A Beacon of Change
With political ties and fame supporting her post-war aims, Florence Nightingale became a prominent advocate for a new focus on hospital design, military health practices and public health (Second part in a two-part series)
The most influential period of Florence Nightingale’s career often has been her most overlooked. The Lady with the Lamp, who worked at correcting the horrific conditions at army hospitals near the front of the Crimean War, devoted her post-war years bringing changes to health care at home in England and abroad-raising the standards for both hospitals and for nursing.
Hospitals in Victorian England were no place for patients. Especially for those who were hoping to get well.
Operated strictly for indigent patients (the well-to-do received home-based care), hospitals were overcrowded and filthy lairs of disease and neglect where one in seven patients died. It was even worse for the larger metropolitan facilities in London, where statistics showed those with 300-plus beds were suffering one death per 2.4 patients-despite the prestige of employing the most well-respected medical staffs and physicians in the country, said medical historian Robert Martensen, MD, Ph.D.
“The term itself for people getting sick in hospitals was called ‘hospitalism’-this notion that the hospital, the building itself, would make one ill,” said Martensen, chair of humanities and ethics in medicine at Tulane University School of Public Health and Tropical Medicine in New Orleans.
The inevitability of rampant deaths in medical institutions was a soberly accepted fact in the 1840s and 1850s. This disturbing reality began to change only after it was smothered under a mountain of facts, data and new ideas from hygienic and sanitation activists-most notably Florence Nightingale.
An 1857 Royal Commission on sanitation, studying the high number of Crimean War deaths between 1854 and 1856, came to the conclusion that nearly 16,000 soldiers died needlessly from organizational mismanagement, neglect and unsanitary conditions at army hospitals. According to historians, the prime evidence was a ground-breaking report written by Nightingale herself, one that was filled with comparative numbers, statistical analysis and carefully drawn pie charts that rarely had been seen in a public policy document. “Our soldiers enlist to death in the barracks,” Nightingale concluded in her nearly 1,000-page report.
Scholars say her largely uncredited contribution to that commission (women could not serve on such public boards) was the starting point for foundational changes in military medical sanitation, training and data collection.
Her ideas also were adopted for civilian hospitals, according to researchers, and helped foment a surge in public health standards in England and across the globe, especially for the poor.
The legend
Nightingale returned from the Crimean War a hero, the “Lady with the Lamp,” who had saved and nurtured British soldiers near the frontlines of an unpopular war. The name was coined because she carried a lamp as she checked on sick soldiers during the night.
Had she done nothing else, her picture still would have adorned British currency a century later. But Nightingale’s incredible career had only begun, and her greatest accomplishments were yet to be established.
Each fall, incoming students at Tulane Medical School arrive in Martensen’s history of surgery class to learn from the deep repository of techniques, theories and practices collected during the past 500 years. Martensen, who has degrees from Harvard, Dartmouth and the University of California, San Francisco, takes them on a tour through the 16th century natural philosophists to the 19th century stewards who applied the scientific model to medicine.
In his eyes, an overview of the 1800s is incomplete without significant discussion of Nightingale.
“Her ideas were not original, but her genius lay in codifying things about hospitals and how they should and should not be run,” Martensen said. “She paid a lot of attention to hospital organization in her [book] Notes on Hospitals, going into elaborate detail on how hospitals needed to be organized in terms of their physical spaces, how they needed to be sited and so forth.
“What she added to that text [of knowledge] and reinforced later was the importance of nurse training,” Martensen said. And “her vision was always one that had as many moral and social ideas as it did medical ideas.”
The statistician
In the years before she worked in the Scutari British Army Barracks hospital in Turkey, Nightingale traveled extensively across Europe, visiting hospitals where she would study and absorb the medical practices of doctors, nurses and religious charity organizations in England and other countries.
For 13 years, Nightingale visited every hospital in London and Paris, as well as military and civilian hospitals in Germany, France, Greece and Italy, according to a 1950 biography of Nightingale by Cecil Woodham-Smith. Her love of mathematics and statistics fueled her relentless analysis of numbers and rates that would yield trends and causal factors. The impact of her use of graphics to chart the deaths of soldiers in army barracks cannot be understated, said Nightingale scholar Deva Marie-Beck, Ph.D., RN. Nightingale knew the “old coots in parliament will understand pretty pictures. They won’t read the reports.”
Nightingale’s mathematical work was so impressive that she was granted membership in the Statistical Society of London in 1858.
In Notes on Hospitals, Nightingale used her numbers to rail against patient overcrowding, poor nutrition for patients and the spread of fungus and vermin. She used comparative data between English and the more advanced practices of some French hospitals to differentiate mortality rates, according to Lois Monteiro, a Nightingale researcher and professor of community health and sociology at Brown University in Providence, R.I.
She also saw the numerical shortcomings of hospital administrations. Until 1859, hospitals did not have uniform systems for diagnosing or even naming diseases, and kept no data on ages, addresses or gender with illnesses and injuries. After Nightingale drafted model hospital statistical forms, 13 London-area hospitals adopted them, according to Woodham-Smith.
The designer
For Nightingale, architectural problems in hospitals were another hot-button issue. She recommended a new “pavilion” design, gleaned from her travels abroad and her military experience. In this design, patients would be segregated into smaller rooms instead of lined side by side in cavernous, open areas. Nightingale wrote that patient areas should be well-lit and have proper ventilation to keep away odors and noise from the operating rooms, kitchens and cleaning operations.
“One contribution she made to hospital design that isn’t often talked about … is placing the nursing station so the nurse was in sight of all the patients,” Martensen said.
These were all theories and ideas she was able to put into practice when she consulted in the 1860 construction of a new St. Thomas’ Hospital in London.
Nightingale had the ear of so many hospital administrators because she was among the few people who had any breadth of experience in international health practices. Fluency in five languages allowed her to read hospital reports and policy manuals in their native languages. She saw firsthand the burgeoning movements of nonsecular training of lay women to work in hospitals, rather than relying solely on devoted nuns and sisters, according to Marie-Beck. Nightingale discovered the unique sanitation and health problems of places like India, and she spent much of her later life working to cure these problems.
“She was able to look at health at the community level, the regional level, the national level and the global level” from the earliest moments of her career, said Marie-Beck, co-author of a forthcoming book on Nightingale.
The pioneer
At the root of Nightingale’s drive to change health care-which she accomplished as a near invalid confined to her home because of a long-term, acute illness-was her well-documented pursuit of raising the professional standards of nursing.
Her Crimean War experience helped prove to a doubting public that women could be useful near the frontlines of a battle. She was now intent on making nursing on the home front a valuable addition to her ideal model, according to historians.
In 1860, through money raised in a foundation named in her honor, Nightin-gale established a training school at St. Thomas’ Hospital. Even with the money and her popularity, several social obstacles stood in her way. Catholic charities, the predominant provider of care and assistance to Europe’s poor, were almost nonexistent in Protestant England, according to Marie-Beck, as were career options for poor women.
Many doctors thought they couldn’t be trained-that nursing care skills came only through experience. Many felt nursing was just fine as it was, and others feared that trained nurses would end up interfering with doctors, according to medical historians.
Nightingale did not envision nurses on par with doctors or practicing medicine in their own right. What she believed nurses could contribute was being the source of health promotion and prevention.
“Nursing was simply one part of a whole approach to public health care” imagined by Nightingale, said Lynn McDonald, Ph.D., a Canadian university professor of sociology and a prominent Nightingale researcher.
The educator
That led Nightingale to her best-selling Notes on Nursing in 1860, which, contrary to popular belief, was not a professional nursing textbook. Notes on Nursing was instead one of the first “how-to” health books for the general public. Besides hygiene and treatments for illness, the book included chapters on patients’ mental needs for distraction (pets, flowers and window views) and conversation.
“Notes on Nursing was for the people nursing their families at home,” said Marie-Beck. In her research on Nightingale history, Marie-Beck said she has found more than 400 references to the book in doctoral research materials.
Throughout the 1850s and 1860s, Nightingale was the most famous woman in England next to Queen Victoria. She wrote thousands of letters to members of Parliament, she oversaw and mentored the graduates of her training school and even caught the attention of the Union Army of the United States on recommendations for organizing its troops during the Civil War.
But according to Monteiro and other Nightingale scholars, her political influence waned in the 1870s, when many of her projects and ideas were starting to mature. Also, key colleagues had passed away (including her close friend and reformist ally, former war secretary Sidney Herbert). Some debate whether she was opposed to the suffragist movement. Monteiro and others believe she was not necessarily against the suffragists, but instead busy with her public health causes. There is also debate about how much she opposed the registration and licensing of nurses. “She didn’t like the idea of unions, of tradesmen,” in nursing, Monteiro said. “She wanted it to be a calling.”
Nightingale also was definitively behind the times when the germ theory of disease began to gain acceptance in the 1870s.
Many prominent health experts of that era, including Nightingale, had trouble accepting the idea that diseases were the result of the arbitrary spread of tiny, bacterial agents. She didn’t trust such a hypothetical assertion when her own experience convinced her that a unified infectious disease model of hygiene, clean atmosphere and even ethical behavior played a prominent role in illness prevention.
“She thought [germ theorists] had nothing to add to the argument,” Martensen said. “In fact, they undermined her argument-it introduced an element of randomness. It didn’t stress the relationship of moral space and social space and those elements of hygiene as much.”
Germ theory proved to be the foundation of modern therapeutics and vaccines that ultimately contained perennial scourges like leprosy, tuberculosis and smallpox. But Nightingale was not entirely wrong in being slow to adopt it, scholars insist. Absent the miraculous cures that would not come for decades, her promotion of sanitary practices-cleanliness, proper nutrition, adequate ventilation and space-since the 1850s had done much to end the propagation of major diseases and cut hospital mortality rates.
“To give her credit, look at overall decline in mortality rates from infectious disease in her time,” Martensen said. “The mortality rate of tuberculosis from 1830 to 1940 … in Europe and Germany went down 90 percent. That’s before the advent of an effective antibiotic.”
Nightingale’s controversial views opposing the germ theory or women serving as physicians exemplifies why understanding the entirety of her life can be thorny, say researchers. It can be difficult to pin down the essential Nightingale from a woman who, over the course of 90 years, changed her mind and learned new ideas through experience and evolving thought. She made the historians’ jobs particularly difficult by leaving behind a trail of 200 books and reports and more than 14,000 handwritten letters.
“It’s like picking a scripture out of the Bible, out of context,” said Linda Freeman, DSN, RN, a professor of nursing at the University of Louisville (Ky.). “You can quote her, and someone will have a quote [from Nightingale] in opposition to that.”
“She was ahead of her time in some ways and behind the times in some other areas,” Monteiro said.
The mystery
Researchers have been long resigned to the fact that Nightingale’s career remains unknown to most nurses. Of the two most often cited biographies on Nightingale-by Edward Cook and Woodham-Smith-Monteiro said she’s never met a nurse who has read either one. Nursing’s continuing unawareness of Nightingale, Marie-Beck said, is the result of the industry’s nearly exclusive focus on individual health and treatment, rather than community health and promotion.
“Because we focus our lens down to the narrowest aperture … we’ve lost our ability to see what she did as a nursing discipline,” Marie-Beck said. “That’s why we’ve lost sight of the larger Nightingale. We’ve lost our ability to look across the continuum, to look across the community.”
Some researchers today are looking to bring fresh light to the Nightingale legacy. They say they are trying to go beyond the myths or mean-spirited caricatures that fail to account for her humanity.
McDonald leads a team of Nightingale researchers who are in the midst of publishing a multivolume set of Nightingale’s entire record of correspondence. McDonald said too many historians and researchers are depending on secondary resources to investigate Nightingale, rather than her own words and deeds. Two recent books about Nightingale, by authors Barbara Montgomery Dossey and Hugh Smalls, take on some of the revisionist backlash against Nightingale, especially those who paint her as a shrewd, ego-driven opportunist or even a mythic fraud.
Dossey and Marie-Beck also are teaming up to write a book about what Nightingale still can teach nursing: Florence Nightingale-Blueprint for 21st Century Health Care.
What would Nightingale think of nursing and health care today? Marie-Beck believes she would have disliked the development of a business model in medicine. But she would have loved to see the expanding professionalism of nursing and the central role that nurses play in the health care model.
“I think she would be impressed with what we’ve accomplished,” Marie-Beck said. “Nurses are right-brained and left-brained, and they bring that emotional concern for the patient. They care for that mental piece of the disease process when they talk to patients and address the families that need spiritual help.
“Nightingale would be very excited.”
