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Contents lists available at ScienceDirect

Collegian
journal homepage: www.elsevier.com/locate/coll

Florence Nightingale’s Environmental Theory and its influence on

contemporary infection control
Heather A. Gilbert (RN)
Melbourne, VIC, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Background: The work of Florence Nightingale has laid the foundation for contemporary nursing practice,
Received 30 April 2020 bringing the fundamental art and science of nursing into the 21st century. Her Environmental Theory
Received in revised form was the beginning of a lifetime’s work, being one of her many healthcare reforms which survive to this
22 September 2020
day as the practice of infection control.
Accepted 27 September 2020
Aim: To discuss the development of Nightingale’s Environmental Theory in the 19th century and its
Available online xxx
application in contemporary 21st century nursing practice.
Methods: A search of Nightingale’s publications, biographers and theorists, selected journal articles and
Keywords:
Nightingale
databases to build a picture of the origins, significance and practice of contemporary infection control.
Environmental theory Findings: Nightingale’s Environmental Theory has changed the face of infection control exponentially.
Health of houses Today’s guidelines are an integral part of nursing practice, to the extent that they continue to evolve,
Infection control particularly as the coronavirus pandemic remains active around the world.
Contemporary Discussion: Investigation of Nightingale’s experiences in the Crimean War, of the disease, infection, death
Nursing practice 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.
© 2020 Australian College of Nursing Ltd. Published by Elsevier Ltd.

Summary of relevance
Issue
To investigate the development of Nightingale’s Environmen-
tal 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) decla-
ration of the Year of the Nurse and the Midwife 2020 (WHO, 2020a),
this paper honours the 200th anniversary of Florence Nightin-
gale’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 pro-
vided 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 infec-
tion control.

2. Background

Florence Nightingale (1820-1910), who died over a century ago,

was a true explorer into uncharted territory. She was a teacher,
E-mail address: hagilbert60@gmail.com reformer, reactionary and revolutionary, championing the cause of

https://doi.org/10.1016/j.colegn.2020.09.006
1322-7696/© 2020 Australian College of Nursing Ltd. Published by Elsevier Ltd.

Please cite this article as: Gilbert, H.A, Florence Nightingale’s Environmental Theory and its influence on contemporary infection control,
Collegian, https://doi.org/10.1016/j.colegn.2020.09.006
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healthcare reform for the good of all. Her prolific research, analyses
and writings included many works on nurses and nursing, nurs-
ing 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,
1855, 1858, 1859a, 1859b, 1860, 1863, 1874, 1885).
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 rea-
sons for nursing actions should be clearly identifiable, become an
integral part of daily patient focus and direct future strategic plan-
ning. By tracing the origins of such important nursing concepts
as Nightingale’s Environmental Theory, and subsequently apply-
ing adaptive measures for contemporary scenarios, nurses will
be better prepared to embrace burgeoning e-health, technologi-
cal 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 fam-
ily 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, 1854), which crit-
icised the British medical facilities there (Bostridge, 2009; Burchill,
1992). 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 Istan-
bul). 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, 2009).
In November 1854, Nightingale, now the ‘Superintendent of
the Female Nursing Establishment of the English General Hospi-
tals in Turkey’, arrived in Scutari with 38 nurses (Times, 1910). Her
first impressions must have been horrific, for she commented, ‘we
are steeped to our necks in blood’ (Nixon, 2011). There were two
main hospitals, the Barrack Hospital (British Army Barracks) where
Nightingale and her nurses were based, and the General Hospi-
tal, 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, Gertsenzon, Mashiach, Kluger, &
Chermesh, 2011). The situation rapidly became considerably worse
with the arrival of 500 more wounded, bringing the total num-
ber of patients to almost 3000 (Bostridge, 2009). Straw beds on
the stone floors stretched for an incredible 6.4 kilometres (4 miles)
throughout the Barrack Hospital (Attewell, 2010). 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, with-
out screens, proper equipment or medicines, ‘Disease, neglect and
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mismanagement had united to render the scene one of unparalleled
hideousness’ (Bostridge, 2009).
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, 2010). Hence the abrupt arrival of
Nightingale and her nurses was seen as highly irregular and com-
pletely 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, 2009). In January 1855, a further 50
nurses arrived to support the nursing work already begun (Times,
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 infec-
tion rate in obstetric patients, drastically reducing the mortality
of women following birthing (Best & Neuhauser, 2004; Dossey,
Selanders, Beck, & Attwell, 2005; Nuland, 2003; Pittet & Boyce,
2001). This work was further expanded upon by Louis Pasteur and
Robert Koch in the 1870s (Ullman, 2007) and antibiotics, specifi-
cally penicillin, discovered by Alexander Fleming in 1928 (Fleming,
1929) 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, 1867), 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 orig-
inally recognised in the 17th century (Butler, Khan, & Ferguson,
2010) for the treatment of malaria, and tincture of opium for the
relief of diarrhoea, because of its gastrointestinal motility prop-
erties. It also contained the opioid morphine, useful for pain relief
(Gill & Gill, 2005). Furthermore, anaesthetics were basic at this time,
with chloroform being the mainstay (Manring, Hawk, Calhoun, &
Andersen, 2009). 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 lat-
ter 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, 2009;
Robins, 1997).
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 & Gill, 2005; McDonald, 2010), the
spread of disease by direct or indirect contact. She saw this at first
hand in the overcrowded, squalid conditions of the Barrack Hospi-
tal, in the form of the communicable diseases mentioned previously
(Bostridge, 2009; Manring et al., 2009). This led her to make the
connection between disease and the state of the environment (Gill
& Gill, 2005). Nightingale believed that cleanliness of the envi-
ronment, 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, 2009; Dossey et al., 2005; Gill & Gill, 2005;
Kudzma, 2006; Nightingale, 1860). Because of this, Nightingale and
her nurses worked hard to provide the sanitary solutions of clean
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bedding, clothing, wound dressings and environment, along with
wholesome and nourishing food, in effect, putting what would
become her Environmental Theory into practice (Bostridge, 2009;
Gill & Gill, 2005Manring et al., 2009).
By the end of the first winter, in February 1855, British mortal-
ity reached a staggering 52% (Bostridge, 2009). 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, 1910).
It was thought that the death rate from disease and infection in
particular, did not initially decrease following the arrival of Nightin-
gale and her nurses, despite improvements in sanitation (Bostridge,
2009). Interestingly, there are contemporary historians, for exam-
ple, Small, Wavell and Brooks, who would question, even lay blame,
with Nightingale for increasing the death rate during the Crimean
War (Brooks, 2011; Small, 1998; Wavell, 2008). Small devised a
‘bizarre scenario’ (Attewell, 2003; McDonald, 2010, 2014) without
any evidence, which accused Nightingale of increasing the mor-
tality rate and that as a result she suffered a ‘nervous breakdown’,
caused by her ‘guilt’ (Small, 1998). In Nightingale’s defence, how-
ever, 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, 1859b, 1885; McDonald, 2014).
Small, Wavell and Brooks also accused Nightingale of making
negative comments about the hospitals in the Crimea (Brooks,
2011; Small, 1998; Wavell, 2008), however this has also been
disproved in her many writings on sanitary reforms over several
decades (Nightingale, 1859a, 1860, 1863, 1866, 1870, 1885, 1892;
McDonald, 2014).
By March 1855, the mortality rate of the Crimean War had
decreased by 20%. Popular thought of the time favoured attribut-
ing the decreasing death rate to the work of Nightingale however
this was not confirmed by her. In her private letters to the Her-
berts (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, 2009; Nightingale, 1855). She was refer-
ring to the work of the Sanitary Commission which was dispatched
to Scutari by the British Government to inspect and improve hos-
pital 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, 2009). 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,
2009). Substantial evidence therefore supports Nightingale’s per-
sonal hand-written accounts, over several years, of her admiration
for hospital improvement once health reforms had been initiated
(McDonald, 2014), 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 & Gill, 2005).
Nightingale was devoted to the provision of holistic patient-
centred care (Dossey, 2010; Dossey et al., 2005; Nightingale, 1874),
a body, mind and spirit approach to healing, which she saw as the
‘essence of nursing’ (Dossey et al., 2005). This included ‘supervisory
and management duties’, hands-on nursing at the bedside (Beck,
2010; Dossey, 1998; McDonald, 2010) and assisting surgeons in
their work (Bostridge, 2009). Patients who had been cared for at the
Barracks Hospital in Scutari wrote home about their experiences of
Nightingale (Bostridge, 2009; Beck, 2010). One wrote, ‘She’s here,
there and everywhere. You never lost sight of her’ (Bostridge, 2009).
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Historical reports attest to her long hours of direct patient care
(Gill & Gill, 2005; Kubler-Ross, Wessler, & Avioli, 1972). She rou-
tinely walked the wards at night, with her Turkish lantern, known
as a fanoos (Attewell, 2003), checking on patients as she passed,
often being on duty for 20 hours or more (Attewell, 2003; Bostridge,
2009; Times, 1910). She was also involved in first line triage activ-
ities, one of the few nurses permitted by British Army Medical
personnel to do so (Gill & Gill, 2005). 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, 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 prac-
tice of her Environmental Theory, now thought to be individual
ideals or philosophies initially presented as fundamental elements
to promote good health (Hegge, 2013), strengthened her advocacy
for Army and Public Health Reform, the Sanitation Movement and
the Public Health Act of 1848 (Ringen, 1979). 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,
1860). In addition, her ability to collect, collate and apply mor-
tality 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, 2009; Cook,
1913). 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, 1860) 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, 1860). She also
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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 effi-
cacious, as shown in her statistical model of war mortality rates
(Nightingale, 1858). Furthermore, the improvement of Workhouse
Infirmary conditions and the introduction of trained nurses therein
(Nixon, 2011) were closely linked to Nightingale’s Environmen-
tal Theory (Nightingale, 1860). 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, 2010; Bostridge, 2009), for example, as in the case of
the cholera epidemics in London in 1831 and 1866 (Halliday,
2001). 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, 1860). Furthermore, she made some interesting
observations on how nurses should ‘behave’ around infection, stat-
ing, ‘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, 1863).
3.4.2. Hospital design and planning
Nightingale was very much involved in hospital design and plan-
ning. In ‘Notes on Hospitals’ (Nightingale, 1863) 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 improve-
ment of sanitary conditions. Her acclaimed quote ‘It may seem a
strange principle to enunciate as the very first requirement in a hospi-
tal that it should do the sick no harm’ (Nightingale, 1863) 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, 1863), 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 hos-
pital 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, 1863). 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 consid-
erations 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 well-
being 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 clean-
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liness is the true disinfectant. The nurse must be taught the nature
of contagion and infection, and the distinctions between deodorants,
disinfectants and antiseptics (McDonald, 2010). It is interesting to
note here that although Ignacz Semmelweiss had introduced hand-
washing 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, 2010).
This pictorial background supports the development and appli-
cation 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 col-
leagues and themselves, suggesting that basic infection control is
the responsibility of all, including individuals at the community
level. Hospital-acquired, or nosocomial infections, which unfor-
tunately 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 immun-
odeficiency virus (HIV), to prevent the transmission of bloodborne
pathogens (Broussard & Kahwaji, 2020). 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 every-
one, regardless of their infection status. They include such things
as handwashing, personal protective clothing, cleaning and dis-
posal of sharps, in relation to contact with body fluid, compromised
skin surfaces and mucous membranes (ACSQHC, 2019; Broussard &
Kahwaji, 2020; WHO, 2007). 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, 2020b), it is important to include comment here, par-
ticularly considering the WHO also declared 2020 as the Year of
the Nurse and the Midwife (WHO, 2020a). The latter would have to
be an unparalleled and unexpected understatement of enormous
proportions due to the presence and nature of the former. Front-
line 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, 2020; Koven, 2020;
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H.A. Gilbert
Stokowski, 2020). Worldwide shortages of personal protective
equipment (PPE) have placed healthcare workers in an unenviable
position (Fedele, 2020; Koven, 2020; Stokowski, 2020), some even
making the ultimate sacrifice, with loss of life, for example, in China,
Italy, Iran, France, UK and the USA (Amnesty International, 2020;
Mhango, Dzobo, Chitungo, & Dzinamarira, 2020; Sahu et al., 2020;
Xiao, Fang, Chen, & He, 2020; Xiang, Li et al., 2020).
Once COVID-19 had been identified in Wuhan, China (Abed
Alah, Abdeen, & Kehyayan, 2020; Rothan & Byrareddy, 2020; Xiang,
Leung, & Leung, 2020; Wu et al., 2020), countries such as Singapore
(Lee & Ong, 2020) and South Korea (Kang et al., 2020) 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
et al., 2020; Lee & Ong, 2020). 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 & Wong,
2020), have had the opportunity to learn from the grave experi-
ences of those who have suffered great loss – China, Italy, Spain,
USA UK (ABC News, 2020; Hiscott et al., 2020), India and Mexico
(ABC News, 2020). 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 Nightin-
gale’s insight and expertise (Dossey, 2020; Hsu, 2020; Martischang,
Peters, Reart, & Pittet, 2020; Nightingale, 1863), 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,
2020), as they do not have the much needed flexibility to accommo-
date 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, 2020; Nightingale,
1863; Tye, 2020). 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, 2020;
Martischang et al., 2020; Nightingale, 1863), 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’ mea-
sures and a clear view of patients for healthcare workers, all part
of Nightingale’s planning and design (Dossey, 2020; Hsu, 2020;
Martischang et al., 2020; Nightingale, 1863).
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 them-
selves, let alone find employment, and worse still, employment
in nursing.
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2. Although Nightingale was confined to her bed throughout much
of her later life, due to chronic illness (Bostridge, 2009; Dossey,
1998; Dossey et al., 2005), this was seemingly no hindrance to
her scholarly output. She was a prolific writer, penning thou-
sands of notes, letters, diaries, reports, manuscripts and books
on all manner of health reform and related topics (Beck, 2010;
Bostridge, 2009; Dossey, 2009; Nightingale, 1860, 1863, 1870).
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 condi-
tions, into the nursing models of care for today, that is, infection
control and sanitary practices like aseptic techniques, respec-
tively. Table 1 provides further examples of Nightingale’s nursing
concepts and their translation into contemporary nursing prac-
tice, with a focus on infection control.
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 physi-
cal environment, psychological environment, nutritional status
and nursing care planning (Dossey et al., 2005) Her clear, con-
cise, 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, 1893) 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 subse-
quent introduction of sterilisation and sterile surgical techniques
(Britannica, 2020). Nightingale’s concepts of basic infection
control techniques, including hand washing, wound care, quar-
antine and isolation (Tulchinsky, 2018), 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, 1858) which origi-
nally 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, 2009; Gladfelter, 2007). Nightingale’s sta-
tistical 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, 2007), 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, 2018).
3. Nightingale laid the groundwork for the establishment of the Red
Cross and Red Crescent Societies. The founder of the Red Cross,
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H.A. Gilbert
Table 1
Comparing Nightingale’s Theory with contemporary infection control practices.
Nightingale’s Environmental Theory
Clean air, clean water, good drainage,
cleanliness and light (Health of houses) to
support a healing environment1,2,3,4
Basic patient care (physical, emotional, mental,
social, cultural and spiritual)1,2,3,4
Observations of the sick1,3,4
Prevention of the spread of contagion,
pyaemia1,2,3,4
Basic wound care1,3,4
Prioritising patient care and workload1,3,4
1,3,4
‘Combination’ patient care
Sanitary reforms1,2,3,4
Statistics1,2,3,4
Nurse training schools1,2,3,4
Hospital administration and management1,3,4
Compiled by H. Gilbert.
References: 1 Nightingale, 1860, 2 Nightingale, 1863, 3 Dossey et al., 2005, 4 Bostridge, 2009.
Henry Dunant, in 1863, attributes the inspiration for the devel-
opment of the organisation to the work of Nightingale during the
Crimean War (ICRC, 2010).
4. Contemporary infection control strategies and the nursing prac-
tice therein have been strongly influenced by Nightingale’s
Environmental Theory and continue to evolve (Attewell, 2010;
Bostridge, 2009; Dossey et al., 2005; McEnroe, 2020; Zborowsky,
2014). Simple tasks like hand hygiene have the potential to
protect patients, visitors and healthcare workers (Nightingale,
1860), particularly during the current COVID-19 pandemic
(WHO, 2020c) and the continued presence of hospital-based
nosocomial infection (Khan, Baig, & Mehboob, 2017). Similarly,
the contribution of Nightingale to sanitary reforms have influ-
enced 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,
2009; Dossey et al., 2005; McEnroe, 2020; Nightingale, 1860,
1863; Zborowsky, 2014).
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 accommo-
date patients with low grade symptoms. In addition, on 27th
April 2020 the Federal Government of Australia released the
COVIDSafe app (Australian Government, 2020), an online plat-
form which has the potential to track the contacts of those who
are infected with the virus, in an effort to keep community trans-
mission low and protect all citizens.
6. The WHO’s Coronavirus disease (COVID-19) Weekly Operational
Update on COVID-19 (WHO, 2020d), 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 writ-
ing. By comparison, more than 50 million people died from the
Spanish influenza virus (H1N1) pandemic, known as the ‘Spanish
Collegian xxx (xxxx) xxx–xxx
Contemporary infection control practices
Hospital planning and design, purpose-built facilities, strategic planning, comprehensive
infrastructure, ‘state of the art’ technology
Holistic patient care, scope of practice
Nursing observations and procedures, nursing care plans, continuity of care
Hand washing, wearing masks and other protective clothing, aseptic techniques, sterilisation
methods, quarantine and isolation techniques, self-isolation, social distancing
Contemporary, advanced wound care techniques
Patient management, triage
Integrated, collaborative patient care
Sanitary practices, immunisation, public health services, government health departments, health
education, personal health care
Research, epidemiology and statistical analysis to enable the ongoing development of infection control
practices and facilities
Infection control certificated courses
Continuing professional development
Leadership, management roles
flu’, during 1918-1919 (WHO, 2020e). 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, 2020e).
Of further interest, similarities can be drawn between the ‘Span-
ish flu’ and COVID-19. At the time of the ‘Spanish flu’, there was no
known vaccine available (Humphreys, 2018; Trilla, Trilla, & Daer,
2008). The virus spread rapidly through global populations and
hospitals were completely overwhelmed with the sick and dying
(Humphreys, 2018; Flecknoe, Wakefield, & Simmons, 2018; Trilla
et al., 2008). 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, 2018; Strochlic & Champine, 2020; Trilla et al., 2008).
Furthermore, businesses were closed and makeshift facilities, util-
ising the Nightingale pavilion-style ward, were set up to cope with
the sheer numbers of infected patients (CDC, 2019).
5. Conclusion
Nightingale’s concepts and reforms created the backbone of
nursing as a profession and laid the foundations for contempo-
rary 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 evi-
denced in her many writings.
Following her experiences in the Crimean War, Nightingale
developed and advised on some of the most life-changing health-
care 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.
6
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H.A. Gilbert
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 what-
ever 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 coro-
navirus (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 out-
comes 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 pub-
lic to observe the ‘old’ infection control measures of washing hands,
wearing masks, social distancing and staying at home, to help pre-
vent the spread of the virus (WHO, 2020f). 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 sig-
nificance 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 statement
There is no conflict of interest to declare by the author
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.
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