenges a person’s whole self, and yet the continuous pattern of chaos–order transcendence is unlimited, energizing human living and adapting lifestyles.

Holistic and individualistic care is effective in promoting comfort, happiness, and well-being through mutual interaction with the environment, just like in the case of school nurses who establish programs that provide safe walking routes to and from school for people who have asthma, pupils, and public health nurses who act as champions make cities safer, livable, and healthy. Pupils are thus considered “unitary” and part of their environment. Making the atmosphere appropriate for students results in a unified whole with integrity and qualities that are more than and different from the sum of its parts. From this perspective, VR technology plays a critical role by bringing about a great leap in nursing practice proficiency and providing justification for creating infrastructure and planning programs (Jones et al., 2019).

Meanwhile, VR can build an environment between the nurse on Earth and the people being nursed in space. Health data from space-based individuals, such as astronauts, can be easily gathered and transmitted back to Earth for diagnostic analysis and appropriate healthcare interventions using telenursing platforms (Barrett, 1993). This demonstrates that the use of VR is not limited to education. Nonetheless, as VR technology grows in popularity and content becomes more diverse, its application is expanding. It is presently being utilized to improve patients’ and caregivers’ treatment experiences, and it is a promising technology that can be employed in various care settings (Son et al., 2022).

Technology and the Evolving Viewpoints of “Space” in Nursing

The future of healthcare lies in nursing’s technological advancements. As more hospitals and healthcare institutions incorporate emerging new and sophisticated technologies into their healthcare environment, technology dependency on technological machinery can positively impact quality patient care.

Nursing through Virtual Technologies

The emergence of telemedicine and telenursing results from the transformation of traditional nursing practices brought about by integrating modern communication technology into healthcare. These advancements allow medical practitioners to provide care virtually and across geographical boundaries. The increasing use of social media and communication tools has improved relationships through video conversations, teleconferences, and other in-person technology, as well as making it simpler to stay updated on world events. The advancement of communication technology has profoundly affected the healthcare industry, enabling nurses to improve care delivery through various virtual means and expand their duties (Naditz, 2009; Souza-Junior et al., 2016). Numerous services are provided via telemedicine and telenursing, such as data gathering, follow-up treatment, pain management, and remote monitoring. Using these technologies, nurses may provide multidisciplinary care to assist families while overcoming geographical barriers (Peck, 2005). Even when physical presence is not feasible, virtual interactions help people feel connected and united (Holopainen et al., 2014). By enabling nurses to have meaningful communication with patients even when they are physically separated, this virtual presence contributes to the transformation of isolation into a shared space of care.

A significant advancement in virtual nursing is using VR, which was initially developed in the 1960s. VR technology, also known as tele-robotics or personal simulators, creates immersive, simulated environments that replicate real-world interactions (Barrett, 1993). By establishing sophisticated communication links between nurses and patients, VR extends the capabilities of nursing care, allowing for remote interactions and support. According to Schubert (2009), the term “spatial presence” describes the cognitive sensation that arises from unconscious cognitive processes and influences conscious thought regarding the condition of the spatial cognitive system. VR enables the creation of environments that mimic reality, which can be beneficial for reducing stress, alleviating symptoms of anxiety and depression, and enhancing overall well-being (Liszio & Masuch, 2019; White et al., 2018). Studies have shown that virtual environments, such as those that simulate nature, can reduce physiological and psychological stress and contribute to a sense of tranquility (Fraser, 2021).

As nursing practices transition into virtual realms, they challenge traditional concepts of corporeality and spatiality. The physical body becomes less relevant in these virtual spaces, and care is mediated through digital representations such as images, data, and virtual interfaces (Sandelowski, 2008). This shift necessitates philosophical inquiries into new concepts of presence and connectedness in care contexts where physical proximity is no longer a factor. The traditional notion of the nurse as a physical presence next to the patient is replaced by a virtual or digital presence, such as a voice on the phone, an email correspondent, or an online avatar (Parse, 1992; Watson, 1999).

Numerous viewpoints have been examined on the role of nurses in virtual environments, including those of a care mode, practice, research, and educational setting. Nursing presence has been associated with conventional notions of the person to place, space, and time as a caring modality. These conventional ideas are being called into question by new care settings that forbid the physical presence of nurses, sparking discussions about moral agency and the capacity of nurses to provide a therapeutic presence. Technology has changed the social space in which nurses and patients interact, as well as our understanding. If not used purposefully, technology may reduce the patient’s experience to preset data sets and obstruct moral autonomy (Grumme et al., 2016).

Despite all of this progress, there are worries regarding the possible flaws and hazards of virtual care environments. These must also be investigated through nursing research. The most recurrent issue is whether or not the art and practice of nursing are being diluted to the point where encounters lose their sense of presence. In virtual care settings, the nursing values of “being there” and “presence” take on a slightly different meaning (Fronczek, 2019). While virtual technologies like VR offer new opportunities for engaging with patients and enhancing their care, addressing these concerns is crucial and ensuring that the fundamental aspects of nursing care—such as genuine presence and emotional connection—are preserved.

Overall, the integration of virtual technologies in nursing presents both opportunities and challenges. It allows for innovative approaches to care delivery, supports patient well-being, and extends the reach of nursing practice. However, it also requires ongoing reflection and adaptation to maintain the essence of nursing care in an increasingly digital world.

Space Nursing in the Pandemic

In the current era, as the world grapples with the impact of the pandemic, nurses remain faithful to their oath. Nurses are at the frontline of the international health crisis. Nurses have played significant roles throughout history, stepping in during crises and providing care and innovation to save lives and reduce suffering (Phillips & Catrambone, 2020). As nurses continued to be at the frontline of human care during the pandemic, they were not exempted from experiencing unintended consequences. In the community, they were actively involved with evaluation and monitoring, while in the hospital, nurses offered personalized, high-quality services, irrespective of the patient’s infectious conditions (Fawaz et al., 2020). From providing direct care to affected hospitalized persons to leading exhaustive public health operations, nurses have been taking innumerable risks, practicing conscientiously around the clock to protect the health and well-being of persons in their care and the public.

In the continuing battle against COVID-19, ethical concerns press for the safety of nurses and other healthcare workers. They work under conditions that substantially risk their overall health and well-being. Faced with the reality that the nursed will suffer, experience exacerbated symptoms, or die, many healthcare professionals find it extremely difficult to make or implement a decision to deny or delay treatment given their human response, their profession’s expectations, and norms about saving lives, relieving suffering, and not abandoning persons in their care (Morley et al., 2020).

Caring in times of a pandemic is considerably stressful. The increasing demand for workload while trying to conform to new and changing protocols adds to the anxiety experienced by nurses. Exacerbated by the need to undergo quarantine after being exposed to the virus and by the lack of resources, such as PPE, puts them at greater risk of contracting the virus. Because of these realities, nurses may experience compassion fatigue, characterized by the depleted ability to cope with their environment, resulting in reduced resilience and burnout. The prevalence of these factors may predispose nurses to leave their profession.

The nurses studied by Sperling (2021) did not convey their intention to leave the profession. Although that study provided evidence of nurses’ conflicting values while caring for the infected person during the pandemic, they showed solid dedication to caring for the sick persons despite experiencing significant personal risk and emotional burden. The determination to provide care to those in need despite the risks makes nurses deserving of special attention with respect to their protection during the COVID-19 pandemic. Because nurses are particularly susceptible to COVID-19, hospital-specific policies must be established to lower the infection risk for nurses dealing with COVID-19-infected individuals. During this pandemic, nurses may benefit from intensive education and training, the implementation of a realistic shift schedule backed by science, a comprehensive infection control system, and avoiding needless encounters (Huang et al., 2020).

As organizations have shifted to remote work in response to the COVID-19 pandemic, adoption of VR and augmented reality technology has increased substantially. It has augmented traditional in-hospital teaching and even patient management. VR simulations in nursing education have enabled repetitive, hands-on instruction to enhance cognitive and mastering abilities in nursing students.

The Sacred Space in Nursing

According to Quinn (1992), there are at least two ways of conceptualizing the nurse’s place in the client-environment process. One is the nurse as being in the client’s environment, and the second is the nurse as the client’s environment. The first-way concerns patterning the environmental field in which the nurse and the one being nursed shape the environment to promote nursing care processes. The latter, however, view the nurse as an energetic, vibrational field integral to the client’s environment. In viewing the nurse as the client’s environment, the nurse can use space as an intervention to mitigate health situations in which the nurse can facilitate nursing care regardless of location on Earth or in outer space.

According to Adelstein (2018), a space can be sacred if it gives individuals who inhabit it a sense of transcendence - being connected to something greater than oneself. As with a religious institution, the sacredness may be intrinsic in the space. Healthcare providers, on the other hand, have the opportunity to create a sacred space of healing in their patient interactions.

Isolated human beings have limited interactions with nature because their confinement limits their own space. Restricted and inadequate access to the outside space can lead to mood changes and psychological stress in individuals. In Trueland (2017) study, it was found that lack of access to outdoor space was the single environmental variable that significantly predicted depressive symptoms. The overall environment of care homes was not associated with depressive symptoms, but being able to enjoy time outside was hugely beneficial to staff and residents. Diminished exposure to the environs of nature damages health and well-being and can exacerbate the growing disconnect that urban populations experience in nature (Soga & Gaston, 2016).

Promoting life satisfaction and well-being is achievable through indirect exposure to nature, such as through windows, and this benefit can be provided to isolated populations (Li et al., 2021). Furthermore, Li et al. (2021) demonstrated that the visibility of nature promoted the frequency and duration of viewing nature through windows. For example, natural grassland parks decrease anxiety and negative feelings compared to walking along a busy main street (Bratman et al., 2015). Nature-based interventions such as garden visits have shown efficacy in promoting well-being in healthcare (Ulrich, 1984).

Nursing Encounter as Caring Space

In Holopainen et al. (2014) description of nursing encounters, they claim that it not only reveals the suffering in the relationship but also helps one find oneself again. When human beings fall ill, they lose control over their bodies. In the encounter with the other, the nurse can facilitate a feeling of regaining control over the body – again becoming more of oneself despite the body’s deficiencies, through recognition of oneself, and through getting to know oneself better through an inner reshaping of oneself. Communication is an essential consideration in this reshaping of oneself, and nurses’ use of digital devices in the workplace to communicate and collaborate with others can facilitate more effective communication. For example, in Finland’s scarcely populated areas, virtual consultation is being used so nurses can meet their clients without making unnecessary trips. This practice has benefited patients because of the advantages of interactive communication (Wikberg, 2007).

However, the excessive use of electronic gadgets among young people has been associated with reduced time spent outdoors with nature (Larson et al., 2019; Pergams & Zaradic, 2006). Researchers have been concerned that “virtual nature” may devalue and even replace actual natural environments (Levi & Kocher, 1999; Litleskare et al., 2020), warning that people may subsequently prefer and adapt well to virtual nature, becoming accustomed to this unreal nature exposure (Kahn Jr et al., 2009). Future research should further distinguish between connectedness and the real versus virtual nature, examining whether or not virtual nature exposure can be translated into more “real nature” experiences.

Optimizing Nurse Well-being Through Safe Healthcare Environments

Quality outcomes of care are typically viewed as the most crucial component of healthcare. As crucial as it is when it comes to any aspect of providing efficient medical care, maintaining a safe environment conveys a degree of compassion and consideration for human welfare. The environment in which healthcare is practiced has a significant impact on the standard of care.

It is evident that since the outbreak of COVID-19, sources of fatigue for nurses have been attributed to the pressures of professional practice, a heavy workload, a demanding practice environment, particularly with extended nursing time, and care expectations. The physical design of the healthcare environment is essential in the provision of secure and safe practice conditions (Ma et al., 2021). For example, in a healthcare setting, natural light, fresh air, and views of green space (Barton & Rogerson, 2017) could effectively reduce the stress and anxiety faced by nurses. Nightingale (Fee & Garofalo, 2010), with all her wisdom, heightened the functional effectiveness of the human environment. As a healthcare condition, the environment attains a primary position in assuring that putting the person in the best possible position for nature to take its course increases human healthcare through an enhanced healing environment.

Meanwhile, actions taken to promote unity and solidarity in facing a public health threat can be challenging. For example, with the COVID-19 pandemic, in the absence of a cure or vaccine, people were required to abide by certain alternative norms of behavior, such as following guidelines set by authorities, thereby limiting socialization. Aside from frequent handwashing and avoiding contact with people, social distancing, an intervention intended to protect at-risk individuals, was practiced, maintaining physical distancing between people. To the best of their abilities, people followed social distancing and isolation protocols believed to slow the spread of the disease by stopping the chains of transmission of COVID-19 (World Health Organization, 2020), which helped to contain the spread of the virus. Social distancing during the COVID-19 pandemic was a public good (Cato et al., 2021). However, while it reduced the probability of infection, it entailed personal costs, from forgoing enjoyable activities to limiting socialization.

Thus, protecting healthcare workers is not limited to keeping them healthy to remain in the workforce but also to preventing them from being vectors of the virus as well as promoting their general well-being. For this reason, implementing measures to protect staff, patients, visitors, and training personnel is part of hospital preparedness (Farsalinos et al., 2021). As such, it is essential to consider not only the physical work environment and personal protective equipment used by nurses but also the healthcare-specific social distancing perspectives (Prin & Bartels, 2020) to maximize health provider safety and well-being in practice environments.

Implications to Nursing

Nursing practice, research, and education will be significantly impacted by the shifting perspectives on “space” in the field, especially regarding technology, VR, and the larger idea of sacred space. When incorporated into nursing practice, VR and other innovative technology can significantly influence patient care and the overall delivery of healthcare. Even in circumstances where physical presence is not feasible, nurses and patients can converse remotely thanks to VR technology, ensuring continuity of care. VR in nursing has been shown to improve cognitive performance and alleviate pain, anxiety, and sadness (Hu et al., 2023). Furthermore, VR exposure-based therapies can lessen anxiety disorders, and they may improve treatment outcomes by revolutionizing the way mental health issues are assessed, understood, and treated (Freeman et al., 2017). Healthcare personnel can be shielded from certain hazards involved with providing direct patient care, such as infection exposure, by utilizing VR and telehealth technologies. Through better symptom monitoring, education, and support, electronic, mobile, and telehealth solutions can help vulnerable patients with chronic diseases feel more empowered and control their own health (Parker et al., 2018). Incorporating these technologies into everyday practice can assist in managing the hazards associated with older approaches while addressing the growing demand for treatment as the healthcare landscape continues to change.

Research opportunities are abundant due to the technological advancements in nursing, especially when it comes to assessing the efficacy of VR and other virtual technologies in clinical settings. Studies can concentrate on the effects of these technologies on healthcare efficiency, nurse-patient interactions, and patient outcomes in general. For instance, studies have demonstrated that VR exposure-based treatments can reduce anxiety disorders, and its potential to transform the assessment, understanding, and treatment of mental health problems could enhance treatment outcomes (Freeman et al., 2017). Additionally, exploring the ethical implications of virtual care, including ethical challenges in virtual communities in health care, such as identity and deception, privacy and confidentiality, and technical issues like sociability and usability (Demiris, 2006), is crucial to ensuring that these technologies are implemented responsibly and effectively. Continued research is needed to assess the long-term benefits and potential drawbacks of integrating VR and other digital tools into nursing practice.

The use of VR and other technological tools in nursing education offers transformative potential for enhancing learning experiences and preparing students for the realities of modern healthcare. By incorporating VR simulations into nursing curricula, knowledge retention and clinical reasoning are improved, and student satisfaction is increased with the learning experience (Padilha et al., 2019). Integrating these technologies into nursing education also prepares students to effectively use digital tools in their future practice, equipping them to manage complex care scenarios and adapt to evolving healthcare environments.

Recommendations for Future Influences of Environment as a Domain of the Metaparadigm of Nursing

Several key recommendations should be considered to effectively influence the development of the “Environment” as a domain within the nursing metaparadigm. First, the conceptualization of the nursing environment should be expanded beyond physical spaces to include virtual and technological contexts. Recognizing that the environment encompasses all nursing care settings—whether in hospitals, clinics, home settings, or digital platforms—will provide a more comprehensive view. Incorporating spatially informed and technologically advanced approaches into nursing practice is also essential. This involves promoting research and the development of new tools and methodologies that leverage technology to enhance patient care and address limitations in traditional settings.

Investing in technology that allows nurses and patients to connect meaningfully is essential. The quality of care can be greatly improved by systems that reduce physical distance and foster better interpersonal and communicative interactions. Additionally, considering how different elements of both real and virtual spaces affect nursing practice and patient outcomes, person-centered care models ought to consider this broader understanding of the environment.

Encouraging and supporting studies examining how geographical factors affect health and care will also be crucial. This research should aim to develop theories that integrate insights about space and place into nursing science. Promoting structural and regulatory reforms that acknowledge the importance of the nursing environment, in its physical and virtual forms, can impact standards and recommendations in healthcare settings. Additionally, nursing education and training programs should be updated to include a comprehensive understanding of the nursing environment. This will equip future nurses with the skills to navigate and optimize various practice settings. Developing and implementing evaluation metrics to assess the impact of different environments on nursing practice and patient outcomes will guide improvements and innovations. By adopting these recommendations, the nursing field can integrate the concept of the environment more effectively into its metaparadigm, ensuring that it supports and enhances nursing practice and patient care across diverse contexts.

Conclusion

A multi-layered perspective on the nursing environment examines the everyday realities and immediate contexts of nursing practice, acknowledging the influence of sociopolitical and economic structures on nursing care ideologies. While the concepts of “space and place” within the nursing environment are familiar, their specific manifestations in practice are crucial as they form the foundation for communication and interpersonal relationships between nurses and patients. Meaningful connectedness is vital for nursing engagement, and technological advancements offer new ways to enhance these relationships, potentially overcoming barriers related to space and place. The environment is the stage for nursing practice and is central to human nurse caring.

As nursing practice evolves and its influence extends into broader social, economic, and political realms, the traditional concept of the nursing environment may need re-evaluation to encompass its role fully. Roxberg et al. (2020) emphasize the importance of spatially informed research, listing topics that include developing methods to communicate spatially related ideas and theories within health and care research. This suggests a need to re-envision the nursing environment as a more expansive and integral domain rather than simply a “setting.” Technology integration in nursing practice will continue to evolve, highlighting the significance of considering the healthcare environment as a dynamic and adaptive factor in optimizing care. This perspective includes not only the physical environment but also virtual spaces where nurse-patient interactions occur. Viewing the nursing environment as a distinct domain of knowledge and practice underscores its value as a critical nursing component, recognizing it as a significant aspect of the discipline and the profession.

Funding Statement

Funding No external grants were received to conduct this study.

Declaration of Conflicting Interest

We declare that two authors are on the editorial board of Belitung Nursing Journal. They have recused themselves from editorial decisions. The manuscript was prepared independently, and we commit to transparency and ethical standards throughout the review process.

Authors’ Contributions

All authors contributed equally to this study according to authorship criteria.

Authors’ Biographies

Epifania Marlene Purisima, RN, PhD, is an Associate Professor at the College of Nursing, University of Northern Philippines, Vigan, Ilocos Sur, Philippines.

Bernardo Oliber Arde Jr., RN, PhD, is a Professor at the College of Nursing, University of Northern Philippines, Vigan, Ilocos Sur, Philippines.

Francis Don Nero, RN, PhD, is an Associate Professor at the College of Nursing, University of Northern Philippines, Vigan, Ilocos Sur, Philippines.Vigan, Ilocos Sur, Philippines.

Rozzano C. Locsin, RN, PhD, FAAN, is a Professor Emeritus at the Christine E. Lynn College of Nursing, Florida Atlantic University. He is also an International Editorial Board Member of Belitung Nursing Journal.

Jed Montayre, RN, MN, DipT, PhD, is an Associate Professor and a School of Nursing Director-Centre of Evidence-based Practice for Health Care Policy at The Hong Kong Polytechnic University. He is also an Editorial Board Member of Belitung Nursing Journal.

Data Availability

Supporting data for this study is available on reasonable request.

Declaration of Use of AI in Scientific Writing

Nothing to disclose.