Below is an article accepted by the BJN for publication in January 2020, but subsequently rejected (further on this below).
The Real Pioneers of Nursing and Founders of the Profession
Key words: Florence Nightingale, pioneer nurses, National Health Service, Nigerian nursing, Workhouse infirmaries, universal access to health care
Questions for discussion:
What criteria should be used in choosing model pioneer nurses?
How important was Florence Nightingale in founding the modern nursing profession?
What five (or up to ten) nurses would you choose as pioneers? And why?
Apart from providing direct nursing services, what role do nurses play in the NHS? And what role could they play?
Is universal access to quality health care at risk in the U.K.? If so, how?
The article contests Price-Dowd’s choice of four pioneer founders of nursing and proposes others.
It notes the failure of the author to give any instances of nursing leadership by its top choice, Mary Seacole, but, instead, gave false ‘information,’ about her, namely that she was twice refused as a nurse by the British government, without providing a credible source, or any source.
It notes that Seacole’s own memoir records no hospital experience, nor the submission of the required formal application to become a Crimean War nurse.
The significance of Nightingale’s leadership in founding the profession is noted (absent in the article). This includes her early articulation of the principles of the National Health Service.
It commends the author’s fourth choice as nursing leader, Kofoworola Pratt, the first black nurse in the NHS, and adds material to show why she deserves recognition as a significant founder of the profession.
The article proposes inclusion of Agnes Jones, for her pioneering contribution to workhouse nursing, an essential step for the raising of the workhouse infirmaries to hospital status, and Angelique-Lucille Pringle, for her taking professional nursing from the Nightingale School to Scotland, at the Edinburgh Royal Infirmary, and later to an Irish Roman Catholic hospital.
Price-Dowd in a recent article (2018) made the case for four ‘real founders of nursing,’ the ‘great leaders,’ the ‘pioneers who turned nursing into the profession we see today. Leading the list is Mary Seacole (1805-81), for whom not one qualification in or experience of nursing was given. Instead a false statement is made about her (without any source) that she was ‘refused twice by the British government’ to go to the Crimean War. Examination of her fine memoir, Wonderful Adventures of Mrs Seacole in Many Lands, 1857, shows that she never submitted an application to become a war nurse, but instead, after Nightingale and her team had left for the war, dropped into various government and war related offices, informally, to try to be sent as a nurse. She had spent two months in London when the teams were being assembled attending to her gold investments, but missed even the second team.
Seacole was a businesswoman who went to the Crimean War to join her business partner to open a for-profit business for officers. This is perfectly clear in her memoir (Chapters 8-18), a basic point that typically ignored by Seacole commentators. Also absent in sources is the fact that she missed the three most important battles of the war (Chapter 8). She did provide much aid and comfort, primarily to officers (Chapters 14-18), and certainly became a celebrity, but she did not nurse one day in any hospital in any country, train any nurse, write any book or article on nursing, or mentor any nurses, work that the four founders to be related here did.
Price-Dowd’s second leader was Florence Nightingale, described as the person that ‘most people see as the epitome of the nurse’ and who was also, she acknowledged, adept at statistics. These points are valid, but more to the point would be that Nightingale was the major founder of the modern nursing profession as the founder of the first nursing school in the world (Abel-Smith, 1960; Baly 1960; McDonald, 2009; Seymer, 1960), author of Notes on Nursing, 1860, with its influential environmental theory of health and health care, and that she mentored many nurses who took the nursing cause to other hospitals and countries.
Nightingale and the NHS
Neglected also is the salient fact that Nightingale was the first person to articulate the vision that the National Health Service embodies, of quality care for all, regardless of ability to pay—not that she had any notion that such a centralized organization would ever materialize. Yet it was she, in 1866 and 1867, who pressed for legislation that would provide professional nursing care in the worst hospitals of the country—the workhouse infirmaries—the only hospitals open to those who could not afford the fees of regular hospitals. She, with a team of people with similar goals, pressed for the next reforms that got skilled nursing into workhouses, and for some workhouses, better buildings, as well. The NHS could hardly have started operations in 1948 if 80% of its hospitals still had bed sharing and only ‘pauper’ nurses, meaning untrained women who notoriously drank their (small) earnings as “nurses.” It was Nightingale who called for quality care for all, to include the destitute. It was she, also, who called for health promotion and disease prevention to be prime goals of the health care system, not only treatment. This was realized in the National Health Services Act of 1946, the legislation that grounded the NHS, which itself opened in 1948.
Universal access to health care
Nightingale is, thus, a pioneer contributor to what is now known as ‘universal access to health care,’ an unthought of concept in her day, when access to a charity ward was the best the ‘sick poor’ could aspire to–most would have to settle for the workhouse. The NHS was the first single-payer system of health care in the world—Germany, notably, had early provided wide access through an insurance system, but the provisions of the NHS were greater and bolder.
Universal access to health care is a key component of the United Nations
‘Sustainable Development Goals,’ issued as a millennial project, and which remain unrealized in most countries. The World Health Organization is recognizing 2020 as the ‘Year of the Nurse,’ not coincidentally, the bicentenary of Nightingale’s birth. Her leadership aiming at universality is worth noting.
Price-Dowd named Edith Cavell as her third choice of nursing founder, but Cavell, who deserves celebration for her patriotism and courage, hardly had the opportunity to contribute much to nursing, certainly not to the NHS. After working as a governess in Belgium, she returned to England to train as a nurse at the London Hospital, whose eminent matron, Eva Luckes, Nightingale mentored. Cavell served as night superintendent at St. Pancras Workhouse Infirmary, whose nursing was started by a Nightingale team. In 1907, she founded Belgium’s first nurse training school. However, on the invasion of Belgium in World War I, she turned to army nursing. She was executed by the Germans in 1915 for assisting British and Belgian soldiers escape to neutral Switzerland.
Kofoworola Abeni Pratt (1915-92), the Nigerian nurse who was Price-Dowd’s final choice as a nursing founder, was an important nursing leader, relevant also as the first black nurse in the NHS. Pratt came to England to train at the Nightingale School because she was inspired by Nightingale. She started training in 1946 and had passed the school’s examinations with honours, and the preliminary state examinations by the time of the launching of the NHS, June 1948, then passed the final state exams in 1949. Pratt took further training in midwifery, tropical diseases and the ward sister’s course. She was encouraged to return to Nigeria to lead in the transformation of Nigerian nursing, then in its earliest stage with a small number of British ex-pat nurses. Pratt was enormously successful in this, rising from ward sister to deputy matron and then matron, the first Nigerian to hold such posts. She made one further trip to England to do the Administration Certificate of the Royal College of Nursing. She won scholarships to travel and observe nursing practices in other countries (Bell, 1967). Pratt as well held top administrative positions in her country, as chief nursing officer for the federal Nigerian government (1965-72) and commissioner for health in Lagos state (1972-75).
Pratt gave back with her leadership in Nigeria, notably starting the first Nigerian training school at University College Hospital, Ibadan, which became the base for starting professional nursing elsewhere in the country (Lagos was second). She oversaw the transition of the hospital-based school into the university system–her school at Ibadan the first, in 1965. Pratt gave back also with leadership in the International Council of Nurses.
Along the way she had racism to confront, which she successfully handled. Here she had the support of leading British nurses, both in England (she had an English patient who objected to her being his nurses) and, in Nigeria, when a British doctor did not want her as his ward sister, despite her having the required British qualifications. In this case, the (British) matron insisted, and Pratt’s own considerable ability was so obvious that the doctor himself was convinced that she was the best wards sister that he had ever had, in the U.K. or Nigeria.
Among the many honours Pratt received, she was made a fellow of the Royal College of Nursing in 1979, and a fellow of the West African College of Nursing in 1980.
Establishing Professional Nursing in the Workhouse Infirmaries
After Nightingale, and often with her considerable assistance and encouragement, numerous other leading nurses can be identified who did much to establish the profession in the U.K. and in other countries. An excellent choice for the next pioneer nurse, after Nightingale, is Agnes Jones (1832-68), founder of professional nursing at the Liverpool Workhouse Infirmary in 1865. William Rathbone, member of a prominent Liverpool family, and himself later an MP, paid for the “experiment” in trained nursing to take place, and worked closely with Nightingale to see it realized. Liverpool thus became the first city to provide skilled nursing care to its indigent, ‘pauper’ population (McDonald, 2004). Jones, who came from a well-off Anglo-Irish family, was motivated by her faith to take on the challenge of leading a team, trained at the Nightingale School. The difficulties were many, but Jones and her nurses were dedicated, and had the full support of Rathbone and Nightingale. Jones sadly died on the job on typhus fever, in 1868, in the third year of the project. Other workhouse infirmaries, in time, got trained nurses, too, and soon got had training schools established at them. St Pancras (Highgate) and St Marylebone in London are good examples, and there were good examples also in Belfast and Birmingham.
Jones’s death caused numerous difficulties, as trained nurses were then so scarce. Nightingale published a tribute to her, ‘Una and the Lion’ (1868), which called on British women to take up the challenge. Many did, not dissuaded by the dangers.
The importance of this workhouse infirmary reform can hardly be understated, as at least 80% of the British population had to use them, so that their improvement was essential. Well trained nurses came to work at them, including Edith Cavell, who was night superintendent at the St Pancras Workhouse Infirmary.
Extending Professional Nursing throughout the U.K.
The Nightingale School at St Thomas’ Hospital was always, for Nightingale, the first, to be followed by others. She looked to nursing schools being established generally, that they would be as common as medical schools at hospitals. It took trained persons, a matron and team of nurses, to make the transition from the old-style, disreputable, untrained nurses to trained professionals. Of the many dedicated nurses who took on the task of establishing nursing at other hospitals, Angelique-Lucille Pringle (1846-1920) deserves special mention. She was part of the team that went to the Edinburgh Royal Infirmary in 1872, the large and rough hospital, that “den of thieves,” as Nightingale called it—excellent for its medical school, but still (largely) with the all too familiar untrained nurses. Pringle took over as matron when the matron sent from London proved to have a substance-abuse problem (opiates and alcohol). Pringle rose to the occasion, presided over the training school when it was established, and was instrumental in getting trained nurses into other Scottish hospitals. She returned to London later to take over the superintendence of the Nightingale School when its matron, Sarah E. Wardroper, retired. Pringle, however, resigned that position on her conversion to Roman Catholicism. She tried, with little success, to get nurse training into Irish workhouse infirmaries, but they continued to use untrained Roman Catholic nuns. In 1902, she was (finally) appointed head of an Irish (R.C.) training school, St. Philomena, in Belfast, attached to the Irish Sisters of Mercy hospital, Mater Informorum. Pringle was next matron for two years at the Waltham Training School, near Boston, and served yet again in Scotland at a war hospital during World War I. Altogether she gave leadership to professional nursing in Scotland, England, Ireland and the United States, in hospitals of the (established) Church of England, and Roman Catholic and secular hospitals. She produced one book on nursing, A Study of Nursing, 1905.
Nursing leadership in the future
Price-Dowd reasonably enough calls for future leaders to ‘lead at the system level,’ and that knowledge is held ‘with others’ (Box 1). This is exactly how Nightingale led. She always worked with a team, multi-disciplinary, with doctors, architects and engineers, to attend to issues of hospital design, and with political leaders, on legislation, regulations and finance. She was not only good at statistics, but saw how they could be used to influence public opinion to call for needed reforms. Spiegelhalter argued this cogently in his 2019 Nightingale Lecture on Statistics, Oxford University.
The NHS Leadership Academy might adopt Nightingale’s requirements for nursing students, that they be ‘honest, truthful and trustworthy,’ redundant, indeed, but accuracy and integrity are essential in addressing public health policy and future needs. Oddly enough, Nightingale’s old-fashioned principles are still worth respecting, as is her vision of quality care for all, and her example of using data—good, hard statistics—to argue for policy advances.
Abel-Smith, B. (1960). A History of the Nursing Profession. London: Heinemann.
Baly, M. (1986) Florence Nightingale and the Nursing Legacy. London: Whurr.
McDonald, L. (2004). The Reform of Workhouse Infirmaries. Florence Nightingale on Public Health Care. Waterloo ON: Wilfrid Laurier University Press.
Bell, L.M. (1967) Kofoworola Abeni Pratt: Third vice-president, International Council of Nurses. Int. Nurs. Rev. 14 No. 5: 7-11.
McDonald, L. (2009) ed. Florence Nightingale: The Nightingale School. Waterloo ON: Wilfrid Laurier University Press.
Nightingale, F. Una and the Lion. Good Words (1 June 1868):360-66.
Price-Dowd, C. The changing face of nursing: from the pioneers to the future of leadership. British Journal of Nursing 27 No. 13 (2018).
Pringle, A.-L. (1905). A Study in Nursing. London: Macmillan.
Seymer, L.R. (1960). Florence Nightingale’s Nurses: The Nightingale Training School 1860-1960. London: Pitman Medical.
Spiegelhalter, D. (2019). What would Florence Nightingale make of the way data is being used today? Oxford University Nightingale Lecture 30 April.