Lynn McDonald *

Department of Sociology and Anthropology, University of Guelph, Canada

Abstract

This article relates the flagrant instances of misinformation on Florence Nightingale, the major founder of professional nursing, in 2020, the bicentenary of her birth, and 2021\. It notes the new trend to “pair” Nightingale with another supposed “nursing pioneer,” who was a businesswoman and generous volunteer, Mary Seacole, but who never portrayed herself as a nurse. The article goes on to cite the promotion of misinformation on the two–by no less than the Queen, in her Christmas message of 2020, and by her heir, the Prince of Wales, on 12 May 2021, Nightingale’s birthday and International Nurses’ Day. The most extreme example of misinformation is that of the prince, who claimed joint status for Seacole with Nightingale in achieving the sanitary reforms in the Crimean War that saved large numbers of lives. Unlike Seacole, Nightingale played a role in these reforms, but credited the doctors and engineers of the Sanitary Commission who did the heavy work of renovation.

The article calls for high standards of ethics and scholarship in nursing and health care publication. Health authorities, such as Britain’s National Health Service, should be the source of reliable information, especially in a pandemic. Misinformation on mere “historical” matters, not clinical, is not acceptable. Diversity and inclusion are valid goals of any health care system, but should be pursued with integrity. The article introduces a fine Black nursing leader, Kofoworola Abeni Pratt, who is ignored and yet should be celebrated for her contributions to nursing both in England and her home country, Nigeria.

Keywords: Florence Nightingale, Nursing pioneers, Ethics, Scholarly standards, Misinformation

Abbreviations: NHS: National Health Service

Introduction

The bicentenary of Florence Nightingale, 2020, oddly became the occasion for the publication of articles denigrating her work, and even making extreme accusations of fault against her, without any documentation. Evidence against such attacks, using primary sources, has subsequently been published.¹

These attacks have typically been linked with the promotion of Mary Seacole, said to be a pioneer nurse, although again without any evidence as to what she pioneered, and contrary to her own description of her contributions in her engaging memoir, Wonderful Adventures of Mrs Seacole in Many Lands, 1857. Then came the announcement by the Florence Nightingale Foundation that it was partnering with the Mary Seacole Trust in the awarding of Seacole Leadership Awards. Yet the purpose of the Foundation, proposed in 1912, two years after Nightingale’s death, was to enable nurses to prepare themselves “to follow in her footsteps.” The proposal came from Ethel Bedford Fenwick, a major British nursing leader, at a meeting of the International Council of Nurses, which immediately adopted it. Fenwick was commissioned to take charge. However, given the disruptions of the First World War, it was not until 1929 that the foundation came into operation.²

The Rewriting of Nursing History

The Florence Nightingale Foundation gave as its justification for the 2021 change in purpose the statement that Nightingale and Seacole were “active at the same time and are both considered pioneers of modern nursing.” They were indeed “active” at the same time, Nightingale in running the nursing and bringing in needed supplies for the army hospitals of the Crimean War, Seacole in running a business (store, bar, restaurant and catering service) for British officers in the Crimea. According to Seacole’s account, they met once, briefly, when she asked Nightingale for a bed for the night at her hospital as she was leaving the next day for the Crimea. Nightingale found one for her.³ There is no mention of the incident in any of the thousands of letters and numerous reports Nightingale wrote. Yet the Foundation’s CEO, Greta Westwood, transmogrified this friendly service into a “partnership”(!) so that joining them in the awards “reunited them” from the encounter 166 years earlier.⁴

Questions put to Westwood to as to what hospitals Seacole ever nursed in, any nurses she trained or mentored, and any books or articles she ever wrote on nursing went unanswered. The answer for each is nil: Seacole did not nurse one day in any hospital in any country of the world, and never said she did. Her one book, the travel memoir, gives menu details and recipes for her restaurant. She describes voluntary services she gave, but there is nothing remotely connected with founding a profession. A timeline is available that lists major activities of both Nightingale and Seacole, where it is evident that they do not coincide.⁵

Major British institutions have engaged in this rewriting. The BBC has put out much misinformation, while the National Portrait Gallery in London for many months displayed a banner of Seacole wearing medals she did not earn, alongside a banner of Lord Nelson, winner of the Battle of Trafalgar, wearing medals he did earn. Six university buildings in the UK are named after Seacole, not a one after Nightingale. The Royal College of Nursing has a Mary Seacole Lecture, but not one to honour Nightingale, which the Royal Statistical Society has.

St Thomas’ Hospital, home of the original Nightingale School, founded in 1860, now has a massive statue of Mary Seacole on its grounds, visible from the House of Parliament across the Thames River, compared with only a modest statue of Nightingale inside a building, seen by few. Yet it was Nightingale who wrote to and met with British members of Cabinet and members of Parliament to press for health care reforms, most notably the raising of the standards of care (bringing in professional nurses) to the dreaded workhouse infirmaries, the only “hospital” recourse then for those who could not pay hospital charges.

The National Health Service (NHS), the first single-payer system in the world, is inconceivable without the reforms that Nightingale worked for. At least 80 percent of “hospital” patients in her time were, in fact, in workhouses, which still had bed sharing, were overcrowded and badly ventilated, and had no trained nurses.

Rewriting Health Care History

An article in the Times by the Prince of Wales takes the misinformation about the two “nursing pioneers” to a new level of misinformation, by crediting Seacole with Nightingale for the broader public health, “sanitary,” reforms that saved lives, not a subject Seacole ever broached. Her memoir contains not one mention of the work of the Sanitary Commission that did the crucial clean-up of the unsanitary conditions of the war hospitals. Yet, says the prince, “It was their emphasis upon hygiene that was credited with saving so many lives. They pioneered the implementation of sanitary regulation in field hospitals so that the wounded could be looked after.”⁶

Diversity and Inclusion on Nursing and Health Care

Diversity and inclusion are now, rightly, goals of nursing and health care institutions. This laudable objective, however, has been made the excuse for the falsification of nursing and health care history more broadly. Pandemic or no pandemic, people should be able to trust the information provided by health authorities.

The promotion of Seacole, valid as its objective is, has led to an obvious injustice: failure to recognize genuine Black and minority nursing leaders, Probably the best example of an unheralded Black nursing pioneer is Kofoworola Abeni Pratt (1915-92), the first Black nurse in Britain’s National Health Service when it opened in 1948, who went on to being the first Black matron of University College Hospital, Ibadan, to being chief nurse in Nigeria and even on to becoming the first nurse to become a Cabinet minister responsible for health in her country (in Lagos State, 1973-75.) In that, she even passed Florence Nightingale (her model), for while Nightingale wrote to and met with Cabinet ministers on nursing and health care reforms, Pratt actually became the minister herself, with, naturally, a male medical doctor as her deputy minister.

Conclusion

Leaders in nursing and health care, and their publications, should adhere to high standards of scholarship and ethics in any material they bring out, and make corrections when errors are brought to their attention. Diversity and inclusion are valid goals, but must be pursued with integrity; propaganda and false facts do not become acceptable as per “the end-justifies-the-means,” not at any time. NHS propaganda on matters only “historical,” not clinical, is not acceptable.

Acknowledgments

None.

Funding

None.

Conflicts of Interest

There is no conflict of interest to declare.

References

¹ McDonald, L. Florence Nightingale: reflections on diversity, the National Health Service and the coronavirus pandemic. ECNH. 2021;3(3):26-31.

² Ward U. The Florence Nightingale Foundation: developing nursing’s leaders. Br J Nurs. 12;27(13):774-775.

³ Seacole M. Wonderful adventures of Mrs Seacole in many lands Oxford: Oxford University Press; 1988.

⁴ Mitchell, G. Mary Seacole Awards to be taken over by a new partnership to “broaden impact.” Nursing Times, 2021.

⁵ McDonald, L. Mary Seacole: the making of the myth. Toronto: Iguana, 2014.

⁶ HRH Prince of Wales. Nurses have done so much to make the nation proud. The Times, 2021.

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Trends in Nursing and Health Care Research | Trends Nur Health Care Res

Teacher, nurse, statistician, author, advocate for health care and occupational health and safety

Nightingale was the major founder of the modern profession of nursing, and health care pioneer, who became famous for leading the first team of British women to nurse in war–the Crimean War of 1854-56.

While Nightingale was famous in her lifetime, and for a long time after it, she is little known today and often mis-represented. She wrote a lot! Not just her most famous book, Notes on Nursing; published in 1860, the same year that her training school opened.

Here are some key points on her work and legacy:

• Nightingale wanted nursing to be an independent profession; nurses would take medical instructions from doctors, but no doctor would hire, fire, discipline or promote a nurse, decisions for senior nurses.
• Her vision for the profession included a career path, with increases in salary and responsibility, and made nursing a well-paying profession. Giving superintendents power to hire, discipline, etc., was to remove it from doctors, then 100% male when nurses were 100% female, and an unspoken measure to prevent sexual harassment of vulnerable women nurses.
• Nightingale consistently argued for good salaries and working conditions for nurses, holidays of at least a month per year; decent pensions; good living conditions during training; and hospital design to save nurses’ energy for patient care. Hospitals should hire cleaners, and nurses ensure that the job was done.
• “Army nurses,” before Nightingale’s time, were recruited from among the wives and widows of privates and non-commissioned officers (doctors were always officers), were paid less than cooks and laundresses, and reported to a sergeant. They did not even speak to a doctor. The belief that Nightingale wanted nurses to be “subordinate to doctors” misses the point, for when her nursing school started, in 1860, women lacked even a high school education, let alone university. Doctors had university/medical qualifications.)
• Nightingale succeeded in improving the status of nurses, from being a “domestic” service occupation in the 1861 Census, to being grouped with “medicine” in 1901 In the army, nurses became “officers,” like doctors.
• She did pioneering work on occupational health and safety as early as 1858. In 1871, she published a pioneering study of maternal mortality post-childbirth, Introductory Notes on Lying-in Institutions. Throughout her life, she worked with doctors, architects, engineers and statisticians to achieve great reforms.
• Nightingale worked to turn the terrible workhouse infirmaries into real hospitals, calling for the same quality of care available to the rich also for the poor.
• Hand washing is the single most effective means of infection control known–Nightingale began urging it in 1860. Hospital architects are turning back to Nightingale for her insights on sunlight and gardens in healing.
• Her writing is now available in a 16-volume Collected Works of Florence Nightingale, collected from more than 200 archives world wide.

Don’t want a 16-volume series? See the 200-page paperback with highlights: Lynn McDonald, Florence Nightingale at First Hand (London: Bloomsbury 2010) and Florence Nightingale, Nursing and Health Care Today (New York: Springer, 2018) 267 pages.

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by Lynn McDonald, 2021

Kofoworola Abeni Pratt (1915-92) was an outstanding nursing leader, well recognized for her work in her home country, Nigeria, but scarcely known in the United Kingdom, despite her significant British connections and international reputation. She was the first Black person to train at the Nightingale School, then based at St Thomas’ Hospital, London, starting in 1946. Then, when the National Health Service was launched in July, 1948, she was on duty—the first Black nurse in the NHS.

Her background and education

Née Kofoworola Abeni Scott, she was born into a privileged Lagos family, early converts to Christianity. She was given a good education in a Church Missionary Society girls’ school, after which she obtained a teaching certificate and taught History at the secondary level for five years. She wanted to become a nurse, but, like Nightingale, was prevented by her family, on account of the unseemly reputation of nurses. In the case of Nigeria, the higher posts were reserved for British expatriate women, with the menial tasks accorded to Nigerians (the practice of the Colonial Nursing Service).

In 1941, the then Miss Scott married a Nigerian pharmacist, Eugene Samuel Oluremi (Olu) Pratt, who shared her faith and strongly supported her aspiration to become a nurse. The couple were married in the Scotts’ and Pratts’ family church, the Cathedral Church of Christ, Lagos, where Mrs Pratt was active in cathedral governance and women’s organizations.

Olu Pratt made the introduction for his wife to the matron at St Thomas’ Hospital in 1946—he had gone to London ahead of her to apply for medical studies for himself. The matron accepted her, subject to the arrival of the required documents, which proved to be in order.

St Thomas’ had been bombed in the war, so that, on Mrs Pratt’s arrival in 1946, its departments were in temporary quarters in other parts of London. She, as well as doing the regular training, getting excellent marks, went on to obtain extra certificates in midwifery (and worked as a midwife), tropical diseases, the ward sister’s course, and, on a return trip, hospital nursing administration, these last two at the Royal College of Nursing. Pratt later won grants to enable her to travel to see nurse training in other countries. In the United States, she was impressed by training based at universities. She would later lead in the introduction of university-based training in Nigeria, achieved in 1965.

Professional nursing in Nigeria

Encouraged by British “Nightingale nurses,” Pratt returned to Nigeria in 1955 to become the first Nigerian ward sister, then, successively, the first Nigerian assistant matron, deputy matron, and, in 1964, matron, at the top hospital in Nigeria, University College Hospital, Ibadan. This transition from expatriate nurses, doctors, other professionals and administrators to Nigerians was called “Nigerianization”. It began with the approach of independence, which was gained in 1960.

After a mere two years as matron at UCH, Ibadan, although enough to demonstrate her ability as an administrator. Pratt took on a greater challenge, as chief nursing officer for the Federation of Nigeria, the first Nigerian in the post. Her domain became the whole country, the largest in Africa, sixth largest in the world. She led in the establishment of other nursing schools and did some of the training herself.

Throughout, Pratt was, unusually for the time, both a wife and mother, with two sons, one born in Nigeria and one while she was training in London. Her husband obtained British medical qualifications, to return to practise in Nigeria.

From nursing to political leadership in health care

Pratt, like Nightingale, saw the importance of political action in the achievement of healthcare reform. Thus, in 1973, when she was offered the post of “Commissioner of Health”—in practice, the Minister for Health for Lagos State, then under military rule—she accepted. During her time in office (only two years) she saw to the expansion of healthcare services, the building of more hospitals, and the equipping of boats to take healthcare services to villages best accessible by water. She made the provision of better conditions for nurses a priority, culminating in the building of a fine nurses’ residence, long delayed by previous governments, dubbed the “Nurses’ Hilton.” Pratt was the first nurse to become Minister of Health for her country or state.

She received many honours, was named “chief,” awarded the Order of the Federal Republic of Nigeria, an honorary doctorate of laws and the Florence Nightingale Medal; she was appointed a fellow both of the Royal College of Nursing and the West African College of Nursing. She died in Lagos in 1992, predeceased by her husband, Dr Olu Pratt, in 1985.

A biography of Pratt

An excellent biography was published about her, An African ‘Florence Nightingale’: a biography of Chief (Dr) Mrs Kofoworola Abeni Pratt. The author, Justus A. Akinsanya, was a distinguished Nigerian-born nursing academic, whose career was mainly in the U.K. Unluckily, the book soon became an “orphan book,” that is, the publisher went out of business and the author died. A PDF link is available on the website of the Nightingale Society. It is otherwise effectively unavailable.

Mrs K.A. Pratt: Role model

Mrs Pratt’s career makes her a fine role model not only for Black and minority ethnic nurses, but ALL nurses who aim high.

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Abstract

The year 2021, the year after Florence Nightingale’s bicentenary, named the Year of the Nurse and Midwife by the World Health Organization, seems a suitable time to assess her ongoing relevance to nursing and healthcare more broadly. Given that the same year was marked by the worldwide spread of the coronavirus pandemic, the question arises as to the utility of her use of research to bring down death rates, from the high death rates at the defective army hospitals of the Crimean War.

The year 2020 also saw much publication on Nightingale, highly favourable in the case of historians of statistics, hostile in the case of several prominent nursing leaders, including charges of racism. An anti-racist herself, Nightingale inspired the first black nurse in the National Health Service, Kofoworola Abeni Pratt, who went on to be the major leader in the introduction of professional nursing in her own country of Nigeria, and more widely in Africa. Reasons for the failure of today’s nurses to give due recognition to this Nigerian nursing leader are explored. Addressing charges of racism, examples from Nightingale’s own work are introduced to show flagrant inaccuracies in the accusations levelled, sometimes with evidence that she took a position to the contrary.

Published March 2021 in EC Nursing and Healthcare. To continue reading, please download the link below:

ECNH-03-00220.pdf

About the author

The author of this book was a distinguished Nigerian-born nurse and educator, Justus Akinbaya Akinsanya (1936-2005). In the late 1950s he went to England to study economics, but instead did nurse training, to qualify as a fever nurse at Abergele Chest Hospital in North Wales. He then did general nurse training at Crumpsall Hospital, Manchester. In 1967, he did courses in orthopaedic, dermatological and psychiatric nursing and qualified as a sister tutor (at the University of London), He did a BSc (hons), then a PhD at the Institute for Education, London.

Akinsanya held teaching positions at the Dorset Institute (now Bournemouth University) and East Anglia Polytechnic University, at the latter as reader, professor and head of head of Health Care and Social Work, to retire as professor emeritus in 1996.

He returned to Nigeria 1975-78, recruited by the Nursing Council of Nigeria, where he held several senior positions, up to acting registrar. He was lecturer at the Institute of Management and Technology, Enegu, 1976-77. He was made a fellow of the Royal College of Nursing, and authored or edited five other books on nursing.

He married in 1967, and was the father of three sons and a daughter.

Like his subject, K.A. Pratt, Akinsanya is credited with “firsts,” notably as the first black member of the English National Board for Nursing, Midwifery and Health Visiting , on which he served 1988-93. He is credited with coining the term “bio-nursing,” stressing the importance of biological science in nursing. His 1984 book, based on his doctoral thesis, was Knowledge of the Life Sciences as a Basis for Practice . He was made a fellow of the Royal College of Nursing in 1988.

Akinsanya said that he never experienced racism himself, but, as a researcher for the Commission on Racial Equality, he saw it in the NHS (Laurence Dopson, “Justus Akinsanya, Nurse-educationist and pioneer of bio-nursing,” The Independent (26 December 2005).

Research for the biography

Akinsanya, while in Nigeria with the Nursing Council, learned of the significance of Pratt’s work, began to collect material on her. He interviewed her extensively, plus her husband, two sons and numerous colleagues and friends. In the U.K., he conducted interviews with Pratt’s key mentors, the senior British nurses who fostered her through the transition process: Louise M. Bell, Irene Morrison, MBE and Margaret Smyth, CBE. He obtained a large number of interesting photographs, from family and friends, nurses and nursing students at various stages in Nigerian nursing. He dedicated the book to Dr Olu Pratt, by then Pratt’s late husband.

About this edition

Akinsanya’s An African ‘Florence Nightingale’: Chief (Dr) Mrs Kofoworola Abeni Pratt was published in 1987, solely as a print book, by Vantage Publishers, Ibadan. It became an “orphan book” on his death and his publisher going out of business. The Nightingale Society is pleased to make it available again in facsimile, exactly as it originally appeared. Readers are invited to send a copy to their own university or nursing faculty library, public library, or wherever it might seem appropriate.

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If you wish a complete scan of this volume, click here: An African ‘Florence Nightingale’
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Gallery

(Significance Magazine)

Written by Lynn McDonald on 30 April 2020

Florence Nightingale (1820–1910) was an early and persistent advocate of the best means to prevent the spread of infectious diseases – frequent handwashing – calling for it in her 1860 Notes on Nursing and adding details on the use of disinfectants in later writing. She was a pioneer of evidence-based health care, from the lessons learned from the high mortality rates of the Crimean War (1854–56). NHS England, in giving the name “Nightingale Hospital” to seven temporary hospitals for Covid-19 patients, is recognizing Nightingale’s relevance to combatting infectious diseases.

Note the parallels between the challenges she faced and the current pandemic:

• Nightingale’s Crimean War Barrack Hospital had 4,000 beds and was then, in 1854, the largest in the world. The newly created NHS Nightingale Hospitals in Birmingham and London’s Docklands may not be the largest in the world, but both have the capacity to house up to 4,000 patients.
• Like the infectious diseases of Nightingale’s day (fevers and bowel diseases), coronavirus has no vaccine or effective treatment. Health care workers help the patient through the crisis, now with respirators, but given the advances in medical sciences since Nightingale’s day, the prospects of a vaccine and/or effective treatment for Covid-19 are great.

One other parallel from then to now: London’s NHS Nightingale Hospital was officially opened by Prince Charles, “attending” remotely from his residence at Birk Hall, on the Balmoral estate in Scotland. Nightingale herself stayed at Birk Hall in 1856, when it was the home of Queen Victoria’s physician, Sir James Paget, a Nightingale ally. The Queen, Prince Albert and Nightingale together, at Balmoral, pressed Lord Panmure, the Secretary of State for War, for a study to be done of what went wrong in the Crimean War hospitals, where high death rates were common. This became Nightingale’s 853-page Notes on Matters Affecting the Health, Efficiency and Hospital Administration of the British Army, published in 1858.

In preparing this analysis, Nightingale and her team of experts learned the lessons of the Crimean War and went on to press, successfully, for higher standards in ventilation, cleanliness and clean water (through improved sewers and drains) in hospitals, barracks, towns and rural areas. The new standards worked: death rates declined.

Evidence of this success can be seen in the declines in the number of hospital beds the British Army needed. The vast army hospital that was built after the war, at Netley on the south coast of England, was over-built, its number of beds based on the usual pre-Crimea percentage. That hospital was not filled to capacity until the Boer War of 1899–1902, more than 30 years after it opened. Nightingale joked to her MP brother-in-law, Sir Harry Verney: “Really, it is not our fault if the number of sick has fallen so much that they can’t fill their hospitals.”

Nightingale was not only an expert herself in analysing statistical data, she could call on leading experts in public health (Dr John Sutherland), medical statistics (Dr William Farr), civil engineering (Robert Rawlinson) and military engineering (Douglas Galton). She typically sent her results to one or more of them, asking for a critique before publishing – this in the time before peer review. She could ask the right questions and bring in the most appropriate data to answer them, including cross-sectional comparisons (making the most relevant comparisons) and longitudinal data (to see what changes after causal factors are altered).

After the Crimean War, and learning its lessons, Nightingale began to call for systematic improvements in data collection, both for the military and general population. Then, as now, epidemics have to be identified and tracked without delay. Good weekly data on disease and death has to be produced, to become daily data as an epidemic appears.

Will the lessons of this coronavirus pandemic be learned? It happens that different countries/states have adopted different measures of prevention, from thorough lockdown to mere voluntary social distancing. The amount of testing done has also varied enormously, from substantial numbers to only the very worst cases. Thus, like it or not, the elements of an experiment are in place. We will soon see who achieves the best results, in terms of the lowest number of deaths per population.

This coronavirus pandemic is likely to carry on for some time, and/or return in later waves. We need medical experts to find an effective vaccine and methods of treatment. As well, especially while waiting for such developments, we need Nightingale-type research to assess the success (or not) of the various measures used to limit that spread.

by Lynn McDonald, for the Nightingale Society

Florence Nightingale (1820-1910) was an early and persistent advocate of the best means to prevent the spread of infectious diseases—frequent handwashing—calling for it in her 1860 Notes on Nursing, and adding details on the use of disinfectants in later writing. She was a pioneer of evidence-based health care, from the lessons learned from the high mortality rates of the Crimean War (1854-56).

The National Health Service, in giving the name “Nightingale Hospital” to five temporary hospitals for COVID-19 patients, is recognizing her relevance to combatting infectious diseases. Note the parallels:

1. Nightingale’s own Crimean War Barrack Hospital had 4000 beds in 1854 and was then the largest in the world. It had high death rates, which were brought down dramatically by the introduction of strict sanitary measures. She herself documented the decline in deaths in a comprehensive analysis after the war.
2. There are great similarities between the infectious diseases (fevers and bowel diseases) of Nightingale’s day and the coronavirus of ours: no vaccine or effective treatment for any of them. Health care workers help the patient through the crisis, now with respirators, and there is now (when available) better protective equipment for them. Given the advances in medical sciences since Nightingale’s day, however, the prospects of a vaccine and/or effective treatment for COVID-19 are great.
3. Nightingale and her team of experts learned the lessons of the Crimean War and went on to press, successfully, for higher standards in ventilation, cleanliness and clean water (through improved sewers and drains) in hospitals, barracks, towns and rural areas. The new standards worked–death rates declined.
4. Evidence of this success can be seen in the declines in the number of hospital beds the British Army needed. The vast army hospital that was built after the war, at Netley on the south coast of England, was over-built, its number of beds based on the usual pre-Crimea percentage. That hospital was not filled to capacity until the Boer War of 1899-1902, more than 30 years after it opened. Nightingale joked to her MP brother-in-law, Sir Harry Verney: “Really, it is not our fault if the number of sick has fallen so much that they can’t fill their hospitals.”
5. Collecting the necessary data. After the Crimean War, and learning its lessons, Nightingale began to call for systematic improvements in data collection, both for the military and general population. Epidemics have to be identified and tracked, without delay. Good weekly data on disease and death had to be produced, to become daily data as an epidemic appeared. Nightingale called for data on health status and housing (as a major determinant of disease) to be collected routinely as part of the Census.
6. One last parallel from then to now: the first NHS Nightingale Hospital (in London’s Docklands) was officially opened by Prince Charles, from his residence at Birk Hall, on the Balmoral estate in Scotland. Nightingale herself stayed at Birk Hall in 1856, when it was the home of Queen Victoria’s physician, Sir James Clark, a Nightingale ally. The Queen, Prince Albert and Nightingale together, at Balmoral, pressed Lord Panmure, the secretary of state for war, for a study to be done of what went wrong in the high death-rate Crimean War hospitals. This became Nightingale’s 853-page Notes on Matters Affecting the Health, Efficiency and Hospital Administration of the British Army¸ 1858.

Will the lessons of this coronavirus pandemic be learned? It happens that different countries/states have adopted different measures of prevention, from thorough lockdown to mere voluntary social distancing. The amount of testing done has also varied enormously from substantial numbers to only the worst cases. Thus, like it or not, the elements of an experiment are in place. What gets the best results– the lowest number of deaths per population?

This pandemic is likely to carry on for some time, and/or return in later waves. We need medical experts to find an effective vaccine and methods of treatment. As well, especially while waiting for such developments, we need Nightingale-type research, to assess the success (or not) of the various measures used to limit that spread.

by Lynn McDonald

Significance, Volume: 17, Issue: 2, Pages: 18-21, First published: 20 March 2020, DOI: (10.1111/1740-9713.01374)

Abstract

To many, Florence Nightingale is a hero. But like all heroes, elements of her story have been exaggerated. Lynn McDonald, editor of Nightingale’s collected works, sorts fact from fiction.

Florence Nightingale (1820–1910), the first woman Fellow of the Royal Statistical Society, elected in 1858, and an honorary member of the American Statistical Association from 1874, deserves all the attention she is getting in 2020, the bicentenary of her birth. At one time it became fashionable for some historians to deprecate her work. But statisticians and quantitative researchers in general have continued to revere her. She was, after all, a pioneer of evidence‐based health care.¹

Her contributions, however, have been exaggerated by such eminent statisticians as Edwin W. Kopf and I. Bernard Cohen, as well as by military and medical historians and other ordinary mortals. Kopf, for example, writing of Nightingale’s work as a nurse in military hospitals during the Crimean War (1854–6), stated correctly that “none of the statistical records were kept in uniform manner”, then added, incorrectly, that “she was able to introduce an orderly plan of recording the principal sickness and mortality data of the military hospital establishments which came within the sphere of her influence”.² Nightingale did not introduce any plan for recording hospital data – but her analysis of the data, post‐Crimea, using official War Office statistics, covered all the hospitals, not just those under her jurisdiction.

These exaggerations, no matter how minor, serve to embellish Nightingale’s story while making a muddle of her legacy. On the 200th anniversary of her birth, it is important to understand what Nightingale did and did not do, so that we might put her real contributions into better perspective.

What Nightingale did not do

To many statisticians, Nightingale will be best known for her Notes on Matters Affecting the Health, Efficiency, and Hospital Administration of the British Army and the striking diagrams within, such as Figure 1, showing the proportions of deaths from various causes during the Crimean War.³ But, contrary to belief, Nightingale never collected data on death rates in Crimean War hospitals, nor could she have. She had no mandate to do so, and no staff. This should be obvious, as the published data show death rates from April 1854 (when the British Army arrived in Turkey), while Nightingale and her nurses arrived only in November.

Also during the Crimean War, Nightingale did not save lives by bedside nursing or her famous walks with a lamp by night, much as they were appreciated by the soldiers. Nor did she ever claim to have. Bedside nursing, however dedicated, cannot overcome the faults of overcrowding, poor ventilation, polluted water and inadequate nutrition (many soldiers arrived with scurvy along with their bowel diseases, fever or wounds).

She also did not invent the chart type shown in Figure 1: often referred to as a polar area chart. But she and Dr William Farr, the leading medical statistician at the time, worked together to produce effective charts, better than any Farr had published before. These charts vividly showed how much “preventable deaths” were of the total, and then showed how the rates came down with the arrival of the British government’s Sanitary Commission in Crimea.

Nightingale probably did not do the mathematics or prepare charts such as these herself. Equations are included in her evidence to the Royal Commission on the Crimean War, and historians of statistics point out that she was instructed in mathematics by an expert, Joseph Sylvester. However, there is nothing in her own hand describing what she learned or how she used it, and the instruction lasted no more than 6 weeks, in April and May 1840. Letters sent to Farr following the Crimean War thank him and his staff for sending tables, and letters from Farr advise of material about to be sent.

It was through her work with Farr and others that Nightingale helped to save lives – if not in the way often supposed. She and her team (and she always worked with experts) arguably saved many more lives by what they learned from the Crimean War than what she and others did during the conflict.

Nightingale’s key contributions

Nightingale was an expert on asking the right questions, analysing data and writing it up persuasively. This was simple data analysis, columns and rows, well organised so that relevant comparisons could be made. For her studies of the Crimean War, she and her team paid attention to time, tracking hospital admissions and deaths month by month. At the time, standard statistical tests were not in use and regression analysis was still decades in the future, so the judgements they made were based on eyeball assessments.

This work was not easy, for there were conflicting sources of death data. Nightingale discussed the problem of discrepancies, noting the troubling fact that the number of burials, collected by the Adjutant‐General, was higher than the number of deaths in three different sets of data collected by army doctors.

In 1858, she published her Notes on Matters Affecting the Health, Efficiency, and Hospital Administration of the British Army,³ a comprehensive 853‐page report, while the Royal Commission published her much shorter evidence to it.⁴ In 1859, she published a very short paper, A Contribution to the Sanitary History of the British Army,⁵ which also contained the famous polar area charts. In the latter publication, she specified that certain tables were prepared by Farr and his office, working from “official documents” presented to Parliament – meaning the two‐volume Medical and Surgical History of the British Army, which was to become the official report of the Crimean War.⁶

But unlike this official report, Nightingale gets the story right about causal factors. The official report includes charts of deaths by barometric pressure and temperature, evidently considering them to be causes, and indeed death rates were higher in hotter months than in cooler ones. Nightingale’s polar area chart, by contrast, which shows the great decreases in death rates achieved, noted the arrival of the Sanitary Commission sent by the British government. This commission, and the Supply Commission that was also sent, were led by civilian experts who were given a mandate to act, not merely report. The leaders of the Sanitary Commission, Dr John Sutherland, a public health expert, and Robert Rawlinson, a civil engineer and water expert, acted vigorously. Their report included detailed amounts, measured variously by cartload or tonne, of “filth”, meaning faecal material, and dead horses removed from the water supply. No barometric pressures or temperatures were noted.

The official report gave no credit to either commission, both of which were sent out by the civilian government of Lord Palmerston, not the Army Medical Department or the War Office. Palmerston, who understood “sanitary science” – or “public health”, as it would later be called – was a neighbour of the Nightingale family in Hampshire, and would be an ally on post‐Crimea reforms.

Beyond Crimea

Nightingale’s great ally in the reforms made after Crimea was Sidney Herbert, the junior war minister at the outset of the war and the person who got her appointed to lead the nursing team (they were friends from meeting in Rome in 1848, when the Herberts were on honeymoon). He chaired the four sub‐commissions established to implement the major reforms recommended in the Royal Commission Report, and he and Nightingale worked together for five years after the war, until his death in 1861. Enormous changes were made in hospitals and barracks for the British Army, changes that brought down their death rates.

Nightingale’s compliment to her friend – his obituary, in effect – was a short paper published in 1863, titled Army Sanitary Administration, and Its Reform under the Late Lord Herbert.⁷ In it, she gave three bar charts that succinctly show Herbert’s success in saving lives (Figure 2). The first chart gives the baseline mortality of the English male population, followed by a chart each for army deaths for the years 1837–46 (before Herbert’s term in office) and 1859–61 (after his term), with dramatic decreases clearly visible.

After Crimea, Nightingale continued to apply her talents for asking questions and analysing data, including for a Royal Commission on India, reporting in 1863, and subsequently working with medical officers on their statistical reports to make them both more accurate and more useful.

In 1862 she wrote an unpublished “Note on the Supposed Protection Afforded against Venereal Disease, by Recognizing Prostitution and Putting It under Police Regulation”,⁸ which served as a refutation of police regulation of prostitution (compulsory inspection and treatment of women, never men) by showing that rates of venereal disease were no lower in army bases where such a system was in effect than in places where it was not.

For the 1863 publication Sanitary Statistics of Native Colonial Schools and Hospitals, Nightingale showed that death rates were roughly twice what they should be.⁹ She called for ongoing monitoring, which did not happen. (Incidentally, with this publication, Nightingale became the first person to reveal the defects of residential schools, which would become notorious later in Canada for their destruction of language and culture, and sexual and physical abuse.)

Then, when a midwifery programme and maternity ward at King’s College Hospital was closed on account of high death rates, Nightingale conducted a comprehensive analysis. Data collection was a great challenge, as there was then no routine recording of maternal deaths, and she was disappointed with what she managed to obtain from sympathetic doctors, including a workhouse doctor, and a small number of publications with comparative data from Europe. Still, her research in the report, Introductory Notes on Lying‐in Institutions, published in 1871, marks an enormous advance on the subject.¹⁰

Nightingale understood the importance of population data, but was unsuccessful in her attempt, in 1860, to get two new items added to the census form for 1861, on health status and housing – the latter being seen as a major cause of sickness (whether a person lived in a hovel, a stable or a mansion). She was turned down then, but housing questions were gradually brought into the census in later decades.

Late in life, Nightingale sought to obtain a university chair or readership in “social physics”, a term that originated from Belgian statistician Adolphe Quetelet in his major publications.¹¹ Quetelet was Nightingale’s main source on statistics and social science research more broadly. She knew his work well, commented on it in detail (as an exercise) and met him when he was in London for the International Statistical Congress in 1860. She regretted that his work was not used in the UK as it could be, although his major books had been translated into English. She chose Oxford University as the venue for her desired chair, as it was the university that trained the most senior civil servants and politicians – that is, the people who should be, but were not, using social data. Indeed, she complained that while governments collected vast amounts of statistics, much of it was stuck in ministers’ pigeon‐holes, “which means not at their disposal”.¹

Nightingale approached the eugenicist Francis Galton to be the intermediary with Oxford, but nothing came of it. The statistician Karl Pearson, in his Life, Letters and Labours of Francis Galton, judged that Galton had messed up and that Nightingale had had a very good idea. What she wanted was data to assess public policy – what works and what does not. Her examples were: the effects of the Education Act that established (compulsory) state schools, including its effect on crime (increasing or decreasing); results from secondary schools, night schools and workhouse schools; general effects of workhouses (children of workhouse inmates becoming inmates themselves); and, in India, the effect of British administration in making the people richer or poorer, their trade and handicrafts flourishing or perishing. This was a call for no less than evidence‐based public policy on a great range of concerns. But her call was not to be answered.

Conclusion

Nightingale’s research was geared towards saving lives, especially of soldiers, the sick poor, famine victims, indigenous peoples, birthing mothers and nurses – people who were not, by and large, priorities in public policy at the time. She not only worked relentlessly herself, but also developed a team of committed experts to pursue these issues. In the course of her work, she and they saw to improvements in the routine collection of data, its analysis and presentation.

Making results accessible – and persuasive – was always part of her mission. She failed in many of her particular endeavours, not because her ideas were poor, but because she was too far ahead of her time. What she did accomplish was formidable. Queen Victoria wished that Nightingale could run the War Office. I would have liked to see her in charge of climate change.

Endnotes

1. McDonald, L. (2001) Florence Nightingale and the early origins of evidence-based nursing. Evidence-Based Nursing, 4(3), 68–69.

2. Kopf, E. (1916) Florence Nightingale as statistician. Publications of the American Statistical Association, 15(116), 388–404.

3. Nightingale, F. (1858) Notes on Matters Affecting the Health, Efficiency, and Hospital Administration of the British Army. London: Harrison.

4. McDonald, L. (ed.) (2010) Florence Nightingale: The Crimean War. Waterloo, ON: Wilfrid Laurier University Press.

5. Nightingale, F. (1859) A Contribution to the Sanitary History of the British Army. London: John W. Parker and Son.

6. Great Britain, Army Medical Department (1858) Medical and Surgical History of the British Army which Served in Turkey and the Crimea during the War against Russia in the Years 1854-55-56. London: Harrison and Sons.

7. Nightingale, F. (1863) Army Sanitary Administration and its Reform under the late Lord Herbert. London: McCorquodale.

8. McDonald, L. (ed.) (2005) Florence Nightingale on Women, Medicine, Midwifery and Prostitution. Waterloo, ON: Wilfrid Laurier University Press.

9. Nightingale, F. (1863) Sanitary Statistics of Native Colonial Schools and Hospitals. London.

10. Nightingale, F. (1871) Introductory Notes on Lying-in Institutions. London: Longmans, Green, and Co.

11. Quetelet, L. A. J. (1869) Physique sociale, ou essai sur le développement des facultés de l’homme. Brussels: Muquardt.

by Lynn McDonald, for the Nightingale Society

The World Health Organization declared 2020 to be the “Year of the Nurse and Midwife” in honour of the Bicentenary of Florence Nightingale (born 1820), for her founding of the nursing profession and her work in health promotion, disease prevention, hospital safety and access to quality health care for all. As well as founding the first nursing school in the world, at St Thomas’ Hospital, her Fund paid for the creation of the first midwifery training programme, at King’s College, London.

Health, according to the WHO definition of on its founding in 1948 is “a state of complete physical, mental and social well-being.” It resembles Nightingale’s “to be able to use well all the powers one has.” But what did Nightingale do for the Commonwealth in particular?

Nursing: Nightingale nurses started professional nursing and founded nurse training schools in Australia, Canada and India. That is, her school sent out teams of matrons and nurses, and Nightingale herself mentored these early nursing leaders.

Hospital reform: Nightingale was a promoter of safer hospital design, through the pavilion model. She advised hospital architects in Canada and Australia on new buildings, to ensure the safest possible design for nurses as well as patients and doctors. She insisted on high standards of cleanliness and comfort in nurses’ residences, that in Sydney, New South Wales, was a world model.

Anti-racism: Since Nightingale’s grandfather worked with William Wilberforce for the abolition of slavery, she early learned liberal, inclusive principles, which guided her work. For further on her anti-racism see:
http://nightingalesociety.com/backgrounders/florence-nightingale-a-leading-anti-racist/

India: Nightingale worked vigorously, for decades, on sanitary reform in India, famine prevention and relief, medical aid for women, women’s rights (against the enforcement of child marriages). She wrote a campaign letter for the first Indian national, Dadabhai Naoroji, to become an MP. She supported the organizations and journals of Indian reform organizations, notably the East India Association, precursor of the Indian National Congress.

Aboriginal peoples: On becoming aware of declining numbers of aboriginal (Indigenous) peoples, Nightingale had a study conducted on disease and mortality in aboriginal schools and hospitals, in Australia, New Zealand, South Africa, Ceylon (Sri Lanka), and Canada. The data showed rates of death twice what they should be, but she was unable to persuade the Colonial Office to carry on the research. Her analysis got wide distribution in Australia, especially. She was the first person to document the high death rates in Canadian residential and day schools, an enormous issue today with the revelation of physical and sexual abuse and loss of language and culture. In 1880, she published a paper, “Woman Slavery in Natal” for the Aborigines’ Protection Society.

Nigeria: The first Nigerian trained nurse, Kofoworola Abeni Pratt (1915-92) wanted to train at the Nightingale School in London, as she admired Nightingale. She started training there in 1946 and passed with distinction, obtaining certificates as well in midwifery, tropical medicine and administration. When the National Health Service opened for service in 1948, Mrs Pratt was its first black nurse. On her return to Nigeria, she became the first Nigerian matron of a hospital, at University College Hospital, Ibadan (and led in its transfer to the University of Ibadan), the first chief nursing officer of Nigeria, the first commissioner for Health, Lagos, co-founder of the National Association of Trained Nurses, vice-president of the International Council of Nurses, winner of the Nightingale Medal, honorary fellow of the Royal College of Nursing, etc.

Action for Commonwealth nurses and midwives: Support recognition of Mrs “Rola” Pratt in the NHS as the first black nurse in the NHS. The Nightingale Society urges that an award be made in her name, to be presented annually. (See letter to the Secretary of State for Health at http://nightingalesociety.com/matt-hancock-2020-01.