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Florence Nightingale's legacy not only remains – but has never been more important. The full scope of her influence on contemporary nurses, nursing care and nursing research, and, for example, on social and health reform, including sanitation, hygiene, hospital design and statistics is often not fully appreciated. Although she is best known as the founder of modern nursing, having established a curriculum and training school for nurses, it is her pioneering health reforms that have probably been her most enduring legacy (Singh & Ernst 2008). Indeed, she had the vision of a modern public healthcare system that encompassed not only nursing, but was based on health promotion and disease prevention (Bostridge 2008). She was able to challenge the sceptical medical, military and political establishment using her excellent mathematical training to marshal statistical arguments to back her claims that improved hygiene led to higher survival rates (Singh & Ernst 2008).

Although women can now serve in the army in front line positions, lead national and multinational organizations, or become world leaders, this was very different in Nightingale's day where career choices for women were limited and nursing was seen as a vocation. Technological and medical advances have altered nurses’ roles and responsibilities and many would argue to the detriment of patient care. For example, hospital-acquired infections remain common and often deadly, and resistant strains of many bacteria are emerging as a major global threat. Despite widespread improvements in treatment and health care, key aspects of nursing care first identified by Nightingale remain. Her focus was on prioritizing hygiene. She outlined the five essential components to optimal healing: pure air, pure water, efficient drainage, cleanliness and light. Some would argue that these components have no relevance to contemporary health care, but, on closer examination, they remain of vital importance to global health:

  • Pure air: Nightingale hypothesized that one of the reasons for the high infection rate during the Crimean war was poor ventilation. Airborne infections pose a challenge to healthcare workers especially with the increase in multi-drug resistant TB and its spread is partly due to poor ventilation and overcrowding. Respiratory diseases (with a statistically significant percentage attributed to poor air quality and air pollution) remain a major killer and is the leading cause of deaths worldwide (14·3% including lung cancers) (World Health Organisation 2012a). As low to middle income countries become more industrialized, the rates of respiratory diseases are predicted to increase.
  • Pure water: Waterborne diseases such as cholera, dysentery, and typhoid were observed by Nightingale in her writings and sadly they continue to be responsible for many deaths today (1·8 million annually). One of the Millennium Development Goals is access to safe drinking water, but in 2010, an estimated 780 million (11% of the world's population) still lacked safe drinking water (World Health Organisation 2012b). Safe drinking water is still an issue for many in sub-Saharan Africa and parts of Asia, although 2 billion people now have access to improved drinking water sources through piped supplies and drinking wells.
  • Efficient drainage: In conjunction with lack of clean water, inefficient sewer systems contribute to disease. 2·5 billion people still lack access to improved sanitation, whereas a large proportion of people (1·1 billion) practice open defecation: 626 million in India, 14 million in China, and 7·2 million in Brazil. A pertinent fact is that more people in the world have mobile phones than access to toilets.
  • Cleanliness: Lack of hygiene, especially hand hygiene is primarily responsible for hospital acquired infections and remains a leading concern, and previous research has highlighted poor standards in cleaning effectiveness (Cooper et al. 2007). Nightingale insisted nurses to scrub the ward clean and it is only recently that nurses are beginning to revisit these basic tasks (Bucior & Cochrane 2010).
  • Light: Poor lighting is a contributing factor in road traffic accidents, whereas kerosene lamps cause fires and burns and often in low-income countries once night has fallen, families have no form of lighting. In 2002, 322,000 deaths worldwide were attributed to kerosene lamps (Peck et al. 2008). The other main ‘light’-related condition that is contentious is Vitamin D deficiency – the sunlight vitamin. Skin cancer is also an important health issue with increasing numbers of melanomas reported.

What is apparent from Nightingale's work is the importance in direct patient care and, in particular, cleanliness and adequate ventilation and sanitation. The early Nightingale-trained nurses became matrons in several leading hospitals, but over time, matrons disappeared from clinical roles and were replaced with nurse managers. The increase in paperwork and administrative tasks for nurses has led to a decrease in ‘hands-on’ care. Although on the face of it, some would doubt how nurses could promote or implement these five components, one does not have to delve too far to reveal contemporary short-falls in nursing care. The poor delivery of hands-on care has been observed by Kalisch (2006) who identified nine elements that were often missed and included basic tasks, such as turning, delayed or missed feedings, and hygiene. As a response to this, in 2002, the modern matron was introduced in the UK to promote strong clinical care and leadership (Gould 2008). The role has had mixed reviews, but there is no doubt that the components Nightingale valued are re-emerging as important priorities.

Nurses are well placed to educate and inform patients from basic health advice about cessation of smoking to ensuring high standards of hygiene are applied in daily clinical practice. In the UK, improvements in cleanliness have recently been reported; the ‘cleanyourhands’ campaign has resulted in statistically significant reductions in MRSA and Clostridium Difficile infections, with nurses playing an important role in its success (Stone et al. 2012). Educating vulnerable people about water-borne diseases and the importance of personal hygiene and hand-washing has the capacity to reduce morbidity and mortality in communicable and non-communicable diseases.

Although technological advances and the widening scope of professional practice may beguile the discipline of nursing, we strongly argue that these five components are increasingly vital aspects of nursing care. The Nightingale Initiative for Global Health aims to rekindle awareness of Florence Nightingale's work and aims to have a healthy world by 2020. Part of the declaration states: ‘We declare our willingness to unite in a program of action, sharing information and solutions to resolve problems and improve conditions – locally, nationally and globally – in order to achieve health for all humanity’. To date, over 22,000 signatories have been obtained (http://www.nightingaledeclaration.net/the-declaration). Health promotion and disease prevention have become a central theme in nursing and we hope the legacy of Nightingale continues and her essential components given the full recognition as health priorities that they deserve.

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