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No one knows if Florence Nightingale deliberately set out to become a nursing champion, but it is clear that the 1859 publication of her book Notes on Nursing: What It Is, And What It Is Not secured her place in nursing history. By the author’s own admission, the work was not written as a training manual for nurses. Yet in many ways, this classic book, which was a best seller when issued and has been continuously in print since it was published 150 years ago, defines the precepts that became the prototype for contemporary nursing practice, provides a compelling historical perspective on the evolution of healthcare delivery, and provides an intimate glimpse into the Victorian Age.
How did this intelligent, upper-class woman come to write a book about nursing – at that time, an occupation for women of the lower classes? At first glance, Nightingale would appear an unlikely candidate for a social reformer and nursing advocate. Born in 1820 in Florence, Italy, to a wealthy aristocratic family, she enjoyed a privileged upbringing. Nightingale was a sickly child who showed an insatiable intellectual curiosity at an early age and a restless spirit that was ill suited to the society life for which she was reared. Uncharacteristically for the times, she received a formal education from her father. She proved to be an apt pupil, particularly in mathematics.
But the timeswere right for social change. Nightingale came of age in Victorian England, during the Industrial Revolution that spawned factory towns, with their slums, filth, and overcrowding. Great social reforms were being introduced to improve conditions in prisons, workhouses, and municipal sanitation. The role of women in society also was changing as a result of an organized feminist movement that managed to get laws passed to protect women’s financial interests and that organized groups to promote education and employment for women.
Significant scientific discoveries were being made at the same time. Just months before Notes on Nursing was published, Charles Darwin published the Origin of Species, his groundbreaking evolutionary theory. Louis Pasteur was making the discoveries that led to his germ theory of disease. In the field of medicine, anesthetic use during surgery was introduced in the mid 1800s, and the first female physicians, Elizabeth Garret Anderson in England, and Elizabeth Blackwell in the United States, were entering into the profession. It would be some years however, before Joseph Lister would introduce antiseptics (1867) and Robert Koch would identify the organisms that caused tuberculosis (1882) and cholera (1883).
At the age of sixteen, Nightingale professed to receive her first of several calls from God. It took some time before she discerned that her call was to minister to the sick. She began to visit hospitals during the family’s many travels abroad and made several unsuccessful attempts to secure work in the London hospitals. A desire to pursue a career would have been astonishing for any wealthy Victorian woman, but nursing, in particular, was considered to be a lowly occupation. Up to that time, most nurses had been professed religious women who practiced in Protestant and Catholic hospitals. In the public hospitals, nursing was relegated to untrained secular women of questionable morals and ill repute, many of whom were said to be alcoholics.
Social connections served her well when, while traveling with friends in Germany, she spent several months in training at the Kaiserswerth Training School for Nurses. This enabled Nightingale to secure her first appointment as a healthcare professional when she was hired as superintendent of a hospital for women on Harley Street in London in 1853. Her family by then had resigned themselves to her choice of pursuits. The invention of the telegraph made possible the first real-time battlefront dispatches from the Crimea – in what is now the Ukraine – when war broke out in 1854. In response to the public outcry that resulted from the daily newspaper accounts of the frightful conditions at the military hospitals, Sydney Herbert, the Secretary for War and also a family friend, asked Nightingale to bring nurses to care for wounded British soldiers at the Barracks Hospital in Scutari.
Upon arrival at the Scutari hospital in December, 1854, Nightingale found that conditions were even more horrible that had been reported. The wounded were housed in buildings built over open sewers, the wards were filthy and overcrowded, and there was a lack of food and the most basic supplies due to a rigid and corrupt military supply chain. Not surprisingly, the mortality rate among the soldiers was high. She and her thirty-eight nurses eventually managed to impose order in the chaos. Nightingale’s superior administrative skills and a large cache of supplies that she had brought, coupled with the work of the Sanitary Commission appointed by the British government to investigate conditions at the battlefront, ultimately improved hospital conditions.
Nightingale returned to England in 1856 amidst a political maelstrom of government investigations into conditions at the military hospitals during the war. Ineligible for appointment to the all-male investigative committees, her input was, nevertheless, highly sought behind the scenes. In preparing a report on the Scutari experience for the British government, she devised a landmark statistical analysis, which graphically displayed that the mortality rate had actually been highest within the first six months of her arrival in the Crimea (5000 men died at Scutari in winter of 1854/5 soon after her arrival). She deduced that poor sanitation had been the root cause of the soldier’s deaths and she vowed to improve military hospitals.
She worked tirelessly during this period, despite having experienced what was then described as a “breakdown” in 1857, which left her an invalid for many years. The origin of her illness remains unknown, but has been ascribed to various disorders. Strachey, one of her early biographers, attributed the illness to what he called her “Demons,” saying that, “Her desire for work could scarcely be distinguished from mania.” This remark was eerily prescient of a recent theory proposed by Dr. Katherine Wisner, a psychiatrist at the University Of Pittsburgh School of Medicine, who theorizes that Nightingale may have suffered from bipolar (manic-depressive) disorder. Other explanations that would have been associated with her war service include post-traumatic stress disorder and chronic brucellosis, a bacterial infection acquired from contact with infected animals or ingestion of contaminated animal products, such as meat or milk.
Nightingale grew weary of the political wranglings over the military, and next turned her attention to reforming the hospitals of London. She drew upon her experience and her skills as an administrator to write two papers on hospital sanitation which eventually were made into the book, Notes on Hospitals, published in 1859. The essential importance of sanitation stressed in this work was to become the foundation of her commentaries in Notes on Nursing. Never married, she would remain a devoted healthcare advocate and a prolific writer throughout her long life, producing a large body of scholarly papers and correspondence before she died at the age of 90.
While still in the Crimea, the Nightingale Fund had been established by Sir Sidney Herbert, a result of her tremendous popularity with the public, who followed her accounts from the battlefront published in The Times. She had changed the public’s image of nursing and had made it respectable. It was decided that the funds would be used to establish a training school for nurses in an effort to improve hospital care. Nightingale wrote Notes on Nursing while the hospital was in the planning stages. The Nightingale Training School for Nurses at St Thomas’ Hospital opened six months later and the book was used as the first training manual for nurses.
By the author’s own admission, the work was not written as a training manual for professional nurses, because Nightingale believed that nurses’ training only could be achieved through direct experience in a hospital ward. Instead, she intended it as a “collection of hints” so that every woman could teach herself the rules of health and sanitation to prevent illness and hasten recovery in the sick. In emphasizing prevention and providing health information to the general public in this way, Nightingale established herself as a forerunner of the nascent public health movement, as noted by Gardner, author of a classic text on public health nursing.
Among other things, Nightingale advocated hospital sanitation as an essential precept of effective health care, along with a well-ordered hospital and compassionate patient care management. Nurses’ responsibilities centered on the creation of the proper environmental conditions essential to effective patient care and careful attention to the patient’s needs. Her detailed descriptions of patients’ dispositions and their reactions to the various interventions of the day may spring as much from her own experience with illness as from her nursing observations at the battlefront.
Nightingale viewed disease as a reparative process and advocated for nature, not medicine, as the cure. She emphasized the benefits of proper nutrition for the sick, allowing as how the nurse should be guided by the patient’s own craving for food.
She viewed nursing as an art as well as a science. Throughout the work, she stressed the paramount importance of observation skills and the application of experience in nursing the sick. So important is the nurse’s observation skills that, without them, Nightingale believed a woman should “give up the practice of nursing.”
But the book is not devoid of misconceptions and inaccuracies, as when Nightingale states that most infections are not contagious, but rather arise spontaneously from poor environmental conditions. She saw little need for nursing education in the medical sciences, because to her, they were of little use in patient care. In her words, “Pathology teaches nothing more than the harm a disease has done,” and “Chemistry has yet afforded little insight into dieting of the sick.”
Several of her biographers have stated their belief that the book may actually be a diatribe against nursing, and that its content is the very antithesis of its title. Small refers to it as “…anti-nursing, anti-hospital and anti-doctor.” Strachey called Notes on Nursing, “…that classical compendium of the besetting sins of the sisterhood, drawn up with the detailed acrimony, the vindictive relish of a Swift … .” Readers can decide whether Nightingale’s sometimes authoritative and acerbic tone, and pointed comments about the medical experts of the day, reflects a true antipathy toward nursing or perhaps consider that in pointing out both beneficial practices and pitfalls, Nightingale’s book holds true to its title.
Notes on Nursing is no longer required reading for nurses in training. This is, perhaps, unfortunate, for the modern nurse might be surprised at how contemporary Nightingale’s writings seem. The observation and patient evaluation skills she defined remain the basis for present-day nursing process that includes the assessment, diagnosis, planning, and implementation of nursing measures. Her emphasis on sanitation and hand washing also presaged the modern healthcare infection control movement, with its focus on eradication of hospital-acquired infections. And, although nurses no longer empty chamber pots, open chimney flues, or worry about their crinoline skirts catching fire, they may be interested to find among Nightingale’s writings such modern-day concepts as the mind-body connection, plant therapy, and pet therapy.
Some things remain unchanged from Nightingale’s day. Women are still the primary caregivers, and nursing remains a predominantly female profession. The care setting has come full circle from the homes of Victorian England, to the modern hospital and outpatient setting, and back again to home-based care. The greatest healthcare expenditures continue to be on treatment of preventable conditions such as obesity, diabetes, and heart disease.
Nursing remains a profession in crisis, despite Nightingale’s initial success in raising its professional status. The strain can be seen in the recent nursing shortages, attributed to expanding career opportunities for women and increasing demands on an aging nursing workforce. Pay equity and political power have eluded the profession, although registered nurses (RNs) comprise the largest segment of the health care work force. The public fails to recognize nurses as health professionals with a unique set of skills that are distinct from, albeit complementary to, medical practice. Buresh and Gordon, journalists who have written extensively on nursing issues, have suggested that nurses themselves are responsible for this failure to communicate the profession’s worth to society. Indeed, one would be hard pressed to name a prominent nursing leader or spokesperson today that approaches Nightingale’s fame.
These are not just nursing issues, but should be of keen interest to all those concerned with the quality and availability of the health services that will be needed by an aging population. Reading Nightingales book with this in mind can serve to open the dialogue on how nursing expertise can help shape the healthcare landscape of the twenty-first century. Perhaps in this way, Nightingale’s reach will have extended into our time, and she will resume her role as a healthcare champion.
One could only speculate about what Nightingale might think of how nursing and healthcare have evolved from her day. Whatever her motivation, the book’s impact on the profession and practice of nursing is incontrovertible. It in no way diminishes Nightingale’s contributions to understand that the times were ripe for social change. Florence Nightingale captured the public’s imagination, changed the prevailing image of nursing as an unsavory profession, and helped focus attention on nursing in a way that has not been duplicated since.
“Were there none who were discontented with what they have, the world would never reach anything better.”
Florence Nightingale 1820-1910
Ramona Salotti received her nursing diploma at Chestnut Hill Hospital School of Nursing and earned a baccalaureate degree in Psychology from Chestnut Hill College. She is an independent consultant who specializes in occupational health. She has written for professional journals and publications, including The AAOHN Journal and Nursing Spectrum, and spent two years as an editor and writer for ECRI, a non-profit healthcare research organization in Plymouth Meeting, PA.