What would Florence Nightingale say? (British Journal of Nursing)

By Lynn McDonald. In British Journal of Nursing, 2013, Vol 22, No 9, p.542

Florence Nightingale needs to be rediscovered and revisited for her vision and early development of professional nursing. It is now more than 100 years since her death (in 1910) and more than 150 years since the founding of her school at St Thomas’ Hospital (in 1860). She stopped being an icon for nurses many years ago, and few nurses now know what she actually stood for—a lot more than she said in her Notes on Nursing (Nightingale, 1860).

Nurses were understandably turned off by the concerted series of attacks on her work that began in 1982 with the publication of F.B. Smith’s Florence Nightingale: Reputation and power. The latest is Theodore Dalrymple’s ‘Bringing Nightingale down to size’ in the British Medical Journal (Dalrymple, 2012). However, the article only mirrors Smith’s unfounded accusations, which have been refuted numerous times during the intervening 30 years. While nurses have been virtually silent on these attacks, and some jumped on the bandwagon, I defend Nightingale, for I have actually read all of her work, and the letters written to her, as editor of the Collected Works of Florence Nightingale.

Nightingale’s contribution to nursing began with the founding of her school, which sent out teams of trained matrons and nurses throughout Britain and the world. This work raised nursing from its unsavoury past as a poor-paying job, with benefits from bribes and the patients’ gin, to a new profession, with ethical standards and (increasingly rigorous) skill requirements.

Contrary to much (erroneous) opinion, Nightingale did not oppose germ theory to her dying days, but in time accepted it, as doctors, too, gradually did. Her school taught a rudimentary version of germ theory as early as 1872 and was the first nursing school to do so.

Nightingale worked with doctors, architects and engineers, in effect a multidisciplinary team, which deferred to her for her vision, and she to them for their technical expertise. She pioneered what is today known as ‘evidence-based health care.’

She was a pioneer also in demanding better working and living conditions for nurses, through labour-saving devices, adequate time off, holidays and opportunities for advancement. She urged the careful monitoring of nurse mortality rates, and published her own study as early as 1858.

Few nurses today understand how young their profession is. While the roots of medicine go back to the 5th century BCE, nursing as patient care scarcely existed pre-Nightingale. Earlier so-called ‘nurses’ were largely hospital cleaners; few gave any patient care, and none were formally trained to do so. Of course nuns served devotedly as nurses; Roman Catholic nuns centuries before Nightingale. However, this did not create a profession.

Nightingale’s mentoring of nurses is another little known area. It was not enough to place matrons in hospitals; they needed ongoing advice and help when subjected to investigations and threatened dismissals, as many of them were.

Perhaps Nightingale’s greatest contribution was the introduction of trained nurses to the dreaded workhouse infirmaries, where the only nurses were women inmates wanting money for drink. In 1864 she argued that there was no reason why the nursing in these places could not be as good as it was in the best civil hospitals. With dedicated colleagues, the experiment began in Liverpool in 1865, and spread gradually throughout the UK. Equal quality of care became a goal of the National Health Service in 1948, and nurses today might ponder on whether her vision has become a reality.

Nightingale’s compassion for the sick might be another timely reminder for today’s nurses when examples of gross lapses in care hit the media. The hospital exists for the patient, not the patient for the hospital (or nurse), she said. Patients should get the best rooms in hospital. They need fresh air, light, variety, nourishing food and peace and quiet to heal. She recognised that nurses require moral qualities as well as practical skills: tact, respect for privacy, sensitivity and kindness. A nurse must above all be able to make the patient comfortable so that nature can do its job of healing, she said. Has the patient changed so much since?

On palliative care, Nightingale often went the extra mile. Her letters to the families of patients who had died, recounting their last days and hours, are remarkable for their ability to evoke the person that was and give comfort to those who mourned them.

Did Nightingale always get it right? No, but when she did not she learned. The warts are few, and when she was at her toughest you can be sure she was defending those unable to speak for themselves. The record of what she envisioned and accomplished is remarkable. It is available in her own words, well chosen, often witty and amazingly kind, however old-fashioned that might appear today.

This comment is published for International Nurses Day, celebrated on Nightingale’s birthday, 12 May. However, the message is that she should not be remembered only then. If her views on adequate patient care had been respected, would the unnecessary deaths at Stafford Hospital have occurred? If her principles on monitoring results had been heeded, would not the consequences of cutting nursing staff have been found out faster and the cuts been reversed? It was a mistake, in my view, to drop Nightingale’s nursing principles from the training of nurses. Her basic principles on health and health care should be re-introduced, and her brilliant work on the role of research in health care and the formulation of policy should be brought into graduate education for senior nurses, midwives and public health experts.

Lynn McDonald is the director of the 16-volume Collected Works of Florence Nightingale (see http://www.uoguelph.ca/~cwfn) and author of Florence Nightingale at First Hand (2010; Continuum)

Nightingale F (1860) Notes on Nursing. D. Appleton and Company, New York

Dalrymple T (2012) Bringing Nightingale down to size. BMJ 344: e2317