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Florence Nightingale's Environmental Theory and its influence on contemporary infection control

Published:October 23, 2020DOI:https://doi.org/10.1016/j.colegn.2020.09.006

      Abstract

      Background

      The work of Florence Nightingale has laid the foundation for contemporary nursing practice, bringing the fundamental art and science of nursing into the 21st century. Her Environmental Theory was the beginning of a lifetime's work, being one of her many healthcare reforms which survive to this day as the practice of infection control.

      Aim

      To discuss the development of Nightingale's Environmental Theory in the 19th century and its application in contemporary 21st century nursing practice.

      Methods

      A search of Nightingale's publications, biographers and theorists, selected journal articles and databases to build a picture of the origins, significance and practice of contemporary infection control.

      Findings

      Nightingale's Environmental Theory has changed the face of infection control exponentially. Today's guidelines are an integral part of nursing practice, to the extent that they continue to evolve, particularly as the coronavirus pandemic remains active around the world.

      Discussion

      Investigation of Nightingale's experiences in the Crimean War, of the disease, infection, death and dying that she encountered there and the subsequent development of her Environmental Theory and its application in 21st century nursing practice.

      Conclusion

      Contemporary infection control is now an integral part of nursing and nursing practice the world over. It is an essential part of creating safe environments that help to promote good healing, good health and wellbeing and good patient outcomes, along with the opportunity for continued development to keep in step with changing patient and global need.

      Keywords

      Summary of Relevance
      Problem or Issue
      To investigate the development of Nightingale's Environmental Theory, acknowledge its place in history and explore its evolution into contemporary infection control.
      What is Already Known
      History confirms the work of Nightingale's healthcare reforms, including the development of her Environmental Theory.
      What this Paper Adds
      This paper adds a contemporary look at the application of infection control in current nursing ideology, guidelines and practice.

      1. Introduction

      Acknowledging the World Health Organisation's (WHO) declaration of the Year of the Nurse and the Midwife 2020 (
      • WHO
      Year of the Nurse and the Midwife.
      ), this paper honours the 200th anniversary of Florence Nightingale's birth. Today, nurses are highly regarded as being amongst the most trusted and respected professions in the world, but it has not always been this way. Nightingale was the catalyst who not only secured nursing as a profession but also gave it the respectability it deserved. Such influence has subsequently provided a platform for the development and application of her many healthcare reforms in contemporary nursing practice, particularly her Environmental Theory, more commonly known today as infection control.

      2. Background

      Florence Nightingale (1820-1910), who died over a century ago, was a true explorer into uncharted territory. She was a teacher, reformer, reactionary and revolutionary, championing the cause of healthcare reform for the good of all. Her prolific research, analyses and writings included many works on nurses and nursing, nursing education, infection and infection control, sanitation, hospital planning, design and construction, hospital administration, health promotion and healthcare and statistical analysis, all of which had a close association with her Environmental Theory (
      • Nightingale F.
      Florence Nightingale’s letter to Sidney Herbert. Held by the British Library. Shelfmark Add MS 43393.
      ,
      • Nightingale F.
      Notes on matters affecting the health, efficiency and hospital administration of the British army founded chiefly on the experience of the late war.
      ,
      • Nightingale F.
      Florence Nightingale’s letter to William Farr (re sanitary matters).
      ,
      • Nightingale F.
      A Contribution to the Sanitary History of the British Army during the Late War with Russia.
      ,
      • Nightingale F.
      Notes on Nursing: What it is and what it is not.
      ,
      • Nightingale F.
      Notes on Hospitals.
      ,
      • Nightingale F.
      Florence Nightingale to her Nurses: A selection of from Miss Nightingale's addresses to probationers and nurses of the Nightingale School at St Thomas's Hospital.
      ,
      • Nightingale F.
      Florence Nightingale's letter to Captain Galton (re Army Sanitary Commission).
      ).
      Contemporary nursing practices are such an integral part of daily patient care that they are often taken for granted, however it is important to understand their origins. As nurses and nursing practices embrace 21st century demands and lifestyles, the reasons for nursing actions should be clearly identifiable, become an integral part of daily patient focus and direct future strategic planning. By tracing the origins of such important nursing concepts as Nightingale's Environmental Theory, and subsequently applying adaptive measures for contemporary scenarios, nurses will be better prepared to embrace burgeoning e-health, technological advances, increasing patient workloads and, ultimately, more responsive, patient-centred care.
      This discussion will focus initially on Nightingale's experiences during the Crimean War so that a clear and comprehensive picture of the subsequent development of her Environmental Theory can be used as a reference point for today's infection control practices.

      3. Discussion

      3.1 Crimean War experiences highlight the need for improved conditions

      In early 1854, Nightingale was asked by the Secretary of State at War, Sir Sidney Herbert, a friend of Nightingale and her family and someone who was aware of Nightingale's keen interest in nursing, to oversee the introduction and administration of nurses to military hospitals in Turkey, during the course of the Crimean War (1853-1856). This was in response to reports by William Russell and Thomas Chenery in The Times newspaper (
      • Times, The
      Thomas Chenery, October 12 1854.
      ), which criticised the British medical facilities there (
      • Bostridge M.
      Florence Nightingale, The Woman and her Legend.
      ,
      • Burchill E.
      Australian Nurses since Nightingale, 1860-1990.
      ). These were reported to be poorly managed and ill-prepared in every respect. They lacked the necessary staff, medical supplies and transport for the wounded, some of whom waited for weeks, without treatment, before being taken from the battlefield by boat across the Black Sea to the British Army Hospital established in the Turkish Selimiye Barracks at Scutari (now Uskudar in modern Istanbul). Conditions were appalling. These reports initiated a Times Fund which raised £11,000 to provide medical supplies and equipment for the British Army hospitals (
      • Bostridge M.
      Florence Nightingale, The Woman and her Legend.
      ).
      In November 1854, Nightingale, now the ‘Superintendent of the Female Nursing Establishment of the English General Hospitals in Turkey’, arrived in Scutari with 38 nurses (
      • Times, The
      The Times Obituary, 15th August, 1910.
      ). Her first impressions must have been horrific, for she commented, ‘we are steeped to our necks in blood’ (
      • Nixon K.
      The World of Florence Nightingale.
      ). There were two main hospitals, the Barrack Hospital (British Army Barracks) where Nightingale and her nurses were based, and the General Hospital, with an initial total of 2300 soldiers, who were either ill from disease or infection, wounded in battle or dying from starvation, frostbite and gangrene (
      • Ben-Ishay O.
      • Gertsenzon H.
      • Mashiach T.
      • Kluger Y.
      • Chermesh I.
      Malnutrition in Surgical Wards: A plea for concern.
      ). The situation rapidly became considerably worse with the arrival of 500 more wounded, bringing the total number of patients to almost 3000 (
      • Bostridge M.
      Florence Nightingale, The Woman and her Legend.
      ). Straw beds on the stone floors stretched for an incredible 6.4 kilometres (4 miles) throughout the Barrack Hospital (
      • Attewell A.
      Florence Nightingale's Relevance to Nurses.
      ). Added to this was the appalling stench of human waste from open, blocked sewers, rat, lice, fly and flea infestations and horse carcasses floating in the water supply. Surgeries were conducted in the open wards, without screens, proper equipment or medicines, ‘Disease, neglect and mismanagement had united to render the scene one of unparalleled hideousness’ (
      • Bostridge M.
      Florence Nightingale, The Woman and her Legend.
      ).
      Traditionally, Army care of the wounded and dying had been undertaken by military male orderlies and women, the latter often following the military camps as ‘comforters’, however many women were also known to be the wives and sweethearts of the sick and wounded (
      • Hallett C.
      Celebrating nursing: A visual history.
      ). Hence the abrupt arrival of Nightingale and her nurses was seen as highly irregular and completely unnecessary. Nightingale, therefore, waited patiently with her nurses for the medical officers to request their attendance on the sick, wounded and dying. Although this was not immediately forthcoming, the sheer number of casualties, and deaths, made the outcome inevitable (
      • Bostridge M.
      Florence Nightingale, The Woman and her Legend.
      ). In January 1855, a further 50 nurses arrived to support the nursing work already begun (
      • Times, The
      The Times Obituary, 15th August, 1910.
      ).

      3.2 The germ theory, disease and dying

      The germ theory (medical bacteriology), a belief that disease was caused by the transmission of micro-organisms from patient to patient, evolved over many years. In the 1840s, the Hungarian physician, Dr Ignaz Semmelweis, discovered that the simple act of handwashing between patients all but eliminated the high infection rate in obstetric patients, drastically reducing the mortality of women following birthing (
      • Best M.
      • Neuhauser D.
      Heroes and Martyrs of Quality and Safety. Ignaz Semmelweis and the birth of infection control.
      ; Dossey, Selanders, Beck, & Attwell, 2005;
      • Nuland S.B.
      The doctors’ plague: Germs, childbed fever and the strange story of Ignac Semmelweis.
      ;
      • Pittet D.
      • Boyce J.M.
      Hand hygiene and patient care: Pursuing the Semmelweis legacy.
      ). This work was further expanded upon by Louis Pasteur and Robert Koch in the 1870s (
      • Ullman A.
      Pasteur–Koch: Distinctive ways of thinking about infectious diseases.
      ) and antibiotics, specifically penicillin, discovered by Alexander Fleming in 1928 (
      • Fleming A.
      On the bacterial action of cultures of a Penicillium, with special reference to their use in the isolation of B. Influenzae.
      ) some 20-70 years after the beginning of the Crimean War, respectively. Therefore, little was available for the treatment of infection and disease in the mid-19th century, not even antiseptics. Although Joseph Lister successfully utilised carbolic acid (phenol), a poisonous, caustic compound, to relieve and eliminate infection in wound care and surgery in the 1860s (
      • Lister J.
      On the antiseptic principle in the practice of surgery.
      ), it was also unavailable during the Crimean War.
      Treatments for wound infection and infectious diseases were therefore limited to medications such as quinine, which was originally recognised in the 17th century (
      • Butler A.R.
      • Khan S.
      • Ferguson E.
      A brief history of malaria chemotherapy.
      ) for the treatment of malaria, and tincture of opium for the relief of diarrhoea, because of its gastrointestinal motility properties. It also contained the opioid morphine, useful for pain relief (
      • Gill C.
      • Gill G.
      Nightingale in Scutari: Her legacy re-examined.
      ). Furthermore, anaesthetics were basic at this time, with chloroform being the mainstay (
      • Manring M.M.
      • Hawk A.
      • Calhoun J.H.
      • Andersen R.C.
      Treatment of war wounds, a historical review.
      ). Apart from the high rate of infection, overcrowded conditions allowed disease to run rampant, with cholera, typhoid, typhus, respiratory infections and dysentery ever present, the latter accounting for at least 50% of deaths. This explains the overall high mortality rate from disease, at almost four times greater than deaths from wounds acquired on the battlefield (
      • Bostridge M.
      Florence Nightingale, The Woman and her Legend.
      ,
      • Robins C.
      Cholera and dysentery in the Crimean War: A Layman's View.
      ).
      It is therefore clear that Nightingale would not have known of bacterial or viral infection at this time, however she was aware of the effect of contagion (
      • Gill C.
      • Gill G.
      Nightingale in Scutari: Her legacy re-examined.
      ,
      • McDonald L.
      Florence Nightingale at first hand.
      ), the spread of disease by direct or indirect contact. She saw this at first hand in the overcrowded, squalid conditions of the Barrack Hospital, in the form of the communicable diseases mentioned previously (
      • Bostridge M.
      Florence Nightingale, The Woman and her Legend.
      ,
      • Manring M.M.
      • Hawk A.
      • Calhoun J.H.
      • Andersen R.C.
      Treatment of war wounds, a historical review.
      ). This led her to make the connection between disease and the state of the environment (
      • Gill C.
      • Gill G.
      Nightingale in Scutari: Her legacy re-examined.
      ). Nightingale believed that cleanliness of the environment, subsequently to be described by her as the ‘Health of houses’ (pure air, pure water, efficient drainage, cleanliness and light) was essential to promote healing and general wellbeing of the patient (
      • Bostridge M.
      Florence Nightingale, The Woman and her Legend.
      ,
      • Dossey B.M.
      • Selanders L.C.
      • Beck D.-M.
      • Attwell A.
      Florence Nightingale today: Healing, leadership, global action.
      ,
      • Gill C.
      • Gill G.
      Nightingale in Scutari: Her legacy re-examined.
      ,
      • Kudzma E.C.
      Florence Nightingale and healthcare reform.
      ,
      • Nightingale F.
      Notes on Nursing: What it is and what it is not.
      ). Because of this, Nightingale and her nurses worked hard to provide the sanitary solutions of clean bedding, clothing, wound dressings and environment, along with wholesome and nourishing food, in effect, putting what would become her Environmental Theory into practice (
      • Bostridge M.
      Florence Nightingale, The Woman and her Legend.
      ,
      • Gill C.
      • Gill G.
      Nightingale in Scutari: Her legacy re-examined.
      • Manring M.M.
      • Hawk A.
      • Calhoun J.H.
      • Andersen R.C.
      Treatment of war wounds, a historical review.
      ).
      By the end of the first winter, in February 1855, British mortality reached a staggering 52% (
      • Bostridge M.
      Florence Nightingale, The Woman and her Legend.
      ). Worse still, 60% of deaths were caused solely by disease, more than the mortality rate of the London population during the Great Plague of 1665-1666, some two hundred years earlier (
      • Times, The
      The Times Obituary, 15th August, 1910.
      ).
      It was thought that the death rate from disease and infection in particular, did not initially decrease following the arrival of Nightingale and her nurses, despite improvements in sanitation (
      • Bostridge M.
      Florence Nightingale, The Woman and her Legend.
      ). Interestingly, there are contemporary historians, for example, Small, Wavell and Brooks, who would question, even lay blame, with Nightingale for increasing the death rate during the Crimean War (
      • Brooks R.
      Nightingale’s nursing “helped kill soldiers”.
      ,
      • Small H.
      Florence Nightingale: Avenging Angel.
      ,
      • Wavell S.
      The liability with a lamp.
      ). Small devised a ‘bizarre scenario’ (
      • Attewell A.
      Throwing light on Florence Nightingale: Of lamps and lanterns.
      ,
      • McDonald L.
      Florence Nightingale at first hand.
      ,
      • McDonald L.
      Florence Nightingale, statistics and the Crimean war.
      ) without any evidence, which accused Nightingale of increasing the mortality rate and that as a result she suffered a ‘nervous breakdown’, caused by her ‘guilt’ (
      • Small H.
      Florence Nightingale: Avenging Angel.
      ). In Nightingale's defence, however, it was known that at that time she was writing a report to assist with the official Royal Commission into the mortality rate of the Crimean War (
      • Nightingale F.
      A Contribution to the Sanitary History of the British Army during the Late War with Russia.
      ,
      • Nightingale F.
      Florence Nightingale's letter to Captain Galton (re Army Sanitary Commission).
      ,
      • McDonald L.
      Florence Nightingale, statistics and the Crimean war.
      ).
      Small, Wavell and Brooks also accused Nightingale of making negative comments about the hospitals in the Crimea (
      • Brooks R.
      Nightingale’s nursing “helped kill soldiers”.
      ,
      • Small H.
      Florence Nightingale: Avenging Angel.
      ,
      • Wavell S.
      The liability with a lamp.
      ), however this has also been disproved in her many writings on sanitary reforms over several decades (
      • Nightingale F.
      Florence Nightingale’s letter to William Farr (re sanitary matters).
      ,
      • Nightingale F.
      Notes on Nursing: What it is and what it is not.
      ,
      • Nightingale F.
      Notes on Hospitals.
      ,
      • Nightingale F.
      Florence Nightingale’s letter to William Farr (re Indian sanitary reform – Administration and mortality statistics).
      ,
      • Nightingale F.
      Florence Nightingale’s letter to Charles C. Plowden (re Sanitary Report for India).
      ,
      • Nightingale F.
      Florence Nightingale's letter to Captain Galton (re Army Sanitary Commission).
      ,
      • Nightingale F.
      Florence Nightingale’s letter to George Hanby De’Ath (re the difficulty of changing the sanitary habits of the poor).
      ,
      • McDonald L.
      Florence Nightingale, statistics and the Crimean war.
      ).
      By March 1855, the mortality rate of the Crimean War had decreased by 20%. Popular thought of the time favoured attributing the decreasing death rate to the work of Nightingale however this was not confirmed by her. In her private letters to the Herberts (Sir Sidney Herbert and his family), she wrote, ‘We pulled this hospital through for four months and without us, it would have come to a standstill’ (
      • Bostridge M.
      Florence Nightingale, The Woman and her Legend.
      ,
      • Nightingale F.
      Florence Nightingale’s letter to Sidney Herbert. Held by the British Library. Shelfmark Add MS 43393.
      ). She was referring to the work of the Sanitary Commission which was dispatched to Scutari by the British Government to inspect and improve hospital conditions. The Sanitary Commission initiated lime washing of walls and floors, cleaning of sewers, daily removal of human waste and improvements to the water supply (
      • Bostridge M.
      Florence Nightingale, The Woman and her Legend.
      ). In addition, the combination of a decrease in the number of patients, ultimately improving conditions in the overcrowded wards, and the improved health of those arriving from the Crimea, particularly as the weather improved, along with the work of Nightingale and her nurses, resulted in improved mortality rates overall (
      • Bostridge M.
      Florence Nightingale, The Woman and her Legend.
      ). Substantial evidence therefore supports Nightingale's personal hand-written accounts, over several years, of her admiration for hospital improvement once health reforms had been initiated (
      • McDonald L.
      Florence Nightingale, statistics and the Crimean war.
      ), robustly challenging the critics she would never meet, who sought to discredit her work.
      British Army deployment totalled a little under 98,000 men. By the end of the war, in 1856, there were 21,500 British dead. Of this number, 4500 were killed in action or died of their wounds, however approximately 17,000 (79%) died of infection and disease (
      • Gill C.
      • Gill G.
      Nightingale in Scutari: Her legacy re-examined.
      ).
      Nightingale was devoted to the provision of holistic patient-centred care (
      • Dossey B.M.
      Florence Nightingale’s vision for health and healing.
      ,
      • Dossey B.M.
      • Selanders L.C.
      • Beck D.-M.
      • Attwell A.
      Florence Nightingale today: Healing, leadership, global action.
      ,
      • Nightingale F.
      Florence Nightingale to her Nurses: A selection of from Miss Nightingale's addresses to probationers and nurses of the Nightingale School at St Thomas's Hospital.
      ), a body, mind and spirit approach to healing, which she saw as the ‘essence of nursing’ (
      • Dossey B.M.
      • Selanders L.C.
      • Beck D.-M.
      • Attwell A.
      Florence Nightingale today: Healing, leadership, global action.
      ). This included ‘supervisory and management duties’, hands-on nursing at the bedside (
      • Beck D.M.
      Remembering Florence Nightingale’s panorama: 21st century nursing – At a critical crossroads.
      ,
      • Dossey B.M.
      Florence Nightingale, her Crimean Fever and Chronic Illness.
      ,
      • McDonald L.
      Florence Nightingale at first hand.
      ) and assisting surgeons in their work (
      • Bostridge M.
      Florence Nightingale, The Woman and her Legend.
      ). Patients who had been cared for at the Barracks Hospital in Scutari wrote home about their experiences of Nightingale (
      • Bostridge M.
      Florence Nightingale, The Woman and her Legend.
      ,
      • Beck D.M.
      Remembering Florence Nightingale’s panorama: 21st century nursing – At a critical crossroads.
      ). One wrote, ‘She's here, there and everywhere. You never lost sight of her’ (
      • Bostridge M.
      Florence Nightingale, The Woman and her Legend.
      ). Historical reports attest to her long hours of direct patient care (
      • Gill C.
      • Gill G.
      Nightingale in Scutari: Her legacy re-examined.
      ;
      • Kubler-Ross E.
      • Wessler S.
      • Avioli L.V.
      On death and dying.
      ). She routinely walked the wards at night, with her Turkish lantern, known as a fanoos (
      • Attewell A.
      Throwing light on Florence Nightingale: Of lamps and lanterns.
      ), checking on patients as she passed, often being on duty for 20 hours or more (
      • Attewell A.
      Throwing light on Florence Nightingale: Of lamps and lanterns.
      ,
      • Bostridge M.
      Florence Nightingale, The Woman and her Legend.
      ,
      • Times, The
      The Times Obituary, 15th August, 1910.
      ). She was also involved in first line triage activities, one of the few nurses permitted by British Army Medical personnel to do so (
      • Gill C.
      • Gill G.
      Nightingale in Scutari: Her legacy re-examined.
      ). She was further endorsed by Queen Victoria, ultimately strengthening her position with the military hierarchy and giving her more freedom to confront much needed health reform (
      • Times, The
      The Times Obituary, 15th August, 1910.
      ). Nightingale's work cannot be underestimated. Her strong leadership style not only urged her to play an active part in patient care so that she was better able to direct her nurses, but also ensured that she led by example, putting patient need first.

      3.3 The beginnings of healthcare reform

      Such historical accounts of the extraordinarily high death rate from disease and infection emphasise the urgency with which Nightingale set about influencing rudimentary health reform, firstly in Scutari, then in the British Army and general population on her return to England. The subsequent development and practice of her Environmental Theory, now thought to be individual ideals or philosophies initially presented as fundamental elements to promote good health (
      • Hegge M.
      Nightingale’s environmental theory.
      ), strengthened her advocacy for Army and Public Health Reform, the Sanitation Movement and the Public Health Act of 1848 (
      • Ringen K.
      Edwin Chadwick, the Market Ideology and Sanitary Reform: On the Nature of the 19th century Public Health Movement.
      ). As she was later to discuss in detail in her ‘Notes on Nursing: What it is and what it is not’, the ‘health of houses’ was paramount to providing the correct environment for patient, healing, comfort and care (
      • Nightingale F.
      Notes on Nursing: What it is and what it is not.
      ). In addition, her ability to collect, collate and apply mortality statistics and develop robust hospital planning enabled far reaching health reforms for all, from the workhouse to the country estate. Queen Victoria was known to have observed, ‘Such a clear head, I wish we had her at the War Office’ (
      • Bostridge M.
      Florence Nightingale, The Woman and her Legend.
      ,
      • Cook E.T.
      The Life of Florence Nightingale, 1820-1861. (Vol 1 of 2).
      ). The health reforms initiated by Nightingale show her great gift for critical thinking and the extent to which her innovative and evidence-based practices have endured globally to this day.

      3.4 Nightingale's Environmental Theory

      Nightingale's Environmental Theory was developed over time, commencing some years before the Crimean War, followed by two difficult years of service during the War and approximately four years post-war, up to the point of publication of Notes on Nursing: What it is and what it is not (
      • Nightingale F.
      Notes on Nursing: What it is and what it is not.
      ) in which she details her concepts on sanitary conditions, aligned with holistic patient care. Nightingale's assessment of the ‘health of houses’, hospital design and planning and nursing practice provide strong evidence of the ongoing development of her Environmental Theory across her lifetime, much of which was written while she was bed-ridden in her senior years.

      3.4.1 Health of houses

      Improved sanitary conditions and the subsequent improvement of the mortality rate during the Crimean War are evidence of Nightingale's belief of, and adherence to, the factors which form her Environmental Theory. Her ‘health of houses’ describes in detail her timeless thoughts on how to improve nursing for the benefit of the patient by achieving and maintaining healthy living conditions. Nightingale states there are five basic concepts to consider which must all be present for houses to provide a healthy environment: pure water, pure air, efficient drainage, cleanliness and light. She states, ‘Without these, no house can be healthy. And it will be unhealthy just in proportion as they are deficient’ (
      • Nightingale F.
      Notes on Nursing: What it is and what it is not.
      ). She also discusses the importance of these things in relation to ‘epidemic disease’, specifically the lack of clean (pure) water. She talks openly and frequently about disease, epidemic and unsanitary conditions, being aware of the effect of ‘contagion’ but not the origin.
      These concepts, together with the basic infection control techniques of hand washing and general cleanliness, proved efficacious, as shown in her statistical model of war mortality rates (
      • Nightingale F.
      Notes on matters affecting the health, efficiency and hospital administration of the British army founded chiefly on the experience of the late war.
      ). Furthermore, the improvement of Workhouse Infirmary conditions and the introduction of trained nurses therein (
      • Nixon K.
      The World of Florence Nightingale.
      ) were closely linked to Nightingale's Environmental Theory (
      • Nightingale F.
      Notes on Nursing: What it is and what it is not.
      ). There was also a close connection with the Miasma Hypothesis, a popular 19th century belief that foul air could cause disease, rather than infected drinking water (
      • Attewell A.
      Florence Nightingale's Relevance to Nurses.
      ,
      • Bostridge M.
      Florence Nightingale, The Woman and her Legend.
      ), for example, as in the case of the cholera epidemics in London in 1831 and 1866 (
      • Halliday S.
      Death and miasma in Victorian London: An obstinate belief.
      ). To her credit, Nightingale noted the importance of hand washing, in essence, basic infection control, stating, ‘Every nurse ought to be careful to wash her hands very frequently during the day’(
      • Nightingale F.
      Notes on Nursing: What it is and what it is not.
      ). Furthermore, she made some interesting observations on how nurses should ‘behave’ around infection, stating, ‘True nursing ignores infection, except to prevent it’, subsequently qualifying this statement by explaining that nurses would employ ‘wise and humane management’ to prevent infection in the first place (
      • Nightingale F.
      Notes on Hospitals.
      ).

      3.4.2 Hospital design and planning

      Nightingale was very much involved in hospital design and planning. In ‘Notes on Hospitals’ (
      • Nightingale F.
      Notes on Hospitals.
      ) she discussed the health of British institutions, documenting their largely unhealthy and overcrowded conditions in 1861 London, compared with those in smaller towns and villages. She also included vital information on the actual and possible recovery rate of patients with the improvement of sanitary conditions. Her acclaimed quote ‘It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm’ (
      • Nightingale F.
      Notes on Hospitals.
      ) showed an insight into the importance of strategic hospital planning, design and administration.
      Nightingale went to great lengths to explain that hospitals were, more often than not, extremely unsanitary places, where ‘disease produced in hospital’ could be life-threatening if not fatal. Here again she mentions contagion, ‘the communication of disease from person to person by contact’ (
      • Nightingale F.
      Notes on Hospitals.
      ), believing that infection, as opposed to contagion, could be inhaled from the air (the Miasma Hypothesis). Nightingale's ‘Notes on Hospitals’ includes, amongst other things, her indepth opinion on their sanitary condition, defects in existing hospital planning and construction, principles of hospital construction and plans, convalescent homes and children's hospitals. She favoured the pavilion-style of hospital build, that is, a detached purpose-built construction separated from all other hospital buildings for the purposes of fresh clean air, plentiful natural light and free communication between pavilions. Wards were to hold no more than 32 patients, often in beds placed down each side of a long ward, also allowing for adequate patient-distancing (
      • Nightingale F.
      Notes on Hospitals.
      ). Many hospitals were subsequently built in this style throughout the world, however single rooms are more in favour today, where appropriate, not only for privacy considerations but also for the improved infection control abilities they provide.

      3.4.3 Nursing practice informs infection control:

      Nurses and nursing practice, as Nightingale saw them, were an integral part of daily hospital life, as they are today. Patient wellbeing always came first, and, as a by-product, was closely followed by cleanliness and good sanitary practices. This was aided by the proper use of antiseptic; carbolic solutions being utilised as ‘the only safe method of disinfection’. Nightingale stated, ‘Absolute cleanliness is the true disinfectant. The nurse must be taught the nature of contagion and infection, and the distinctions between deodorants, disinfectants and antiseptics (
      • McDonald L.
      Florence Nightingale at first hand.
      ). It is interesting to note here that although Ignacz Semmelweiss had introduced handwashing with disinfectant between obstetric patient examinations in Vienna in 1847-1848 to reduce the mortality rate, Nightingale was unfamiliar with his work, although she had contact with other researchers who discussed similar views. Furthermore, her own statistical analysis of obstetric mortality rates concurred with that of her peers. In the mid-19th century, more than one clinician recognised the presence of hospital-bound infection, at that time called ‘hospitalism’, and the high mortality rate associated with it due to a lack of general sanitation, and in particular, the absence of hand washing by doctors and nurses alike (
      • McDonald L.
      Florence Nightingale at first hand.
      ).
      This pictorial background supports the development and application of Nightingale's Environmental Theory, for what would become contemporary infection control guidelines and techniques in the years following, up to the present day.

      3.5 Contemporary infection control

      Although current understanding of the ‘germ theory’ and infection control seems common knowledge, much is owed to Nightingale's solid sanitary foundations. Healthcare workers today are responsible for the health and safety of their patients, their colleagues and themselves, suggesting that basic infection control is the responsibility of all, including individuals at the community level. Hospital-acquired, or nosocomial infections, which unfortunately are still active today, primarily come from healthcare workers themselves, often due to a lack of adherence to basic hand hygiene. Guidelines have been developed to assist healthcare workers in maintaining robust sanitary conditions and practices in support of patient wellbeing, whilst also attending to their own health and safety.

      3.5.1 Universal precautions

      These guidelines were introduced in 1985 by the Centers for Disease Control (CDC), primarily in response to the human immunodeficiency virus (HIV), to prevent the transmission of bloodborne pathogens (
      • Broussard I.M.
      • Kahwaji C.I.
      Universal Precautions.
      ). They were subsequently replaced by the Standard precautions which remain in use today.

      3.5.2 Standard precautions

      In 1996, Standard Precautions were subsequently adapted from Universal Precautions and one other set of guidelines relating to Body Substance Isolation. Standard precautions were developed as a set of basic infection prevention and control strategies for everyone, regardless of their infection status. They include such things as handwashing, personal protective clothing, cleaning and disposal of sharps, in relation to contact with body fluid, compromised skin surfaces and mucous membranes (
      • ACSQHC
      Australian Commission on safety and quality in healthcare: Infection prevention and control systems.
      ,
      • Broussard I.M.
      • Kahwaji C.I.
      Universal Precautions.
      ;
      • WHO
      Standard precautions in healthcare. Aide-memoire.
      ). These standards make up the current guidelines for infection control.

      3.5.3 Coronavirus (COVID-19)

      In view of the unprecedented global coronavirus pandemic, declared by the World Health Organisation (WHO) on 11th March 2020 (
      • WHO
      WHO made the assessment that COVID-19 can be characterised as a pandemic.
      ), it is important to include comment here, particularly considering the WHO also declared 2020 as the Year of the Nurse and the Midwife (
      • WHO
      Year of the Nurse and the Midwife.
      ). The latter would have to be an unparalleled and unexpected understatement of enormous proportions due to the presence and nature of the former. Frontline healthcare workers, including nurses, willingly put themselves at great risk every day of contracting COVID-19 from their patients and their colleagues, but, like Nightingale, are completely dedicated to the care and wellbeing of others (
      • Fedele R.
      “It”s surreal’: Nursing during the COVID-19 pandemic.
      ,
      • Koven S.
      They call us and we go.
      ,
      • Stokowski L.A.
      Inside a COVID-19 ICU: “I”m terrified’. Medscape Nurses, Medscape Medical News.
      ). Worldwide shortages of personal protective equipment (PPE) have placed healthcare workers in an unenviable position (
      • Fedele R.
      “It”s surreal’: Nursing during the COVID-19 pandemic.
      ,
      • Koven S.
      They call us and we go.
      ,
      • Stokowski L.A.
      Inside a COVID-19 ICU: “I”m terrified’. Medscape Nurses, Medscape Medical News.
      ), some even making the ultimate sacrifice, with loss of life, for example, in China, Italy, Iran, France, UK and the USA (
      • Amnesty International News
      Global: Amnesty analysis reveals over 7,000 health workers have died from COVID-19.
      ;
      • Mhango M.
      • Dzobo M.
      • Chitungo I.
      • Dzinamarira T.
      COVID-19 risk factors among healthcare workers: A rapid review.
      ;
      • Sahu A.K.
      • Amrithanand V.T.
      • Mathew R.
      • Aggarwal P.
      • Nayer J.
      • Bhoi S.
      COVID-19 in healthcare workers – A systematic review and meta-analysis.
      ;
      • Xiao J.
      • Fang M.
      • Chen Q.
      • He B.
      SARS, MERS and COVID-19 among healthcare workers: A narrative review.
      ;
      • Xiang B.
      • Li P.
      • Yang X.
      • Zhong S.
      • Manyande A.
      • Feng M.
      The impact of novel coronavirus SARS-CoV-2 among healthcare workers in hospitals: An aerial view.
      ).
      Once COVID-19 had been identified in Wuhan, China (
      • Abed Alah M.A.
      • Abdeen S.
      • Kehyayan V.
      The first few cases and fatalities of Corona Virus Disease 2019 (COVID-19) in the Eastern Mediterranean Region of the World Health Organisation: A rapid review.
      ;
      • Rothan H.A.
      • Byrareddy S.N.
      The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak.
      ;
      • Xiang J.T.
      • Leung K.
      • Leung G.M.
      ; Wu et al., 2020), countries such as Singapore (
      • Lee W.C.
      • Ong C.Y.
      Overview of rapid mitigating strategies in Singapore during the COVID-19 pandemic.
      ) and South Korea (
      • Kang J.H.
      • Jang Y.Y.
      • Kim J.H.
      • Han S.-H.
      • Lee K.R.
      • Kim M.
      • Eom J.S.
      South Korea's responses to stop the COVID-19 pandemic.
      ) were able to prepare for the expected colossal influx of infected patients. They did so by accessing large numbers of Intensive Care Unit (ICU) beds and ventilators for the more seriously ill, along with experienced healthcare workers who had attended patients during the Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) outbreaks in previous years (
      • Kang J.H.
      • Jang Y.Y.
      • Kim J.H.
      • Han S.-H.
      • Lee K.R.
      • Kim M.
      • Eom J.S.
      South Korea's responses to stop the COVID-19 pandemic.
      ,
      • Lee W.C.
      • Ong C.Y.
      Overview of rapid mitigating strategies in Singapore during the COVID-19 pandemic.
      ). However, infection control in this global scenario has the potential to look quite different in each country. Countries with fewer reported positive cases of the virus and deaths, like Australia and New Zealand (
      • Fitzgerald D.A.
      • Wong G.W.K.
      A tale of two pandemics across the Asia-Pacific region.
      ), have had the opportunity to learn from the grave experiences of those who have suffered great loss – China, Italy, Spain, USA UK (
      • ABC News
      Coronavirus update: Mexico surpasses UK to have third highest death toll in the world.
      ,
      • Hiscott J.
      • Alexandridi M.
      • Muscolini M.
      • Tassone E.
      • Palermo E.
      • Soultsioti M.
      • Zevini A.
      The global impact of the coronavirus pandemic.
      ), India and Mexico (
      • ABC News
      Coronavirus update: Mexico surpasses UK to have third highest death toll in the world.
      ). This builds a useful picture of future need and challenges the current infrastructure, just as Nightingale did 150 years ago.
      Although modern hospitals have gained much from Nightingale's insight and expertise (
      • Dossey B.M.
      2020 The year of the nurse and the midwife. Matters of Note.
      ;
      • Hsu J.
      How the COVID-19 pandemic may reshape US hospital design.
      ;
      • Martischang R.
      • Peters A.
      • Reart A.N.
      • Pittet D.
      The voice of nurses in epidemiology and infection control: An Example from the 19th century.
      ;
      • Nightingale F.
      Notes on Hospitals.
      ), resulting in state-of-the-art facilities along with cutting edge technology, it seems this is just the beginning. As a potentially ‘positive’ outcome of COVID-19, hospital planners and designers are faced with a new set of challenges. Current hospital design, world-wide, is no match for the great influx of patients currently needing treatment (
      • Hsu J.
      How the COVID-19 pandemic may reshape US hospital design.
      ), as they do not have the much needed flexibility to accommodate sudden fluctuations in patient numbers. Makeshift treatment centres and hospitals have been quickly constructed or buildings converted to manage the overwhelming patient load, including the use of conference rooms, convention centres, halls, cafeterias, tents and quickly built temporary ‘pavillions’ (
      • Hsu J.
      How the COVID-19 pandemic may reshape US hospital design.
      ,
      • Nightingale F.
      Notes on Hospitals.
      ,
      • Tye J.
      Florence Nightingale's lasting legacy for healthcare.
      ). While still early days, this shift in thinking allows for data collection and analysis of the COVID-19 experience, akin to Nightingale's statistical analysis, to better inform hospital design of the future. Furthermore, some of these temporary facilities closely resemble Nightingale's open wards of the 19th century (
      • Hsu J.
      How the COVID-19 pandemic may reshape US hospital design.
      ,
      • Martischang R.
      • Peters A.
      • Reart A.N.
      • Pittet D.
      The voice of nurses in epidemiology and infection control: An Example from the 19th century.
      ,
      • Nightingale F.
      Notes on Hospitals.
      ), her pavilion-style, using the same design principles, but for patients with mild COVID-19 symptoms only. Interesting to note that this ward style offers plenty of fresh air and light, the required ‘social distancing’ measures and a clear view of patients for healthcare workers, all part of Nightingale's planning and design (
      • Dossey B.M.
      2020 The year of the nurse and the midwife. Matters of Note.
      ,
      • Hsu J.
      How the COVID-19 pandemic may reshape US hospital design.
      ,
      • Martischang R.
      • Peters A.
      • Reart A.N.
      • Pittet D.
      The voice of nurses in epidemiology and infection control: An Example from the 19th century.
      ,
      • Nightingale F.
      Notes on Hospitals.
      ).

      4. Implications for nursing

      4.1 Historical contribution

      • 1.
        Historically speaking, contemporary nursing is infinitely gifted with the innovative, progressive concepts for nursing and healthcare reform, developed, in the main, by Nightingale 150 years ago. This was quite remarkable considering women of her class in Victorian England were not expected to think for themselves, let alone find employment, and worse still, employment in nursing.
      • 2.
        Although Nightingale was confined to her bed throughout much of her later life, due to chronic illness (
        • Bostridge M.
        Florence Nightingale, The Woman and her Legend.
        ,
        • Dossey B.M.
        Florence Nightingale, her Crimean Fever and Chronic Illness.
        ,
        • Dossey B.M.
        • Selanders L.C.
        • Beck D.-M.
        • Attwell A.
        Florence Nightingale today: Healing, leadership, global action.
        ), this was seemingly no hindrance to her scholarly output. She was a prolific writer, penning thousands of notes, letters, diaries, reports, manuscripts and books on all manner of health reform and related topics (
        • Beck D.M.
        Remembering Florence Nightingale’s panorama: 21st century nursing – At a critical crossroads.
        ,
        • Bostridge M.
        Florence Nightingale, The Woman and her Legend.
        ,
        • Dossey B.M.
        Florence Nightingale: Mystic, visionary and healer (Commerative edition).
        ,
        • Nightingale F.
        Notes on Nursing: What it is and what it is not.
        ,
        • Nightingale F.
        Notes on Hospitals.
        ,
        • Nightingale F.
        Florence Nightingale’s letter to Charles C. Plowden (re Sanitary Report for India).
        ). This clear, concise and trackable historical record enables a better understanding of Nightingale's work. It empowers the contemporary nursing profession to adapt her concepts, for example, Environmental Theory and improving sanitary conditions, into the nursing models of care for today, that is, infection control and sanitary practices like aseptic techniques, respectively. Table 1 provides further examples of Nightingale's nursing concepts and their translation into contemporary nursing practice, with a focus on infection control.
        Table 1Comparing Nightingale's Theory with contemporary infection control practices.
        Nightingale's Environmental TheoryContemporary infection control practices
        Clean air, clean water, good drainage, cleanliness and light (Health of houses) to support a healing environment1,2,3,4Hospital planning and design, purpose-built facilities, strategic planning, comprehensive infrastructure, ‘state of the art’ technology
        Basic patient care (physical, emotional, mental, social, cultural and spiritual)1,2,3,4Holistic patient care, scope of practice
        Observations of the sick1,3,4Nursing observations and procedures, nursing care plans, continuity of care
        Prevention of the spread of contagion, pyaemia1,2,3,4Hand washing, wearing masks and other protective clothing, aseptic techniques, sterilisation methods, quarantine and isolation techniques, self-isolation, social distancing
        Basic wound care1,3,4Contemporary, advanced wound care techniques
        Prioritising patient care and workload1,3,4Patient management, triage
        ‘Combination’ patient care1,3,4Integrated, collaborative patient care
        Sanitary reforms1,2,3,4Sanitary practices, immunisation, public health services, government health departments, health education, personal health care
        Statistics1,2,3,4Research, epidemiology and statistical analysis to enable the ongoing development of infection control practices and facilities
        Nurse training schools1,2,3,4Infection control certificated courses
        Continuing professional development
        Hospital administration and management1,3,4Leadership, management roles
        Compiled by H. Gilbert.
        References: 1
        • Nightingale F.
        Notes on Nursing: What it is and what it is not.
        , 2
        • Nightingale F.
        Notes on Hospitals.
        , 3
        • Dossey B.M.
        • Selanders L.C.
        • Beck D.-M.
        • Attwell A.
        Florence Nightingale today: Healing, leadership, global action.
        , 4
        • Bostridge M.
        Florence Nightingale, The Woman and her Legend.
        .
      • 3.
        Nightingale's Environmental Theory was one of the most provocative concepts of her day, with practical, daily application for contemporary nursing, including management of the physical environment, psychological environment, nutritional status and nursing care planning (
        • Dossey B.M.
        • Selanders L.C.
        • Beck D.-M.
        • Attwell A.
        Florence Nightingale today: Healing, leadership, global action.
        ) Her clear, concise, critical thinking and vision have survived, and although the language has changed somewhat, the precepts remain. Suffice to say, the Nightingale Pledge, to ‘devote ourselves to the welfare of those committed to our care’ (
        • Gretter L.E.
        The Nightingale pledge.
        ) can be translated into every single area of nursing in the 21st century.
      • 4.
        Germ theory, contagion and the Miasma hypothesis were all current trends, or beliefs in the 19th century. Although little was known on each account, germ theory acknowledged the presence of disease-causing micro-organisms and the subsequent introduction of sterilisation and sterile surgical techniques (
        • Britannica Encyclopaedia
        Germ Theory.
        ). Nightingale's concepts of basic infection control techniques, including hand washing, wound care, quarantine and isolation (
        • Tulchinsky T.H.
        Case Studies in Public Health. Book Chapter 4: Semmelweis, Crede, Lister and Nightingale: Pioneers in Controlling Hospital Infections.
        ), have become an integral part of infection control practices today.
      • 5.
        A lifelong interest in collecting data and tabulating outcomes led Nightingale to develop the first statistical pie graph, known as a polar graph, or coxcomb (
        • Nightingale F.
        Notes on matters affecting the health, efficiency and hospital administration of the British army founded chiefly on the experience of the late war.
        ) which originally represented the mortality rate from all causes during the Crimean War. This fine work was finally recognised by the Royal Statistical Society, when she became the first woman elected to join in 1860, an amazing achievement for a woman in Victorian England (
        • Bostridge M.
        Florence Nightingale, The Woman and her Legend.
        ,
        • Gladfelter J.
        Florence Nightingale … What you may not know.
        ). Nightingale's statistical and analytical output informed her proposed healthcare reforms from the Crimean War onwards.

      4.2 Practical contribution

      In practical terms, the nursing practice of infection control has come a long way, supported on its journey by the work of many, but particularly Nightingale.
      • 1.
        Although there is no direct connection between Nightingale and the global infection control guidelines, the Standard Precautions (
        • WHO
        Standard precautions in healthcare. Aide-memoire.
        ), her foundational work has undoubtedly paved the way for such achievements over the last 150 years.
      • 2.
        The International Classification of Diseases (ICD) was, in part, initiated by Nightingale, who, upon returning from service in the Crimean War, advocated for the need to collect data on the cause of disease and death, using a systematic approach. In 1893, the French physician Jacques Bertillon formalised the collection of this data. In 1940, the World Health Organisation (WHO) took control of the system, which continues to this day, the current version being ICD-11 (
        • WHO
        ICD-11: Classifying disease to map the way we live and die.
        ).
      • 3.
        Nightingale laid the groundwork for the establishment of the Red Cross and Red Crescent Societies. The founder of the Red Cross, Henry Dunant, in 1863, attributes the inspiration for the development of the organisation to the work of Nightingale during the Crimean War (
        • ICRC
        Florence Nightingale: Her legacy continues.
        ).
      • 4.
        Contemporary infection control strategies and the nursing practice therein have been strongly influenced by Nightingale's Environmental Theory and continue to evolve (
        • Attewell A.
        Florence Nightingale's Relevance to Nurses.
        ,
        • Bostridge M.
        Florence Nightingale, The Woman and her Legend.
        ,
        • Dossey B.M.
        • Selanders L.C.
        • Beck D.-M.
        • Attwell A.
        Florence Nightingale today: Healing, leadership, global action.
        ,
        • McEnroe N.
        The art of medicine: Celebrating Florence Nightingale’s bicentenary.
        ,
        • Zborowsky T.
        The Legacy of Florence Nightingale's Environmental Theory: Nursing Research focusing on the Impact of Healthcare Environments.
        ). Simple tasks like hand hygiene have the potential to protect patients, visitors and healthcare workers (
        • Nightingale F.
        Notes on Nursing: What it is and what it is not.
        ), particularly during the current COVID-19 pandemic (
        • WHO
        Promote hand hygiene to save lives and combat COVID-19.
        ) and the continued presence of hospital-based nosocomial infection (
        • Khan H.A.
        • Baig F.K.
        • Mehboob R.
        Nosocomial infections: Epidemiology, prevention, control and surveillance.
        ). Similarly, the contribution of Nightingale to sanitary reforms have influenced the ongoing development of infection control strategies, from aseptic techniques and sterilisation methods to quarantine practices and isolation nursing care procedures, which continue to form part of infection control strategies today (
        • Bostridge M.
        Florence Nightingale, The Woman and her Legend.
        ,
        • Dossey B.M.
        • Selanders L.C.
        • Beck D.-M.
        • Attwell A.
        Florence Nightingale today: Healing, leadership, global action.
        ,
        • McEnroe N.
        The art of medicine: Celebrating Florence Nightingale’s bicentenary.
        ,
        • Nightingale F.
        Notes on Nursing: What it is and what it is not.
        ,
        • Nightingale F.
        Notes on Hospitals.
        ,
        • Zborowsky T.
        The Legacy of Florence Nightingale's Environmental Theory: Nursing Research focusing on the Impact of Healthcare Environments.
        ).
      • 5.
        Infection control measures in response to COVID-19 continue to evolve, having their absolute foundation in Nightingale's concepts. Even her hospital design and planning models are currently in vogue, with the construction of makeshift medical facilities akin to her pavilion-style ward layout, to accommodate patients with low grade symptoms. In addition, on 27th April 2020 the Federal Government of Australia released the COVIDSafe app (
        • Australian Government, Department of Health
        COVIDSafe: New app to slow the spread of coronavirus.
        ), an online platform which has the potential to track the contacts of those who are infected with the virus, in an effort to keep community transmission low and protect all citizens.
      • 6.
        The WHO's Coronavirus disease (COVID-19) Weekly Operational Update on COVID-19 (
        • WHO
        Coronavirus disease (COVID-19) Weekly Epidemiological Update and Weekly Operational Update on COVID-19.
        ), dated 9th October 2020, which contains the overall number of confirmed infected cases and deaths, both globally and by country in the previous 24 hours, reported just over 36 million cases and just over one million deaths (globally). These reports are updated on a weekly basis; the figures presented here were correct at the time of writing. By comparison, more than 50 million people died from the Spanish influenza virus (H1N1) pandemic, known as the ‘Spanish flu’, during 1918-1919 (
        • WHO
        Influenza Spotlight.
        ). Interestingly, the death toll from the ‘Spanish flu’ also surpassed the death toll from World War One, which the WHO records at 17 million people (
        • WHO
        Influenza Spotlight.
        ).
      Of further interest, similarities can be drawn between the ‘Spanish flu’ and COVID-19. At the time of the ‘Spanish flu’, there was no known vaccine available (
      • Humphreys M.
      The influenza of 1918: Evolutionary perspectives in a historical context.
      ; Trilla, Trilla, & Daer, 2008). The virus spread rapidly through global populations and hospitals were completely overwhelmed with the sick and dying (
      • Humphreys M.
      The influenza of 1918: Evolutionary perspectives in a historical context.
      ;
      • Flecknoe D.
      • Wakefield B.C.
      • Simmons A.
      Plagues and wars: The “Spanish flu” pandemic as a lesson in history.
      ;
      • Trilla A.
      • Trilla G.
      • Daer C.
      The 1918 ‘Spanish flu’ in Spain.
      ). Measures to prevent and treat the ‘Spanish flu’ were similar to those being employed in the current fight against COVID-19. Strategies utilised (for the ‘Spanish flu’) included the wearing of (cloth) masks, hand washing, social distancing, quarantine and self-isolation, contact tracing and banning of public gatherings (
      • Humphreys M.
      The influenza of 1918: Evolutionary perspectives in a historical context.
      ,
      • Strochlic N.
      • Champine R.D.
      How some cities “flattened the curve” during the 1918 flu pandemic.
      ,
      • Trilla A.
      • Trilla G.
      • Daer C.
      The 1918 ‘Spanish flu’ in Spain.
      ). Furthermore, businesses were closed and makeshift facilities, utilising the Nightingale pavilion-style ward, were set up to cope with the sheer numbers of infected patients (
      • CDC
      1918 Pandemic (H1N1 virus).
      ).

      5. Conclusion

      Nightingale's concepts and reforms created the backbone of nursing as a profession and laid the foundations for contemporary nursing and infection control practices, which remain current today. She was a strong advocate for disease prevention and health promotion, bringing a fresh approach to clinical nursing, as evidenced in her many writings.
      Following her experiences in the Crimean War, Nightingale developed and advised on some of the most life-changing healthcare reforms of all time. The ensuing years, both during her lifetime and beyond, have seen the ongoing development of these reforms on a global level. Her detailed and ordered concepts which make up her Environmental Theory have opened a world of infection control innovation, modification and advancement, producing healthcare systems today that would be far beyond what even she might have dreamt of.
      Just as in Nightingale's day, contemporary infection control techniques and guidelines play a pivotal role in maintaining good health for everyone, be that frontline healthcare workers, in whatever capacity, or the general public, at both national and global levels.
      Contemporary infection control measures are currently being dramatically stretched with the unprecedented and ongoing coronavirus (COVID-19) crisis, a pandemic of enormous proportions, second only to the Spanish influenza pandemic following the First World War. Mortality rates from both pandemics are/were high, while infection control measures mirror each other more closely than would be expected. The 21st century advantage of modern technology, has, in some ways, made a significant difference to outcomes today, with the use of ventilators in ICU settings, PPE for frontline healthcare workers and coronavirus phone apps to alert individuals of close contact with those who are infected. However, the World Health Organisation continues to advise the general public to observe the ‘old’ infection control measures of washing hands, wearing masks, social distancing and staying at home, to help prevent the spread of the virus (
      • WHO
      Coronavirus (COVID-19) advice for the public.
      ). There is no doubt that there is much to be learned from both pandemics. Infection control practices will need to be further researched and developed. Life will never be the same again, as the ‘new normal’ becomes the accepted norm. Ultimately however, much infection control lies at the grass roots, in the ‘hands’ of the people, which is exactly what Nightingale acknowledged and committed to paper 150 years ago.
      In this, the Year of the Nurse and Midwife 2020, even more significance and responsibility has been placed on nurses and nursing than was ever expected, largely due to the COVID-19 pandemic. Nurses have stepped up selflessly to make every patient contact count, just as Nightingale would have done. Not only nurses and nursing but the whole of mankind owes so much to the gift of Florence Nightingale.

      Conflict of interest

      None.

      Sources of support

      This paper and its author did not receive any funding from any agency in the public, commercial, or not-for-profit sectors.

      Ethical statement

      An ethical statement is not applicable for this paper.

      Funding

      There is no financial support.

      CRediT authorship contribution statement

      The paper properly credits the meaningful contributions of co-authors and co-researchers.

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