Celebrating the Contribution of Florence Nightingale to Contemporary Nursing

ABSTRACT

Emeritus Professor Alan Glasper, from the University of Southampton, discusses how Florence Nightingale and her contemporaries launched a new and worldwide profession.

Introduction

The World Health Organization (WHO) has designated 2020 as the “International Year of the Nurse and the Midwife” in honor of the 200th anniversary of Florence Nightingale’s birth.

Florence Nightingale (1820–1910) was the instigator of modern nursing. Although all societies throughout history attended to the sick and injured, it was the arrival of nursing linked to religious orders that established the beginnings of an embryonic profession. Baly (2002) gives a good description of nursing within these religious orders prior to the modern era, although not all of these nursing orders relied on nuns. For example, the celibate Hospitaller Knights of the crusades combined the tending and caring for the sick with defending the Crusader kingdom. Later in the earlier part of the nineteenth century in countries such as Germany the protestant church established Deaconess Institutes such as that at Kaiserwerth founded in 1836 by Theodor and Friederike Fliedner with an emphasis on caring for the sick. Florence Nightingale herself spent several periods there in the years before the Crimean War (Florence Nightingale Museum, 2020a).

Most nurses, however, in the pre-Nightingale era were often considered slovenly and incompetent. Charles Dickens’s fictional nurse character Sairey Gamp from the novel Martin Chuzzlewit (Dickens, 1843) was portrayed as a dissolute drunkard who was untrained and incompetent. She was to become representative of all that was bad with nursing.

It is important to stress that throughout the whole of the nineteenth century and the first two decades of the 20th, anyone in the UK was able to call themselves a nurse irrespective of what level of training they had acquired. Nursing was not perceived as being respectful, nor was it an activity that was thought to demand either skill or training. In Florence Nightingale’s words nursing was left to “those who were too old, too weak, too drunken, too dirty, too stupid or too bad to do anything else” (Thomas, 2016, p. 1).

It was in this empty landscape of nursing that Nightingale grew up and by the time she was 17 she became convinced that nursing was to be her calling and deeply believed that God had spoken to her personally and given her a quest to better humanity and that this was to be her Christian duty (History.com, 2020).

In this context, it has recently been confirmed that Florence Nightingale heard voices and suffered a number of depressive episodes in her teen years coupled with periods of extraordinary scholarly output. These features are believed to be consistent with the diagnosis of a bipolar disorder (Washington Times, 2003).

Her wealthy and socially prominent family did not want Florence to take up nursing but being from a privileged background she was able to spend some time touring Europe. She used this opportunity to secretly spend some time visiting and observing nursing care delivery at the Kaiserwerth hospital in 1849. Later in 1851, she returned to Kaiserwerth where she was able to further explore the concept of nursing. However, it is important to stress that Florence never actually undertook formal training as a nurse and always denied having been trained at Kaiserwerth where she believed nursing was nonexistent and the hygiene conditions appalling. Florence recognized that formal education had to be a fundamental and crucial component of preparation to be a nurse!

Sir Sydney Herbert, a member of parliament and a friend of the family, arranged for Florence to be appointed as the superintendent for the institution for the care of Sick Gentlewomen in Harley Street London in early 1853. Over the coming months, she conducted inspection visits to other hospitals. Through this, she was becoming an authoritative figure on all aspects of nursing and as the winds of war were looming closely on the horizon with Russia “cometh the hour, cometh the woman.”

When the Crimean war dragged Britain and France into the hostilities in the spring of 1854 Florence was well placed to become the hero who was so badly needed to help alleviate the suffering of the common British soldier in what became a war of attrition and is now referred to as Britain’s 19th century Vietnam (Facts and Details, 2016).

At the beginning of this war senior military officers displayed an appalling disregard for the lives of British soldiers. However, this was to be the first war where war correspondents were allowed to be present on the battlefield and they sent back first-hand accounts of army health care to their respective newspapers. William Howard Russell, the war correspondent for the Times newspaper, brought the inadequate hospital provision for soldiers to the attention of the public in no uncertain manner in highlighting that “the sick have not a bed to lie on” (Baly, 2002). These and similar editorials enraged the public who poured their vitriolic anger on the now minster for War, Sir Sydney Herbert, who in desperation on October 15, 1854 asked Florence Nightingale to recruit a cadre of nurses for duty in the war zone. As a testimony to her logistical skills Florence managed within a few days to enlist a group of 38 volunteer nurses and set sail for the war zone on the October 21, 1854 (Royal Parks.org., n.d.).

On arriving at the army hospital at Scutari, once a former Turkish barracks in Istanbul, Florence cited Dante’s famous quotation “abandon hope all ye that enter here” (Quinones, n.d.).

Importantly Florence had at her disposal some £30,000 worth (over four million pounds in 2020; 5,268,800.00 USD) from the Times newspaper monetary fund raised from public donations and intended to help sick wounded soldiers. The converted barracks were wholly derisory with little clean water available, and the toilet arrangements were grossly inadequate for the thousands of casualties. Ten times more soldiers were dying of diseases such as typhus, typhoid, cholera, and dysentery than from battle wounds (Fee & Garofalo, 2010). The army doctors were totally opposed to the presence of Nightingale and her nurses and refused to cooperate with them. However, just two days after her arrival the disastrous battle of Inkerman commenced and soon thousands of sick and wounded soldiers were being ferried across the Bosporus to the British hospital.

Desperate for help in the face of the huge numbers of casualties the doctors and orderlies formally requested the help of Florence and her contingent of nurses. With the Times newspaper fund at her disposal the British army doctors soon realized that Florence was someone who had the power and authority to bypass the inefficiencies of the system to buy provisions and equipment for the management of these patients.

Florence worked tirelessly day and night without rest or sleep, and Baly (2002) reports that she often spent 8 hours a day on her knees dressing wounds. Her reputation as the lady of the lamp was born as she conducted her nighttime rounds of the hospital carrying a simple Turkish paper concertina lantern. The wounded men began to call her the angel of the Crimea and would kiss her shadow as she walked by the beds. This adoration soon spread to the British public at home following the publication of a pen and ink drawing of her carrying a lamp on her ward round in The Illustrated London News in 1855. Desperate for a hero to emerge from the Crimean campaign which was tainted by sheer and reckless foolhardiness the British public had at last found one (Bostridge, 2011).

Sadly Florence contacted Crimean fever and became gravely ill. It is said that the soldiers of the Scutari hospital turned their faces to the wall and cried, praying for her recovery. She eventually recovered, although the toll on her health remained. When she returned home after the war in 1856 she inevitably sailed out of the pages of history and into legend.

After returning to Britain Florence became a bedridden invalid plagued by periods of depression which only improved after she reached 60 years of age. Mackowiak and Batten (2008) are confident that her symptoms were of a character and intensity consistent with criteria currently used today to define post-traumatic stress disorder (PTSD). Allegedly she never spoke of her wartime experiences after returning to England and she never returned to nursing practice, possibly because she wanted to avoid care scenarios which might have rekindled those traumatic memories (Mackowiak, 2015).

Despite her illness she continued to write prolifically. Her book Notes on Nursing: What It Is and What It Is Not (Nightingale, 1859) was the first nursing textbook of its kind to be published and actually written before the opening of the first modern-era school of nursing in July 1860. This textbook became the core text for many future schools of nursing. Interestingly, there is no doubt that Florence was not kindly disposed to the care of sick children although in her Notes she states: “Children: they are affected by the same things [as adults] but much more quickly and seriously.”

The opening of the Nightingale school of nursing

It was the establishment of the first UK school of nursing for which Nightingale will be long remembered, for it was this which changed the face of nursing forever. A fund had been set up for Nightingale that enabled members of the public and the armed forces to contribute. By 1859 the fund amounted to £45,000 (worth today about £5. 7 million; 7,509,750.00 USD). Florence decided that a dedicated school of nursing within the grounds of St Thomas’s Hospital London would be the best way forward to utilize the fund (Baly, 2002). As Florence was too sick she appointed matron of the hospital Mrs. Sarah Wardroper as the first superintendent of the school, the first secular training school for nurses in the world.

However, many of the medical establishment at St Thomas’s Hospital were very much opposed to the notion of a nursing school, believing that nurses needed little training other than the traditional duties of a housemaid (Life and Times of Florence Nightingale, n.d.).

If the initiative was not to be stifled at birth by the medical fraternity then the first probationers for the school must be beyond reproach! To help maintain their reputation Florence commissioned the development of a nurses’ home where the probationers (students) lived and where each had their own bedroom. Nurses’ homes later became ubiquitous across all hospitals in the UK and elsewhere (National Archives, n.d.).

The launch of the first nursing school in 1860 drew a line in the sand, finally overcoming nursing’s former Sairy Gamp image and creating a new horizon where nursing would be respected as a professional career choice for women. However, formal nurse registration in Britain was still nearly 60 years away and Nightingale herself was not supportive of later campaigns to introduce statutory state registration for nurses.

It should be stressed that during the early years of the Nightingale school the cohorts of probationers were not actually trained to nurse but rather they were trained to train others. These Nightingale disciples were poised to promote the Nightingale training methodology across the whole of the country and further afield into other countries such as America and Australia.

The Nightingale disciples soon widely disseminated the success of the St Thomas’s School of Nursing.

Linda Richards (1841–1930)

In 1872 Linda Richards, after undergoing nurse training at the New England Hospital for Women and Children in the United States, became its first graduate in 1873. In 1877 she was invited to pursue further training in Great Britain and enrolled as a pupil at the St. Thomas’s nursing school after personally meeting Florence Nightingale. On her return to the United States, she went on to pioneer the establishment of high quality and professional Nightingale-type nurse training schools across the country (Florence Nightingale Museum, 2020b; Hanink, 2020).

Lucy Osburn (1836–1891)

Lucy Osburn was born in Leeds and was the daughter of a well-known Egyptologist. She was well educated and spoke several languages. Like Nightingale she showed an interest in nursing from an early age. Also like Nightingale Lucy spent some four months observing nursing practice at the Kaiserworth hospital in Germany, and in 1866 – much against her parents’ wishes – she enrolled as a probationer at the Nightingale school of nursing. After a request from an influential Australian politician Florence Nightingale asked Lucy to take up a senior position as lady superintendent at the Sydney Infirmary. Lucy is now widely regarded as the founder of modern nursing in Australia (Griffith, 1974).

Rebecca Strong (1843–1944)

Rebecca Strong was widowed at a very young age with a child to rear and was motivated to pursue a nursing career. At only 20 years of age, Rebecca was accepted as a probationer at the St. Thomas’s Hospital Nightingale Training School in 1867. Following her training, she worked at a number of hospitals and in 1879 was appointed as the matron of Glasgow Royal Infirmary. She is now widely regarded as the founder of modern nursing in Scotland. Her unique contribution to nurse education was to initiate the block apprenticeship training program which would soon become commonplace throughout schools of nursing everywhere, i.e., short bursts of periodic theoretical input within the school of nursing followed by periods of nursing practice. She was also credited with introducing the concept of the preliminary training school (PTS) which persists around the world in one form or another in schools of nursing to this day (Nutting, 1901; Parry, 2013).

Alice Fisher (1839–1888)

After the death of her academic father at the age of 36 Alice Fisher enrolled as a probationer at the Nightingale school of nursing in 1872. After completing her studies she had a meteoric career and was successful in securing a series of senior nurse leadership positions in England. However, in 1884 she decided to emigrate to the United States and secured a senior position at Philadelphia General Hospital where she was appointed as the superintendent as no American nurse could be found with her attributes. It was here that she established a nurse training school with the first pupils entering service on the wards of the hospitals in 1885. Uniquely Alice Fisher helped establish Philadelphia Hospital as one of the finest in the United States. Although she died prematurely at the age of only 49 she is still remembered as a Nightingale disciple who helped promote modern nurse education (American Association for the History of Nursing, n.d.; Kings College London, 2020; Lynaugh, 1990).

Culmination of the Nightingale era

These and other disciples of Nightingale ensured the consolidation of the embryonic nursing profession, preparing it for further development in the years to come. However, despite the success of Nightingale’s educational reforms to nurse education, there was still no standardized length of training for nurses and no statutory qualification leading to registration. In the latter decades of the nineteenth century it became apparent that there were more kudos linked to where a nurse had trained rather than what was actually taught (Sullivan, n.d.).

The very success of Nightingale’s educational reforms launched the development of a cadre of well-educated senior nurses, some of whose ambitions for the nursing profession became divergent from that of Florence Nightingale herself. Despite this, Nightingale’s reforms to nurse education had created a new profession which had arisen like a phoenix from the ashes of the old. However, the end of the initial Nightingale era was over, and by 1892 it was time for other influential nurses to pick up the gantlet that was professional nursing, culminating in full state registration in the UK in 1919.

Conclusion

There can be no doubt that Florence Nightingale was the instigator of modern secular nurse training. If she were alive today, she would look back in amazement at how successful the profession has been since the launch of that first modern school of nursing in 1860.