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Global Activism, Advocacy, and Transformation: Florence Nightingale’s Legacy for the Twenty-first Century 

Global Activism, Advocacy, and Transformation: Florence Nightingale’s Legacy for the Twenty-first Century
Chapter:
Global Activism, Advocacy, and Transformation: Florence Nightingale’s Legacy for the Twenty-first Century
Author(s):

Deva-Marie Beck

, Barbara M. Dossey

, and Cynda H. Rushton

DOI:
10.1093/med/9780199860739.003.0041
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date: 21 September 2018

Integrative Nursing and Global Health

Global nursing practice is a large-scale contribution to human health. The missing link in the global goals discussion is often the missing voice of nurses who are striving to actually achieve these goals at grassroots levels with their extensive knowledge and experience. Large-scale global dialogue may seem to be beyond nursing’s grassroots scope of practice. But if we can widen our nursing practice worldviews—to contribute our much-needed grassroots knowledge and experience to global dialogues—we can actually provide that essential missing voice. Today, nurses have unprecedented global networking and communications tools that do allow us to enter and contribute to the global arena in innovative ways. This can become the world’s much-needed grassroots-to-global advocacy. (Dossey, Beck & Rushton, 2011). In Part VI, we will learn about the Caritas Path of Peace and integrative nurses’ global endeavors to address universal needs for healing, health and wellbeing at grassroots levels in Germany, Turkey, England, Ireland, Iceland, and Sweden.

Integrative nursing recognizes health as an ever-changing pattern of creative, adaptive relationships—across all dimensions of human experience. Our integrative nursing lens acknowledges the fundamental unity within and between all beings and their environments. Thus, the health and wellbeing of people everywhere can be seen as having common ground—a worldview to secure a sustainable, prosperous future for everyone. Integrative nursing also focuses on the health and wellbeing of caregivers, as well as those they serve. Even as we see ourselves each as key contributors to global health, we also need to see our own essential self-care as a sustaining contribution to the overall health and wellbeing of all humanity.

Across this world, nurses actively serve on the front lines of healthcare—in rural communities, suburbs and cities, refugee camps, hospitals, war zones, and street clinics. Globally, more than 17 million nurses and midwives are involved in the being-knowing-doing required to advance the health and wellbeing of people, families, and communities (World Health Organization [WHO], 2006). Physically, mentally, emotionally, socially, and spiritually, nurses are prepared and educated to effectively accomplish traditional, integrative, and emerging interventions to support whole-person/whole-systems healing. Everywhere, our knowledge, expertise, wisdom, and dedication are required for humanity to be and remain healthy. Nurses have traditionally worked to achieve local goals. We understand grassroots needs and know how to be on-the-ground activists to meet these needs.

Severe health needs exist in almost every community and country. These are no longer isolated problems in far-off places. Across humankind, we all face common health concerns and global health imperatives. With globalization and global warming, no natural or political boundaries stop the spread of disease. In the developed world, healthcare is increasingly more complex and demanding. In the developing world, healthcare is marginalized and sometimes even nonexistent.

In almost every nation, the severe and chronic global nursing shortage continues to threaten the health of people across the world. This remains a major component of the continuing crises in global healthcare delivery and one of the key dynamics we, as nurses, continually address within our demanding workplaces (WHO, 2006). Struggling to achieve more than we can in any given day, wider global health needs directly impact our own professional and personal lives. In the next section, we review how Florence Nightingale’s life remains vitally relevant to today—still helping us to respond to our twenty-first–century global health challenges—as we follow in her footsteps.

Nightingale: The Global Activist

Today, we recognize Florence Nightingale’s (1820–1910) legacy as global nursing and global healthcare (Dossey, 2010a; Dossey, Selanders, Beck & Attewell, 2005). She envisioned what a healthy world might be and worked tirelessly to both articulate and realize this vision. Nightingale was a genius of both intellect and spirit, and her legacy resonates today as forcefully as during her lifetime. While most often remembered as the philosophical founder of modern nursing and the first recognized nurse theorist, she also ranks among the most brilliant sanitary, medical, and healthcare reformers in history.

After returning home from her famous achievements during the Crimean War (1854–1856), Nightingale continued—for nearly four decades—to work on the global challenges of her time. She analyzed data, wrote statistical reports, and informed politicians, crafting documents that resulted in legislation. She designed hospitals and sought to improve environments—in both rural and urban areas—by developing collaborative partnerships with others who agreed with her proposed reforms. She met with Queen Victoria, Prince Albert, and other royalty, dignitaries, viceroys, and military officers in India and from around the world, also serving as a consultant to both the North and South during the American Civil War. She changed political will by informing and interacting with government leaders across the British Empire and elsewhere.

Based on her own foundational experience with battlefield conditions, she actually drafted the British position papers presented to the first in a series of Geneva conventions that directly led to establishing the International Red Cross, then the League of Nations, and later, the United Nations. Anticipating the wider interconnected concerns we readily see today, she called for better conditions for women, children, the poor and hungry and for better education programs for marginalized people. She identified environmental health determinants (clean air, water, food, houses, and so on) and social health determinants (poverty, education, family relationships, employment)—local to global (Beck, 2010a).

With a worldwide network of colleagues and from a wide worldview of caring, Nightingale took her own courageous stand as a global advocate for the needs of others around the world. As a result, she gained new a ground of concern for the sick and impoverished people everywhere and sought to remedy the causes of this suffering. Although she faced many barriers, she stood on her own conviction to advocate changes that were necessary. In doing so, she became a catalyst for an emerging worldview that created nursing as we know it today (Beck, 2010b).

Nightingale also actively networked with a wide range of colleagues. As a result, 14, 000 of her letters and her 200-plus official reports and books exist today in collections around the world. She also directly contributed to the print journalism of her time. For example, her Notes on Hospitals (Nightingale, 1859) clearly describes components of hospital design that we recognize today as factors of optimal healing environments. Her Notes on Nursing (Nightingale, 1860a) (79 pages) was written first for the general public and became an immediate bestseller upon first printing. Later, this text—published as a Notes on Nursing, Revised (Nightingale, 1860b)—was recognized as the first nursing textbook. While writing her own articles for newspapers and magazines, she also consciously cultivated her connections with the media professionals of her time, making sure they understood, communicated, and shared her messages.

She used these effective advocacy skills to shape public awareness, actively promoting health as a priority for people throughout the world. As a strong global advocate, she was a change agent who confronted apathy and indifference wherever she encountered them. Nightingale called all of these activities “health-nursing” and declared “health is not only to be well, but to use well every power we have” (Nightingale, 1893). In this way, she remains a model for nurses today, as we participate in achieving the UN Millennium Goals discussed next.

Global Activism and Achieving the United Nations Millennium Development Goals (MDGs)

During the year 2000, world leaders convened a United Nations Millennium Summit to establish eight Millennium Development Goals (MDGs) that must be achieved for the twenty-first century to progress toward a sustainable quality of life for all of humanity (United Nations Development Programme, n.d.). These interrelated goals, listed in Box 41.1, are an ambitious agenda for improving lives worldwide. Of these eight MDGs, three—#4: Reduce Child Mortality, #5: Improve Maternal Health, and #6: Combat HIV/AIDS, TB, malaria, and other diseases—are directly related to health and nursing.

World Health Organization Director General Margaret Chan has noted that efforts to achieve all the MDGs have clearly improved health across the world (WHO, 2013). This points directly back to the work Nightingale achieved in her time. Hence, all the UN goals have aims similar to those we as nurses work to achieve every day, at grassroots levels, everywhere. Nurses are engaged with various endeavors to address the global health included within the scope of the UN MDGs. Nurses are truly global activists who create new structures—widening health and healing worldviews with local dialogues and activities that shift behaviors and create new meaning-making towards health, including the process of health-making globally. We are continuing Nightingale’s relevance and legacy for grassroots-to-global health with our authentic advocacy, as discussed next.

Authentic Advocacy

The word “advocacy” is derived from the Latin advocatus, “counselor, ” and advocare, “to summon or to aid.” An advocate is a person who speaks or writes in support of something. Nursing organizations have codes of ethics recognizing advocacy as nursing’s moral foundation—required for all those who take on the title and role of nurse. Examples include the International Council of Nurses (ICN) Code of Ethics for Nurses (International Council of Nurses, 2006) and the American Nurses Association (ANA) Code of Ethics with Interpretive Statements (American Nurses Association, 2008).

Coined by Rushton, “authentic advocacy” refers to actions taken on behalf of others that arise from a deep alignment of one’s beliefs, values, and behaviors (Rushton, 2013). Rushton further develops authentic advocacy in her model of “compassion-based ethics”—the ability to be present for all levels of suffering, to acknowledge the suffering of others, to transform this suffering, and to engage in helping those who suffer (Rushton, 2007). This kind of authenticity in action is a fundamental element of integrity, as well as a foundation that allows for meaning, service, and fulfillment to arise. Similarly, in this context, authenticity also refers to alignment with the beliefs, values, and desired actions of those who are in need of advocacy. This connotes an “egoless” engagement with the other—or others—for the purpose of both benefitting them and serving from one’s highest purpose.

When applied to nursing, authentic advocacy and compassion-based ethics form the intrinsic moral foundation of nursing where we are each morally required to demonstrate, in all our interactions, respect for the inherent human dignity of individuals—including the “self” of each nurse—as well as for patient safety and continuity of care. An authentic advocate (Rushton & Penticuff, 2007) understands the fundamental ethical principle of respect—the act of esteeming one another and attending to the whole person. For example, authentic advocacy involves patients and families in decision-making, provides family-centered care, and adopts broader perspectives marked by cultural humility. As authentic advocates, we demonstrate self-awareness with clearly defined values and the knowledge and skills of ethical discernment, analysis, and action.

Authentic advocates express opinions or preferences that stem from a deep sense of our own inner self, beliefs, and vision of what is possible. We inform and educate both others and ourselves about health and human rights. We understand and reflect our own beliefs as well as those learned from others and external sources. Instead of adopting a stance of “expert, ” we engage in discovering right actions through a process of inquiry, deep listening, and engagement to address the full spectrum of solutions stemming from individuals, systems, and underlying causes (Sharma, 2004).

Modeling a determined passion for what they care about, authentic advocates share their voice and soul’s purposes and meaning, incorporating their very being and believing into the ability to facilitate change. They integrate co-advocacy through presence and deep listening to the stories of others in order to explore the suffering of others, as well as their own suffering. They seek language to express suffering and aim toward finding new expressions and insights, new meaning-making, and new identity around suffering and frustrations (Rushton, 2009).

Empowered, thus, to increase the health of the entire human family and the whole earth, authentic advocates connect with the larger goals of society. In all these ways, we can experience a sense of fulfillment, personal satisfaction, and accomplishment. As we become advocates for others, our lives are also impacted in profound ways.

The reflective questions of authentic advocacy include: (Rushton, 2009) How do you self-advocate, taking into account your own needs at home and work? How do you advocate strengthening relationships among your colleagues, patients, and others? How do you advocate by learning new behaviors and new communication skills for yourself? How do you advocate change in healthcare systems and structures and other grassroots-to-global conditions related to health?

Nightingale modeled authentic advocacy across her lifetime. She was an advocate for individuals, for soldiers, for families and communities, for the health of villages, cities, and nations, as well as for the health and wellbeing of her nursing students, urging them to integrate this mandate into their own work (Dossey, 2010a). Due to the prolonged illness she contracted in the 1850s during the Crimean War—recognized today as chronic brucellosis—Nightingale deeply understood what she needed to nurture herself and practice self-advocacy (Dossey, 2010b). Living until 1910, she worked on this for decades—practicing self-care at physical, emotional, mental, and spiritual levels. This component of her life continues to have deep relevance for the health and wellbeing of today’s nurses, who regularly face rigorous working conditions and—in some parts of the world—severe hardships very similar to those Nightingale faced during the Crimean War. Her work gives us a deeper understanding of our role in global advocacy, discussed next.

Global Advocacy

The general public consistently rate nurses as the most trusted and well-respected profession in the world. But the roles we play in society are not well known, nor widely understood. The public sharing of our stories—related to both nursing and health—is not on nursing’s traditional agenda. The strength of public advocacy for health has not yet fully evolved into nursing’s capacity to voice our concerns through the wider public promotion of healthcare—to influence other groups and to dialogue and collaborate with other disciplines, particularly the media (Burish & Gordon, 2006).

We have always been good at communicating with each other—about our patients, our concerns, and our commitments to society. We know and tell each other how and why these issues matter. Like Nightingale, we have been excellent activists at the bedside of the suffering and for the promotion of health in local community settings. But we also need to discover—like Nightingale did—how to take our activism and evolve this work into global advocacy, providing nursing with new levels of global participation and impact.

At large-scale levels, the actions required to address global needs are related to global discussion and networking, to the telling of “news” stories to wider audiences, and to wider-scale communications to debate and share ideas. But when these global discussions carry on without being grounded in related grassroots knowledge and experience, this dialogue can become ineffective and even detrimental to achieving the global outcomes of health for all humanity.

An applicable approach to this global-to-grassroots gap is called Development Support Communications (DSC) (Food and Agriculture Organization of the United Nations [FAO], n.d.). It was first initiated by the United Nations Development Programme (UNDP) in the 1970s to empower people by mobilizing wider public opinion from grassroots “bottom-up” levels, rather than from the “top-down” global levels. From its beginnings, DSC was shaped as a community-level experiential process in which participants developed capacities to better articulate and widely communicate issues critical to their work and needs. Even in its early stages, this approach sought to empower individuals and small groups with networking and participatory communications—particularly through emerging media capacities—first in community-based print journalism, radio, and video broadcasts, and later through emerging Internet capacities.

DSC is also about people acquiring communication strategies as drivers of their own development. With communications skills at its core, DSC is a multifaceted process, encouraging people to use these emerging skills to identify problems, create solutions, and build wider consensus in doing so. Integrating the knowledge thus gained from these experiences, participants evolve new individual and interactive capacities to convey their knowledge beyond their own communities. To achieve these aims, DSC encourages the co-creation and sharing of grassroots knowledge globally—further calling for and contributing to sustainable change—particularly for the benefit of the most marginalized and impoverished people (FAO, n.d.).

DSC can be applied as a useful tool to extend nursing knowledge—the sharing of nursing’s grassroots experience—for the wider promotion of twenty-first–century health. Using this approach, we can enhance and broaden our networking, advocacy, and media communications to the world beyond nursing’ own circle to both strengthen nursing practice and widely promote the conditions required for the health of humanity. The DSC approach can provide global and virtual settings for nursing’s voice and foster global networks to widely communicate the needs nurses see. This can more effectively articulate many aspects of our interactions with each other, including our continuing need for personal and interpersonal renewal, cross-cultural understanding, and effective communication outreach—going beyond our own nursing circles to include other disciplines. This approach can enhance our abilities to become global advocates for the wider issues that impact the health of every person we seek to help. It can directly promote solutions for healthier homes and workplaces. It can effectively articulate global concern to address the environmental and social determinants that directly impact the health and wellbeing of everyone. The use of DSC approaches can empower nurses to become stronger grassroots-to-global authentic advocates, facilitate the promotion of health, and enhance the connections of health to all development aims worldwide (Beck, Dossey, & Rushton, 2013)

An example of nurses’ global advocacy is the “Nightingale Declaration for a Healthy World, ” crafted by the Nightingale Initiative for Global Health (NIGH) as seen in Box 41.2. One member of the founding NIGH team has indeed worked within United Nations networks since the 1970s and, within this work, has been involved in the application of Development Support Communications to meet the needs of people worldwide. Because of this direct connection, this declaration’s opening phrase—“We, the nurses and concerned citizens of the global community”—was intentionally modeled after the Preamble to the Charter of the United Nations (1945), which begins with the words, “We, the peoples of the United Nations, [are] determined” and the subsequent Universal Declaration for Human Rights (1948). Recalling Nightingale’s own exemplary work to communicate her concerns worldwide, this declaration was written to clarify and commit to communicating shared goals and purposes as we work together to build a better world for everyone. Its text challenges its signers—all nurses and all concerned citizens—to commit to our own emerging individual and collective global advocacy and to call for the achievement of a healthy world, together and each in our own way (Nightingale Initiative for Global Health [NIGH], 2007).

With communications tools unparalleled in human history, now is the time for us to find the courage and confidence to use these tools for the dynamic and innovative promotion of health at local, regional, national, and global levels. Now is the time to widen the scope of our nursing practice—to widely communicate the concerns we care about most with everyone else.

Like Nightingale in her time, nurses can effectively use media tools to demonstrate global advocacy. Our trusted voices can address many issues impacting health and nursing practice, including human conflict, poverty, lack of social justice, toxic environments, loss of family and community values, and even the forgetting to take personal care of one’s own health and wellbeing. Nursing’s voice can tell the stories of how we can and do contribute to solving these critical problems.

To achieve this, our challenge as global nurses and authentic advocates is to develop further collaborative pathways to positive interdisciplinary relationships with healthcare colleagues, as well as with journalists, broadcasters, multimedia professionals, and other national and international networking groups. Our nursing practices can incorporate further the development of networking and communications capacities and media-related interviewing, writing and Internet skills, as well as health coaching (Hess et al., 2013). These contributions will further feed the flame of Nightingale’s continuing global relevance—further building momentum toward the worldwide nursing activism and advocacy that will be needed in the months and years ahead for the global transformation discussed next.

Global Transformation

Our integrative nursing global challenges set the stage for newly articulated global desires to achieve health in every community throughout the world. As nurses continue their being-knowing-doing to advance the health and wellbeing of all, we can tap these global desires, which we also heartily desire for ourselves.

Researching how Nightingale achieved such deeply transformative work, Nightingale’s biographers have noted that her life encompassed social action and sacred radical activism—a transforming force of compassion-in-action born of a fusion of deep spiritual knowledge, courage, love, passion and practice (Harvey, 2009). As well, she experienced and recorded her personal understanding of the awareness that something greater than she, the Divine, was present in all aspects of life (Dossey, 2009). Her deep inner work continually transformed her own life, allowing her to be a change agent and sustain her change agency for global transformation across her lifetime.

In today’s specialized world, we may be tempted to compartmentalize our lives, placing our personal, professional, spiritual, political, and ethical concerns into different corners, without integrating these spaces. To Nightingale, this kind of fragmentation would have been unthinkable. As an icon of wholeness, an emblem of a united, integrated life, her shining example invites each of us to integrate our meaning and purpose across our own individual journey through life (Dossey, 2010d).

Monica Sharma, a physician who has worked through United Nations agencies to collaborate with people at the village level in Africa and India, has noted that “today, the most urgent and sustainable response to the world’s problems is to expand solutions for problems—that are driven solely by technology—[to those solutions] generated from personally-aware leadership” (Sharma, 2004, 2007). This type of leadership, which Sharma calls “global architecture for personal to planetary transformation, ” can arise from applying ourselves to Nightingale’s broader and deeper legacy. Sharma’s philosophy can inspire and instill world-centric leadership values and capacities. It is also a transformative approach to develop nurses as global citizens—beyond the tasks of merely coping with today’s local problems—so we may become agents of global transformation, creating new local-to-global solutions.

In the 1880s, Nightingale wrote letters indicating her belief that it would take 100 to 150 years before educated and experienced nurses would arrive to actually continue the global transformations she herself had begun. The nurses of the twenty-first century are literally the generations she foresaw and set her own hopes upon. We are twenty-first–century Nightingales who can carry forth her vision to achieve a healthier world together. Our own deep personal and professional integrative nursing mission can continually transform our own lives, thus allowing each of us to become effective catalysts for human health and to sustain our change agency for global transformation, across our lifetimes and to the generations who follow us.

Conclusion: Finding Our “Must”

Nightingale called her work her “must” (Dossey, 2010a). As we increase our awareness of the deepest needs of the world, this knowledge continues to help all of us—nurses and concerned citizens alike—identify our own “musts.” This keeps us focused and empowered. Nightingale saw nineteenth-century problems and created twentieth-century solutions. We have seen twentieth-century problems and can continue to create twenty-first–century solutions by developing approaches that address global issues—such as the United Nations Millennium Goals (MDGs)—as well as the grassroots concerns we find in our own communities and healthcare settings. By increasing global public awareness about the priority of health and empowering nurses, nursing students, and concerned citizens to address the critical grassroots-to-global health issues of our time, these interrelated approaches will continue to keep Nightingale’s deep and broad legacy alive across the twenty-first century and beyond.

Reflecting on Nightingale’s global legacy of activism, advocacy, and transformation—and the possibilities for what we can achieve in our time—consider following these seven recommendations (Beck, 2010b):

  • Make health—and activating positive health determinants—a top priority in human affairs.

  • Value and sustain nurses in their caring to achieve health goals everywhere.

  • Collaborate across disciplines and across cultures to promote health in community settings.

  • Think globally; act to create and sustain local health literacy for everyone, across the lifespan.

  • Make media a catalyst for nursing and for health.

  • Keep health holistic, integrative, and transdisciplinary.

  • Answer your own calling, your “must.”

Selected References

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Beck, D. M., Dossey, B. M., & Rushton, C. H. (2013). Building the Nightingale Initiative for Global Health—NIGH: Can we engage and empower the public voices of nurses worldwide? Nursing Science Quarterly, 26(10), 366–371.Find this resource:

Burish, B., & Gordon, S. (2006). Silence to Voice: What Makes Nurses Know and Communication to the Public, Second Edition. Cornell, NY: Cornell University Press.Find this resource:

Dossey, B. M. (2010a). Florence Nightingale: Mystic, Visionary, Healer [Commemorative Edition]. Philadelphia, PA: F.A. Davis Company.Find this resource:

Dossey, B. M. (2010b). Florence Nightingale and her chronic illness. Journal of Holistic Nursing, 28(1), 38–53.Find this resource:

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