Florence Nightingale

Florence Nightingale

Florence Nightingale (12 May 1820 – 13 August 1910), known as The Lady with the Lamp, was a founder of modern nursing. In changing the bedside care of the sick from an occupation of only marginal repute into a respected profession, Nightingale applied both a mathematician's logic and a deaconess' concept of duty. Her insistence on hygiene and sanitation, through the application of principals of biology, helped make the nursing profession into one of the health sciences. She was also a noted statistician, travel writer, and founding contributor to the field of public health.

Early life

Born into a wealthy, socially-connected British family while they sojourned in Florence, Italy, she was named after the city of her birth. In that, she followed her older sister Parthenope, who'd received the Greek name for the city of Naples. Her parents, William Edward Nightingale and Frances Nightingale, socialites who traveled extensively, clearly had a sense of whimsy, at least insofar as their children's names was concerned. At the time of Nightingale's birth, Florence was no more common a girl's first name than was Parthenope. That change is another that can be ascribed to her life's influence.

As a child, Florence Nightingale received the standard education of a wealthy British girl of her time: languages, drawing, music, dance and other fashionable humanities. She showed her unusual interests even as a child, demanding formal study in mathematics. Appalled at such a request, her mother refused it.

Inspired by what she understood to be a divine calling, experienced first in 1837 at Embley Park and later throughout her life, Nightingale made a commitment to assuage human suffering through the care of the sick. Her decision was viewed as outright rebellion by her family, who were committed to living socially acceptable lives as members of the British upper class. In those days, nursing was a career with a poor reputation, filled mostly by women who were not only financially needy, but of questionable moral purity, including female "hangers-on" who followed the armies. While on duty, nurses were equally likely to function as cooks as to provide supportive care to the sick and wounded. Upper class ladies of nineteenth-century England did not perform the work of servants, most especially if that work entailed exposure to unclothed men and the lady was an unmarried one.

Nightingale's diaries and essays show that she was extremely concerned with being a good person. This desire to do right created an enormous conflict for her, she felt she had a sacred duty to help ease human suffering, yet she knew she had a duty to obey her parents' wishes and to bring them pride rather than shame.

Nightingale was shocked by the dismal quality of medical care for poor and indigent people. In December 1844, in response to a pauper's death in a workhouse infirmary in London that had become a public scandal, she publicly advocated improved medical care in the infirmaries and immediately engaged the support of Charles Villiers, then president of the Poor Law Board. This led to a leading role in the reform of the Poor Laws. It was also in 1844 that Nightingale would first announce her decision to enter nursing, evoking intense anger and distress from her family, particularly her mother.

Florence Nightingale was courted by politician and poet Richard Monckton Milnes, 1st Baron Houghton, but she rejected him, convinced that marriage would interfere with her ability to follow her calling to nursing.

Rather than allow their daughter to begin nursing, her parents deflected her plans with a series of European tours. So Nightingale travelled, occupying herself with writing. In 1846, she managed to visit Kaiserswerth, Germany, and to learn more of the model hospital there first-hand. Kaiserswerth was established by Theodor Fliedner and managed by an order of Lutheran deaconesses, its high standards were revolutionary for a public facility of that time. She was profoundly impressed by the quality of care and by the commitment and practices of the deaconesses.

A year later, in 1847, she suffered a nervous breakdown from the continued strain of trying to please her family despite her calling to an occupation that was generally perceived as not only unladylike but actually dirty and dangerous. In a last attempt to distract her from her persistent resolve to engage in bedside nursing, her parents sent her off to Rome. "There, Nightingale wrote the letters later published as Florence Nightingale in Rome (1981), in which she begins to develop the "religious and philosophical views that would guide her life".

While in Rome she met Sidney Herbert, a politician who had been Secretary at War (1845 – 1846), a position he would hold again (1852 – 1854) during the Crimean War. Herbert was already married, but he and Nightingale were immediately attracted to each other and they became life-long close friends. Herbert was instrumental in facilitating her later work in Crimea, and she became a key advisor to him in his political career. In 1851 she rejected Milnes' marriage proposal, against her mother's wishes.

Nightingale's career in nursing began in earnest in 1851 when she received four months' training in Germany as a deaconess of Kaiserswerth. She undertook the training over strenuous family objections concerning the risks and social implications of such activity, and the Roman Catholic (rather than Protestant) foundations of the hospital. While at Kaiserswerth, she reported having the most intense and compelling experience of her divine calling.

On August 12, 1853, Nightingale took a 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 £300,000 in present terms) that allowed her to live comfortably and to pursue her career.

Crimean War

A depiction of Nightingale at Scutari, Istanbul, 1854.

Nightingale's most famous contribution came during the Crimean War, which became her central focus when reports began to filter back to Britain about the horrific conditions for the wounded. On October 21, 1854, she and a staff of thirty-eight female volunteer nurses, trained by Nightingale and including her aunt Mai Smith, were sent (under the authorization of Sidney Herbert) to Turkey, some 545 km across the Black Sea from Balaklava in the Crimea, where the main British camp was based.

Nightingale arrived early in November 1854 in Scutari (modern-day Üsküdar in Istanbul). She and her nurses found wounded soldiers being badly cared for 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.

Nightingale and her compatriots began by thoroughly cleaning the hospital and equipment and reorganizing patient care. However, during her time at Scutari, the death rate did not drop. On the contrary, it began to rise. The death count would be highest of all other hospitals in the region. During her first winter at Scutari, 4077 soldiers died there. Ten times more soldiers died from illnesses such as typhus, typhoid, cholera and dysentery than from battle wounds. Conditions at the hospital were so fatal to the patients because of overcrowding and the hospital's defective sewers and lack of ventilation. A sanitary commission had to be sent out by the British government to Scutari in March 1855, almost six months after Nightingale had arrived, which flushed out the sewers and improved ventilation. Death rates were sharply reduced thereafter.

Nightingale continued believing the death rates were due to poor nutrition and supplies and overworking of the soldiers. It was not until after she returned to Britain and began collecting evidence before the Royal Commission on the Health of the Army, that she came to believe that most of the soldiers at the hospital were killed by poor living conditions. This experience would influence her later career, when she advocated sanitary living conditions as of great importance. Consequently, she reduced deaths in the Army during peacetime and turned her attention to the sanitary design of hospitals.

Return home

Nightingale returned to Britain a heroine on August 7, 1857, and, according to the BBC, was arguably the most famous Victorian after Queen Victoria herself. Nightingale moved from her family home in Middle Claydon, Buckinghamshire to the Burlington Hotel in Piccadilly. However, she was stricken by a fever, in part a delayed response to the stress of her work in the Crimean War and her bout with Crimean fever. She barred her mother and sister from her room and rarely left it. It has been suggested that she may have suffered from bipolar disorder.

In response to an invitation from Queen Victoria – and despite the limitations of confinement to her room – Nightingale played the central role in the establishment of the Royal Commission on the Health of the Army, of which Sidney Herbert became chairman. As a woman, Nightingale could not be appointed to the Royal Commission, but she wrote the Commission's 1,000-plus page report that included detailed statistical reports, and she was instrumental in the implementation of its recommendations. The report of the Royal Commission led to a major overhaul of army military care, and to the establishment of an Army medical School and of a comprehensive system of army medical records.

It has also been suggested that Nightingale may have used her relationship with Queen Victoria to repress suggestions that Mary Seacole, another nurse working to treat the injured, should be honoured for her work, although this has been contested by Mark Bostridge in a review of The Collected Works of Florence Nightingale published in the Times Literary Supplement (18 Nov. 2005, p. 6). Seacole was, unlike Nightingale, actually based in the Crimea at Spring Hill, near Kadikoi, between Balaclava and Sevastopol.

Later career

While she was still in Turkey, on November 29 1855, a public meeting to give recognition to Florence Nightingale for her work in the war led to the establishment of the Nightingale Fund for the training of nurses. There was an outpouring of generous donations. Sidney Herbert served as the honorary secretary of the fund, and the Duke of Cambridge was chairman. Nightingale was also considered a pioneer in the concept of "medical tourism" as well, based on her letters from 1856 in which she would write to spas in Turkey detailing the health conditions, physical descriptions, dietary information, and other vitally important details of patients whom she directed to those spas,which were significantly less expensive than spas in Switzerland. She was obviously directing patients of meagre means to affordable treatment.

By 1859 Nightingale had £45,000 at her disposal from the Nightingale Fund to set up the Nightingale Training School at St. Thomas' Hospital on July 9 1860. It is now called the Florence Nightingale School of Nursing and Midwifery and is part of King's College London. The first trained Nightingale nurses began work on May 16 at the Liverpool Workhouse Infirmary. She also campaigned and raised funds for the Royal Buckinghamshire Hospital in Aylesbury, near her family home.

Nightingale wrote Notes on Nursing, which was published in 1860, a slim 136-page book that served as the cornerstone of the curriculum at the Nightingale School and other nursing schools established. Notes on Nursing also sold well to the general reading public and is considered a classic introduction to nursing. Nightingale would spend the rest of her life promoting the establishment and development of the nursing profession and organizing it into its modern form.

During her bedridden years, she also made pioneering work in the field of hospital planning, and her work propagated quickly across England and the world.

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. Although her ideas met official resistance, they inspired the volunteer body of United States Sanitary Commission.

In 1869 Nightingale and Elizabeth Blackwell opened the Women's Medical College.

By 1882 Nightingale nurses had a growing and influential presence in the embryonic nursing profession. Some 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 the United Kingdom, e.g. Royal Victoria Hospital, Netley; Edinburgh Royal Infirmary; Cumberland Infirmary; and Liverpool Royal Infirmary; and Sydney Hospital, in New South Wales, Australia.

In 1883 Nightingale was awarded the Royal Red Cross by Queen Victoria. In 1907 she became the first woman to be awarded the Order of Merit. In 1908 she was given the Honorary Freedom of the City of London.

Beginning in 1896 Florence Nightingale was not able to leave her bed. She is believed to have had what is now known as chronic fatigue syndrome (CFS) and her birthday is now celebrated as the international CFS awareness day. She died at age 90, on August 13, 1910. The offer of burial in Westminster Abbey was declined by her relatives; she is buried in the graveyard at St. Margaret Church in East Wellow, England.

Contributions to statistics

Florence Nightingale exhibited a gift for mathematics from an early age and excelled in the subject under the tutorship of her father. She had a special interest in statistics, a field in which her father was an expert, and had taught her in childhood. Keeping track of mortality and morbidity in the patients under her care, she analysed the results and applied them to plans for changes in hospital architecture, sanitation, and nursing care. This work was a pioneering contribution to the nascent field of epidemiology. Throughout her professional career, she made extensive use of statistical analysis in the compilation, analysis and presentation of statistics on medical care and public health.

During the Crimean War, Nightingale invented a diagram she called the coxcomb or polar area chart—equivalent to a modern circular histogram or rose diagram —to illustrate seasonal sources of patient mortality in the military field hospital she managed. These were essentially the first contributions to circular statistics. She made extensive use of the coxcomb to present reports on the nature and magnitude of the conditions of medical care in the Crimean War to Members of Parliament and civil servants who would have been unlikely to read or understand traditional statistical reports. As such, she was a pioneer in the visual presentation of information, also called information graphics, and has earned high respect in the field of information ecology. In her later life Nightingale made a comprehensive statistical study of sanitation in Indian rural life and was the leading figure in the introduction of improved medical care and public health service in India.

In 1858 Nightingale was elected the first female member of the Royal Statistical Society and she later became an honorary member of the American Statistical Association.

Contributions to nursing practice

Nightingale was acutely aware that much of disability and deleterious effects of severe illness came not from the primary disease process, or initial injury, but from the effects of being bedridden, and from being confined in unsanitary conditions.

Legacy and memory

Florence Nightingale's lasting contribution has been her role in founding the nursing profession. She set a shining example for nurses everywhere of compassion, commitment to patient care, and diligent and thoughtful hospital administration.

In many ways she was extremely 'modern' in her attitude to health management - especially in her attitude to outcomes and statistical measurement.

The work of the Nightingale School of Nursing continues today. There is a Florence Nightingale Museum in London and another museum devoted to her at her family home, Claydon House. International Nurses Day is celebrated on her birthday each year.

Three hospitals in Istanbul are named after Nightingale: F. N. Hastanesi in Şişli, (the biggest private hospital in Turkey), Metropolitan F.N. Hastanesi in Gayrettepe, and Avrupa F.N. Hastanesi in Mecidiyeköy, all belonging to the Turkish Cardiology Foundation.

During the Vietnam War, Nightingale inspired many US Army nurses, sparking a renewal of interest in her life and work. Her admirers include Country Joe of Country Joe and the Fish, who has assembled an extensive web site in her honour.

The Agostino Gemelli Medical Centre in Rome, the first university-based hospital in Italy and one of its most respected medical centres, honoured Nightingale's contribution to the nursing profession by giving the name "Bedside Florence" to a wireless computer system it has developed to assist nursing.

Many foundations are named after Florence Nightingale. Most are nursing foundations, but there is also Nightingale Research Foundation in Canada, dedicated to the study and treatment of chronic fatigue syndrome, which Nightingale is believed to have had.