Nurses Week: Florence Nightingale Part I

 Florence Nightingale OM RRC DStJ (/ˈnaɪtɪŋɡeɪl/; 12 May 1820 – 13 August 1910) was an English social reformer, statistician and the founder of modern nursing. Nightingale came to prominence while serving as a manager and trainer of nurses during the Crimean War, in which she organized care for wounded soldiers at Constantinople. She significantly reduced death rates by improving hygiene and living standards. Nightingale gave nursing a favorable reputation and became an icon of Victorian culture, especially in the persona of "The Lady with the Lamp" making rounds of wounded soldiers at night.

Recent commentators have asserted that Nightingale's Crimean War achievements were exaggerated by the media at the time, but critics agree on the importance of her later work in professionalizing nursing roles for women. In 1860, she laid the foundation of professional nursing with the establishment of her nursing school at St Thomas' Hospital in London. It was the first secular nursing school in the world and is now part of King's College London. In recognition of her pioneering work in nursing, the Nightingale Pledge taken by new nurses, and the Florence Nightingale Medal, the highest international distinction a nurse can achieve, were named in her honor, and the annual International Nurses Day is celebrated on her birthday. Her social reforms included improving healthcare for all sections of British society, advocating better hunger relief in India, helping to abolish prostitution laws that were harsh for women, and expanding the acceptable forms of female participation in the workforce.

Nightingale was a pioneer in statistics; she represented her analysis in graphical forms to ease drawing conclusions and actionables from data. She is famous for the usage of the polar area diagram, also called the Nightingale rose diagram, equivalent to a modern circular histogram. This diagram is still regularly used in data visualization.

Nightingale was a prodigious and versatile writer. In her lifetime, much of her published work was concerned with spreading medical knowledge. Some of her tracts were written in simple English so that they could easily be understood by those with poor literary skills. She was also a pioneer in data visualization with the use of infographics, using graphical presentations of statistical data effectively. Much of her writing, including her extensive work on religion and mysticism, has only been published posthumously.

Early life

Florence Nightingale was born on 12 May 1820 into a wealthy and well-connected British family at the Villa Colombaia, in Florence, Tuscany, Italy, and was named after the city of her birth. Florence's older sister Frances Parthenope had similarly been named after her place of birth, Parthenope, a Greek settlement now part of the city of Naples. The family moved back to England in 1821, with Nightingale being brought up in the family's homes at Embley, Hampshire, and Lea Hurst, Derbyshire.

Florence inherited a liberal-humanitarian outlook from both sides of her family. Her parents were William Edward Nightingale, born William Edward Shore (1794–1874), and Frances ("Fanny") Nightingale (née Smith; 1788–1880). William's mother Mary (née Evans) was the niece of Peter Nightingale, under the terms of whose will William inherited his estate at Lea Hurst, and assumed the name and arms of Nightingale. Fanny's father (Florence's maternal grandfather) was the abolitionist and Unitarian William Smith. Nightingale's father educated her.

A BBC documentary reported that "Florence and her older sister Parthenope benefited from their father's advanced ideas about women's education. They studied history, mathematics, Italian, classical literature, and philosophy, and from an early age, Florence, the more academic of the two girls, displayed an extraordinary ability for collecting and analyzing data which she would use to great effect in later life."

Young Florence Nightingale

In 1838, her father took the family on a tour in Europe where she was introduced to the English-born Parisian hostess Mary Clarke, with whom Florence bonded. She recorded that "Clarkey" was a stimulating hostess who did not care for her appearance, and while her ideas did not always agree with those of her guests, "she was incapable of boring anyone." Her behavior was said to be exasperating and eccentric and she had little respect for upper-class British women, whom she regarded generally as inconsequential. She said that if given the choice between being a woman or a galley slave, then she would choose the freedom of the galleys. She generally rejected female companies and spent her time with male intellectuals. Clarke made an exception, however, in the case of the Nightingale family and Florence in particular. She and Florence were to remain close friends for 40 years despite their 27-year age difference. Clarke demonstrated that women could be equal to men, an idea that Florence had not learned from her mother.

Nightingale underwent the first of several experiences that she believed were calls from God in February 1837 while at Embley Park, prompting a strong desire to devote her life to the service of others. In her youth she was respectful of her family's opposition to her working as a nurse, only announcing her decision to enter the field in 1844. Despite the anger and distress of her mother and sister, she rejected the expected role of a woman of her status to become a wife and mother. Nightingale worked hard to educate herself in the art and science of nursing, in the face of opposition from her family and the restrictive social code for affluent young English women.

As a young woman, Nightingale was described as attractive, slender, and graceful. While her demeanor was often severe, she was said to be very charming and have a radiant smile. Her most persistent suitor was the politician and poet Richard Monckton Milnes. Still, after a nine-year courtship, she rejected him, convinced that marriage would interfere with her ability to follow her calling to nursing.

In Rome in 1847, she met Sidney Herbert, a politician who had been Secretary at War (1845–1846) who was on his honeymoon. He and Nightingale became lifelong close friends. Herbert would be Secretary of War again during the Crimean War when he and his wife would be instrumental in facilitating Nightingale's nursing work in Crimea. She became Herbert's key adviser throughout his political career, though she was accused by some of having hastened Herbert's death from Bright's disease in 1861 because of the pressure her program of reform placed on him. Nightingale also much later had strong relations with academic Benjamin Jowett, who may have wanted to marry her.

Nightingale continued her travels (now with Charles and Selina Bracebridge) as far as Greece and Egypt. While in Athens, Greece, Nightingale rescued a juvenile little owl from a group of children who were tormenting it, and she named the owl Athena. Nightingale often carried the owl in her pocket, until the pet died (shortly before Nightingale left for Crimea).

Her writings on Egypt, in particular, are testimony to her learning, literary skill, and philosophy of life. Sailing up the Nile as far as Abu Simbel in January 1850, she wrote of the Abu Simbel temples, "Sublime in the highest style of intellectual beauty, intellect without effort, without suffering ... not a feature is correct — but the whole effect is more expressive of spiritual grandeur than anything I could have imagined. It makes the impression upon one that thousands of voices do, uniting in one unanimous simultaneous feeling of enthusiasm or emotion, which is said to overcome the strongest man."

At Thebes, she wrote of being "called to God", while a week later near Cairo she wrote in her diary (as distinct from her far longer letters that her elder sister Parthenope was to print after her return): "God called me in the morning and asked me would I do good for him alone without reputation." Later in 1850, she visited the Lutheran religious community at Kaiserswerth-am-Rhein in Germany, where she observed Pastor Theodor Fliedner and the deaconesses working for the sick and the deprived. She regarded the experience as a turning point in her life and issued her findings anonymously in 1851; The Institution of Kaiserswerth on the Rhine, for the Practical Training of Deaconesses, etc. was her first published work. She also received four months of medical training at the institute, which formed the basis for her later care.

On 22 August 1853, Nightingale took the post of superintendent at the Institute for the Care of Sick Gentlewomen in Upper Harley Street, London, a position she held until October 1854. Her father had given her an annual income of £500 (roughly £40,000/US$65,000 in present terms), which allowed her to live comfortably and pursue her career.

Crimean War

Florence Nightingale's most famous contribution came during the Crimean War, which became her central focus when reports got back to Britain about the horrific conditions for the wounded at the military hospital on the Asiatic side of the Bosporus, opposite Constantinople, at Scutari (modern-day Üsküdar in Istanbul). Britain and France entered the war against Russia on the side of the Ottoman Empire. On 21 October 1854, she and the staff of 38 women volunteer nurses including her head nurse Eliza Roberts and her aunt Mai Smith, and 15 Catholic nuns (mobilized by Henry Edward Manning) were sent (under the authorization of Sidney Herbert) to the Ottoman Empire. On the way, Nightingale was assisted in Paris by her friend Mary Clarke. The volunteer nurses worked about 295 nautical miles (546 km; 339 mi) away from the main British camp across the Black Sea at Balaklava, in the Crimea.

Letter from Nightingale to Mary Mohl, 1881

Nightingale arrived at Selimiye Barracks in Scutari early in November 1854. Her team found that poor care for wounded soldiers was being delivered by overworked medical staff in the face of official indifference. Medicines were in short supply, hygiene was being neglected, and mass infections were common, many of them fatal. There was no equipment to process food for the patients:

This frail young woman ... embraced in her solicitude the sick of three armies. — Lucien Baudens, La guerre de Crimée, les campements, les abris, les ambulances, les hôpitaux, p. 104.

After Nightingale sent a plea to The Times for a government solution to the poor condition of the facilities, the British Government commissioned Isambard Kingdom Brunel to design a prefabricated hospital that could be built in England and shipped to the Dardanelles. The result was Renkioi Hospital, a civilian facility that, under the management of Edmund Alexander Parkes, had a death rate less than one-tenth of that of Scutari.

Stephen Paget in the Dictionary of National Biography asserted that Nightingale reduced the death rate from 42% to 2%, either by making improvements in hygiene herself or by calling for the Sanitary Commission. For example, Nightingale implemented handwashing in the hospital where she worked.

During her first winter at Scutari, 4,077 soldiers died there. Ten times more soldiers died from illnesses such as typhus, typhoid, cholera, and dysentery than from battle wounds. With overcrowding, defective sewers, and lack of ventilation, the Sanitary Commission had to be sent out by the British government to Scutari in March 1855, almost six months after Nightingale had arrived. The commission flushed out the sewers and improved ventilation. Death rates were sharply reduced, but she never claimed credit for helping to reduce the death rate. Head Nurse Eliza Roberts nursed Nightingale through her critical illness of May 1855.

In 2001 and 2008 the BBC released documentaries that were critical of Nightingale's performance in the Crimean War, as were some follow-up articles published in The Guardian and the Sunday Times. Nightingale scholar Lynn McDonald has dismissed these criticisms as "often preposterous", arguing they are not supported by the primary sources.

Nightingale still believed that the death rates were due to poor nutrition, lack of supplies, stale air, and overworking of the soldiers. After she returned to Britain and began collecting evidence before the Royal Commission on the Health of the Army, she came to believe that most of the soldiers at the hospital were killed by poor living conditions. This experience influenced her later career when she advocated sanitary living conditions as of great importance. Consequently, she reduced peacetime deaths in the army and turned her attention to the sanitary design of hospitals and the introduction of sanitation in working-class homes (see Statistics and Sanitary Reform).

According to some secondary sources, Nightingale had a frosty relationship with her fellow nurse Mary Seacole, who ran a hotel/hospital for officers. Seacole's own memoir, Wonderful Adventures of Mrs. Seacole in Many Lands, records only one, friendly, meeting with her, when she asked her for a bed for the night and got it; Seacole was in Scutari en route to the Crimea to join her business partner and start their business. However, Seacole pointed out that when she tried to join Nightingale's group, one of Nightingale's colleagues rebuffed her, and Seacole inferred that racism was at the root of that rebuttal. Nightingale told her brother-in-law, in a private letter, that she was worried about contact between her work and Seacole's business, claiming that while "she was very kind to the men and, what is more, to the Officers – and did some good (she) made many drunk". Nightingale reportedly wrote, "I had the greatest difficulty in repelling Mrs. Seacole's advances, and in preventing association between her and my nurses (absolutely out of the question!) ... Anyone who employs Mrs. Seacole will introduce much kindness – also much drunkenness and improper conduct". On the other hand, Seacole told the French chef Alexis Soyer that "You must know, M Soyer, that Miss Nightingale is very fond of me. When I passed through Scutari, she very kindly gave me board and lodging."

The arrival of two waves of Irish nuns, the Sisters of Mercy, to assist with nursing duties at Scutari met with different responses from Nightingale. Mary Clare Moore headed the first wave and placed herself and her Sisters under the authority of Nightingale. The two were to remain friends for the rest of their lives. The second wave, headed by Mary Francis Bridgeman met with a cooler reception as Bridgeman refused to give up her authority over her Sisters to Nightingale while at the same time not trusting Nightingale, whom she regarded as ambitious.

The Lady with the Lamp

During the Crimean War, Nightingale gained the nickname "The Lady with the Lamp" from a phrase in a report in The Times:

She is a "ministering angel" without any exaggeration in these hospitals, and as her slender form glides quietly along each corridor, every poor fellow's face softens with gratitude at the sight of her. When all the medical officers have retired for the night and silence and darkness have settled down upon those miles of prostrate sick, she may be observed alone, with a little lamp in her hand, making her solitary rounds.— William Russell, Cited in Cook, E. T. (1913). The Life of Florence Nightingale. Vol. 1, p. 237.

The phrase was further popularized by Henry Wadsworth Longfellow's 1857 poem "Santa Filomena":

Lo! In that house of misery

A lady with a lamp I see

Pass through the glimmering gloom,

And flit from room to room.

Nightingale was nicknamed "the lady with the hammer" by the troops after using a hammer to break into locked storage to access medicine to treat the wounded. However, Russell thought the behavior was unladylike, and invented an alternative, leading to "The Lady with the Lamp".

Later career

In the Crimea on 29 November 1855, the Nightingale Fund was established for the training of nurses during a public meeting to recognize Nightingale for her work in the war. There was an outpouring of generous donations. Sidney Herbert served as honorary secretary of the fund and the Duke of Cambridge was chairman. In her 1856 letters, she described spas in the Ottoman Empire, detailing the health conditions, physical descriptions, dietary information, and other vital details of patients whom she directed there. She noted that the treatment there was significantly less expensive than in Switzerland.

Nightingale had £45,000 at her disposal from the Nightingale Fund to set up the first nursing school, the Nightingale Training School, at St Thomas' Hospital on 9 July 1860. The first trained Nightingale nurses began work on 16 May 1865 at the Liverpool Workhouse Infirmary. Now called the Florence Nightingale Faculty of Nursing and Midwifery, the school is part of King's College London. In 1866 she said the Royal Buckinghamshire Hospital in Aylesbury near her sister's home Claydon House would be "the most beautiful hospital in England", and in 1868, called it "an excellent model to follow".

Nightingale wrote Notes on Nursing (1859). The book served as the cornerstone of the curriculum at the Nightingale School and other nursing schools, though it was written specifically for the education of those nursing at home. Nightingale wrote, "Every day sanitary knowledge, or the knowledge of nursing, or in other words, of how to put the constitution in such a state as that it will have no disease, or that it can recover from disease, takes a higher place. It is recognized as the knowledge which every one ought to have – distinct from medical knowledge, which only a profession can have".

Notes on Nursing also sold well to the general reading public and is considered a classic introduction to nursing. Nightingale spent the rest of her life promoting and organizing the nursing profession. In the introduction to the 1974 edition, Joan Quixley of the Nightingale School of Nursing wrote: "The book was the first of its kind ever to be written. It appeared at a time when the simple rules of health were only beginning to be known when its topics were of vital importance not only for the well-being and recovery of patients when hospitals were riddled with infection, when nurses were still mainly regarded as ignorant, uneducated persons. The book has, inevitably, its place in the history of nursing, for it was written by the founder of modern nursing".

As Mark Bostridge has demonstrated, one of Nightingale's signal achievements was the introduction of trained nurses into the workhouse system in Britain from the 1860s onwards. This meant that sick paupers were no longer being cared for by other, able-bodied paupers, but by properly trained nursing staff. In the first half of the 19th century, nurses were usually former servants or widows who found no other job and therefore were forced to earn their living by this work. Charles Dickens caricatured the standard of care in his 1842–1843 published novel Martin Chuzzlewit in the figure of Sarah Gamp as being incompetent, negligent, alcoholic, and corrupt. According to Caroline Worthington, director of the Florence Nightingale Museum, "When she [Nightingale] started out there was no such thing as nursing. The Dickens character Sarah Gamp, who was more interested in drinking gin than looking after her patients, was only a mild exaggeration. Hospitals were places of last resort where the floors were laid with straw to soak up the blood. Florence transformed nursing when she got back [from Crimea]. She had access to people in high places and she used it to get things done. Florence was stubborn, opinionated, and forthright but she had to be those things to achieve all that she did."

Though Nightingale is sometimes said to have denied the theory of infection for her entire life, a 2008 biography disagrees, saying that she was simply opposed to a precursor of germ theory known as contagionism. This theory held that diseases could only be transmitted by touch. Before the experiments of the mid-1860s by Pasteur and Lister, hardly anyone took germ theory seriously; even afterward, many medical practitioners were unconvinced. Bostridge points out that in the early 1880s, Nightingale wrote an article for a textbook in which she advocated strict precautions designed, she said, to kill germs. Nightingale's work served as an inspiration for nurses in the American Civil War. The Union government approached her for advice in organizing field medicine. Her ideas inspired the volunteer body of the United States Sanitary Commission.

Nightingale advocated autonomous nursing leadership, and that her new style of matrons had full control and discipline over their nursing staff. The infamous "Guy's Hospital dispute" in 1879–1880 between matron Margaret Burt and hospital medical staff highlighted how doctors sometimes felt that their authority was being challenged by these new-style Nightingale matrons. This was not an isolated episode and other matrons experienced similar issues, such as Eva Luckes.

In the 1870s, Nightingale mentored Linda Richards, "America's first trained nurse", and enabled her to return to the United States with adequate training and knowledge to establish high-quality nursing schools. Richards went on to become a nursing pioneer in the US and Japan.

By 1882, several Nightingale nurses had become matrons at several leading hospitals, including, in London (St Mary's Hospital, Westminster Hospital, St Marylebone Workhouse Infirmary, and the Hospital for Incurables at Putney) and throughout Britain (Royal Victoria Hospital, Netley; Edinburgh Royal Infirmary; Cumberland Infirmary and Liverpool Royal Infirmary), as well as at Sydney Hospital in New South Wales, Australia.

In 1883, Nightingale became the first recipient of the Royal Red Cross. In 1904, she was appointed a Lady of Grace of the Order of St John (LGStJ).

In 1907, she became the first woman to be awarded the Order of Merit. In the following year, she was given the Honorary Freedom of the City of London.

Her birthday is now celebrated as International May 12th Awareness Day.

From 1857 onwards, Nightingale was intermittently bedridden and suffered from depression. A recent biography cites brucellosis and associated spondylitis as the cause. Most authorities today accept that Nightingale suffered from a particularly extreme form of brucellosis, the effects of which only began to lift in the early 1880s. Despite her symptoms, she remained phenomenally productive in social reform. During her bedridden years, she also did pioneering work in the field of hospital planning, and her work propagated quickly across Britain and the world. Nightingale's output slowed down considerably in her last decade. She wrote very little during that period due to blindness and declining mental abilities, though she still retained an interest in current affairs.

Relationships

Although much of Nightingale's work improved the lot of women everywhere, Nightingale believed that women craved sympathy and were not as capable as men. She criticized early women's rights activists for decrying an alleged lack of careers for women at the same time those lucrative medical positions, under the supervision of Nightingale and others went perpetually unfilled. She preferred the friendship of powerful men, insisting they had done more than women to help her attain her goals, writing: "I have never found one woman who has altered her life by one iota for me or my opinions.” She often referred to herself as, for example, "a man of action" and "a man of business".

However, she did have several important and long-lasting friendships with women. Later in life, she kept up a prolonged correspondence with Irish nun Mary Clare Moore, with whom she had worked in Crimea. Her most beloved confidante was Mary Clarke, an Englishwoman she met in Paris in 1837 and kept in touch with throughout her life.

Some scholars of Nightingale's life believe that she remained chaste for her entire life, perhaps because she felt a religious calling to her career.