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TRANSCRIPT
ARTICLE
A COMPREHENSIVE BIOGRAPHY OF FLORENCE NIGHTINGALE
“ THE LADY WITH THE LAMP ”
Nursing has never been simple. Early care stressors included exposure to
the elements and a lack of knowledge as to how to treat serious injuries or
diseases. Through ensuing generations, environmental conditions have
improved and science has provided effective treatment pathways. However,
other complexities, including societal acceptance of the profession, gender
discrimination, and educational and regulatory disarray, have created a
multifaceted and complicated backdrop against which nurses continue to
provide the most basic of human interventions: caring.
In the nineteenth century, one woman, because of her religious
convictions and profound vision of the potential of nursing, altered the status of
nursing from that of domestic service to that of a profession and the strength of
her own person to create a permanent professional transformation One of the
most effective tools that she employed was advocacy, both for individuals and
for the nursing collective. The purpose of this article is to explore Nightingale’s
use of advocacy as a tool and to identify the continuing value of her conceptual
and practical advocacy strategies for the nursing profession in the 21stcentury.
WHO WAS FLORENCE NIGHTINGALE?
On May 12, 1820, Florence Nightingale was born as the second of two
daughters to English parents. As a young woman, she displayed exceptional
intellect, learning multiple languages and being particularly capable in
mathematics. Nightingale seemed to be most comfortable in the solitary
activities of reading, writing in her journals, and attempting to discern purpose
in her life. She deeply believed that she had a God-given purpose to better
mankind, but the route to achieving this goal was unclear
As a young woman, Nightingale wished for meaningful work and began to
imagine herself caring for others, defying her parents’ desire that she marry into
a socially prominent family. On at least three occasions she declined proposals,
indicating that she could not pursue her own goals as a married woman .By the
age of 17 she had discerned that she had a Christian duty to serve humankind.
By the age of 25 she had identified nursing as the means to fulfil this mandate .
When she was 30 years old, she was permitted two brief periods of instruction
in nursing at Kasiserswerth, a Protestant institution in Germany . This
experience helped her to understand the essential components of basic nursing,
hospital design, and personnel administration. Of even greater consequence was
Nightingale’s perception that formalized education was a necessary component
of nurse preparation .
In 1852 Nightingale was offered the superintendency of a small hospital on
Harley Street in central London . During her twelve months in this position, she
developed effective administrative skills, identified appropriate qualifications
for those employed as nurses, and affirmed her belief that egalitarian and
competent care were basic human rights for all people .As Nightingale was
preparing to leave the Harley Street position, she was appointed by the
Victorian government to lead a group of thirty-eight women to Ottoman,
Turkey, to provide nursing care for British soldiers fighting the Crimean
War .Nightingale’s singular motivation was to improve the light of the
wounded. She stated, “...I did not think of going to give myself a position, but
for the sake of common humanity” .Her administrative skills allowed her to
negotiate the male worlds of both the military and medicine. She successfully
solved the issues of supply purveyance, resolved interpersonal squabbles
between nursing factions, and designed care modalities in the face of massive
overcrowding, incompetence, uncaring physicians, and a military structure that
was outdated and inept. In a letter to her uncle, Nightingale stated that the
Purveyor had intentionally withheld supplies for his own gain, noting, “This
little Fitzgerald [Purveyor] has starved every hospital when his store was full- &
not, as it appears from ignorance, like some of the honourable men who have
been our murderers, but from malice presence.”
On her return from the Crimea, Nightingale worked tirelessly to develop
nursing as an essential and educated component of healthcare. Her
establishment of the Nightingale School in London in 1860, and the distribution
of trained nurses abroad established the basis for nursing education worldwide.
Through the support of Queen Victoria and Prince Albert she was able to design
improvements for the British military and establish public health standards in
India. Additionally, her lifetime of work and her passion for improving
healthcare provided nursing with a foundational philosophy .
Nightingale remained actively concerned with the development and
behaviour of the Nightingale nurses educated at the Nightingale School until her
death in 1910 at age 90. Between 1872 and 1900, she wrote a series of thirteen
letters to the Nightingale nurses that both documented the progress nursing
made in the late nineteenth century and warned nurses that they must remain
current, competent, and caring. In 1897, she wrote of the danger of relying on
words over actions:
“There is no doubt that this is a critical time for nursing... ...There is a curious
old legend that the nineteenth century is to be the age for women and has it not
been so? Shall the twentieth century be the age for words? God forbid.” .
ADVOCACY IN NURSING
Advocacy has been defined as an active process of supporting a cause or position However, advocacy has not always been a clear expectation in nursing. Seminal documents in the development of the American nursing curriculum, such as Nursing and Nursing Education in the United States and A Curriculum Guide for Schools of Nursing do not explicitly mention advocacy. Early nursing education emphasized conformity and a position subservient to the physician. Isabel Hampton Robb, an early leader in the development of American nursing education, encouraged obedience as the primary activity of the nurse. In 1900 Robb stated:
Above all, let [the nurse] remember to do what she is told to do, and no more;
the sooner she learns this lesson, the easier her work will be for her, and the less
likely she will be to fall under severe criticism. Implicit, unquestioning
obedience is one of the first lessons a probationer must learn, for this is a quality
that will be expected from her in her professional capacity for all future time.
While Nightingale expected obedience in following the rules and medical
direction, her intent was to allow nurses the autonomy of purpose to advocate
for patients and the profession .It is probable that she would have disapproved
of Robb’s emphasis on obedience.
NIGHTINGALE AND ADVOCACY
The term ‘advocacy’ was first utilized in the nursing literature by the
International Council of Nurses in 1973. Today the American Nurses
Association (ANA) states that high quality practice includes advocacy as an
integral component of patient safety. Advocacy is now identified both as a
component of ethical nursing practice and as a philosophical principle
underpinning the nursing profession and helping to assure the rights and safety
of the patient. Nurses are seen as advocates both when working to achieve
desired patient outcomes and when patients are unable or unwilling to advocate
for themselves.
Since 1973 advocacy has been considered a major component of nursing
practice - politically, socially, professionally, and academically. Despite the
seeming lack of a professional focus on advocacy before the early 1970s, it is
argued that Nightingale implicitly laid the foundation for nurse advocacy and
established the expectation that nurses would advocate for their patients.
The scope of Nightingale’s effect on nursing and her utilization of advocacy
as a functional principle, like the profession itself, is complex. Nightingale did
not directly address the concept of advocacy. She did, however, demonstrate
advocacy in exceptional ways throughout her lifetime. We know of
Nightingale’s actions, thoughts, and motivations through her correspondence.
At least 13,000 letters remain in public archives and private collections. She
was the shadow author for a number of official government documents relating
to healthcare in the military and the subcontinent of India. Some of her most
insightful writings, such as those found in Suggestions for Thought, were
published privately, thus controlling the distribution to friends and colleagues.
The volumes Nightingale published for public consumption, including Notes on
Hospitals and Notes on Nursing: What it is and what it is not, specifically
outline the role of the nurse and the environment in which care should occur..
Nightingale was a singular force in advocating for as opposed
to with individuals, groups, and the nursing profession. Her expressions of
advocacy grew with age, experience, and public acceptance of her as both nurse
and expert. Her significant contributions include her advocacy for egalitarian
human rights and for advocacy in her leadership roles. Nursing is now
recognizing how her ideas and techniques can be useful in the 21stcentury.
ADVOCACY THROUGH PROMOTION OF EGALITARIAN HUMAN RIGHTS
As a young woman, Nightingale became acutely aware of the unequal
status and opportunity provided to men as compared to women in English
society. Stark described the social structure:Victorian England was a country in
the grip of an ideology that worshipped the woman in the home. Women were
viewed as wives and mothers, as potential wives and mothers, or as failed wives
and mothers. The woman who was neither wife nor mother was called the “odd
woman” or the “redundant woman” .
In Nightingale’s frustration, she wrote the lengthy essay Cassandra, named
after the tragic Greek mythological figure who, although able to predict the
future, was not believed, and therefore, was powerless. As a part of this diatribe,
she compares the perceived value of a woman’s activity to that of a man:Now,
why is it more ridiculous for a man than a woman to do worsted work and drive
out everyday in a carriage?... Is man’s time more valuable than woman’s? or is
it the difference between man and woman this, that woman has confessedly
nothing to do?
Nightingale’s first significant demonstration of advocacy for individuals came
as she was superintendent of the Hospital for Gentlewomen in Distressed
Circumstances. On one hand, assuming the superintendency of this institution
had to have been extremely daunting for a woman of 32 entering her first
employment. The hospital was a newly acquired facility in poor condition with
inadequate furnishings and a poorly trained staff. She reported that in the first
month of occupancy she had experienced a gas leak with small explosions, a
fight between workmen in the drawing room, a drunken foreman, and the death
of 5 patients . On the other hand, it was the opportunity to participate in a
healthcare situation under her control that allowed her to create and utilize
environmental and patient care standards that were to become foundational to
the development of modern nursing .
Nightingale did have the general support of the Ladies’ Committee, the
body to whom she reported. Her first major concern, however, was a policy held
by the Committee stating that only individuals who were members of the
Church of England would be admitted to the institution. Nightingale could not
accept this position, perhaps because of her liberal Unitarian upbringing and her
deeply rooted beliefs in the value of individuals without respect to religious
preference. In a private note to her close friend and ally, Mary Clarke Mohl, she
airs her frustration, indicating she would leave the post if this disagreement
could not be resolved:
Eventually, she won the battle with the Committee so that patients of all
faiths – or no faith – were equally admitted to the hospital . The importance of
this event cannot be overlooked in Nightingale’s development as a social
reformer and healthcare advocate. She won this encounter partially through
logical persuasion, but also because of her status as a ‘lady’ – a person of the
upper class. This allowed her to meet the committee members on equal social
footing. Use of personal position and social acquaintances, logic and debating
skills, and the development of statistical evidence were tools she would refine
and employ over the next fifty years. This immediate victory helped her to
retain her moral convictions and to move forward as an advocate for women
and nursing.
Nightingale next turned her attention to the development of care
standards for patients, including the right to a peaceful death. The chronically
and the mentally ill were often ignored by staff. Those determined to be
‘malingerers’ and the dying did not meet the criteria for admission .
Nightingale, however, accepted these patients and allowed them to remain as
long as she believed that they were benefiting from care despite staff objections.
For a staff member to refuse to work to Nightingale’s standard resulted in
dismissal, signalling the application of administrative standards of care. This is
explicitly demonstrated in her May 15, 1854, report to the Governors when she
wrote, “I have changed one housemaid on account of her love of dirt and
inexperience, & one nurse, on account of her love of Opium & intimidation” .
Nightingale advocated for patients on a larger stage during her 20 months
in Scutari and the Crimea. These nurses were individually selected for their
ability to nurse, the likelihood that they would accept authority, and the
expectation that they would remain for the duration of the conflict. Ultimately,
many of those selected did not fulfil these criteria. However, Nightingale never
wavered from the idea that a basic human right was high-quality patient care
provided by a dedicated nursing staff.
ADVOCACY THROUGH LEADERSHIP
Leadership was one of Nightingale’s innate qualities. During her fifty
productive years, she continually benefited from the cumulative experiences of
Harley Street, Scutari, the Crimea, and her interactions with government
officials in determining the potential of nursing. Her education, social stature,
extensive range of acquaintances, and international travel provided essential
context, opportunity, and a public voice. Her major contributions to the
profession had evolved from leadership of a few at Harley Street and in the
Crimea to the professional collective. She was able to explore the potential of a
refocused nursing, as opposed to remodelling the status quo.
A second major outcome/theme of Nightingale’s leadership was the
establishment of the Nightingale School at St. Thomas’ Hospital in London. She
advocated for educated nurses who had a knowledge base and a specific role in
healthcare. Further, she envisioned the extension of nursing as the essential
force which would meet the growing healthcare needs in sectors outside of the
hospital. This resulted in the development of nursing in the military, midwifery,
poor law nursing (care of paupers), and nurse visiting . This role expansion
created a full range of services in and out of the hospital and across the life
span, thus further expanding the role and autonomy of the nurse.
Nightingale’s continuing complaint from adolescence and into
adulthood concerned the strict social mores relative to women and work outside
of the home. Nursing actually served to begin to change the location of
women’s work from the home into a formal workplace. Two factors contributed
to the success of this change. The first was that nursing education under the
Nightingale model took place in a tightly controlled environment that included a
nurses’ home with a matron who functioned as parent and guardian . This
allowed families to agree to send their daughters to nursing school, as nursing
education was deemed to be in safe surroundings. The second factor was that
nursing was initially viewed as domestic work that had been transplanted into
the hospital, thus extending the typical woman’s sphere
THE VOICE OF FLORENCE NIGHTINGALE ON RESEARCH
The historical context of nursing research Florence Nightingale is often seen
as the very first nurse researcher. Her research in the 1850s focussed on
soldiers’ morbidity and mortality during the Crimean War. Nightingale
identified ‘research’ questions in practice and undertook a systematic collection
of data to try to find answers to the problems. Her‘research’ eventually led to
changes in the environment for sick people including cleanliness, ventilation,
clean water and adequate diet. However, Nightingale’s contribution is seen as
atypical with Kirby pointing out that the development of nursing research in the
United Kingdom really only started with the inception of the National Health
Service (NHS) – now the world’s largest publicly funded health service – in the
late 1940s. Prior to this, the development of nursing research had relied on a
few highly determined individuals and was bound up with the
professionalization of nursing, the demands for suitable nurses, and the raising
of educational standards for nurses . Furthermore, in the 1950s, sociologists and
psychologists were more likely to be undertaking research into nursing and
nurses; only a small number of pioneering nurses were researching nursing and
nurses themselves, one being Marjorie Simpson, who started the first self-help
group for nurse researchers in 1959 called the Research Discussion Group .This
went on to become The Research Society of the Royal College of Nursing,
which continues today. The Royal College of Nursing is the body in the UK that
represents nurses and nursing, promotes excellence in practice and shapes
health policies
A PASSIONATE STATISTICIAN Let's begin by looking at Nightingale as a systemic thinker and a “passionate
statistician.” Her work in nursing and social reform was informed by a religious
faith or philosophy that favoured a systemic approach: God made the world and
runs it by laws, which we can discover by research in both the biophysical and
social spheres. For Nightingale, this entailed the best possible research, access
to the best available government statistics and expertise, and the collection of
new material where the existing stock was inadequate. Nightingale's leadership
style was very much knowledge based.
She herself was a pioneer developer of survey instruments, always vetted
by other experts and pretested on appropriate cases. She was also a pioneer in
the graphical presentation of data. At a time when research reports were only
beginning to include tables, Nightingale was using bar and pie charts, which
were colour coded to highlight key points (eg, high mortality rates under certain
conditions). Nightingale was keen not only to get the science right but also to
make it comprehensible to lay people, especially the politicians and senior civil
servants who made and administered the laws.
EVIDENCE-BASED PRACTICE Several examples clearly reflect an evidence-based framework,
ranging from Nightingale's first work after her return as a heroine from
the Crimean War in 1856, to a late attempt to influence social policy with
a proposal for a chair in “social physics” at Oxford University in 1891.
SYSTEMATIC DATA COLLECTION Nightingale returned from the Crimean War with a conviction that the
desperate loss of life she witnessed should never occur again. She pressed for
the creation of a royal commission to investigate the causes of the high
mortality (eg, for every 1 soldier that died from his wounds, 7 died from
disease). She worked with a team of “sanitary experts,” including William Farr,
who was Britain's leading social statistician at the time. The royal commission
report that was eventually produced showed Nightingale's work from its
conception, terms of reference, choice of members, and analysis of data to its
recommendations for change. One recommendation was for the creation of a
statistical department to track rates of disease and mortality and to identify
problems so that they could be dealt with promptly.
Nightingale revolutionized hospital data collection and invented a
statistical wedge diagram equivalent to today’s circular histograms or circular
statistical representation, and in 1858 she became the first woman admitted to
the Royal Statistical Society. She developed and wrote protocols and papers on
workhouses and midwifery that lead to successful legislation reform. She was a
recognized expert on the health of the British Army and soldiers in India for
over 40 years; she never went to India but collected data directly from Army
stations, analyzed the data, and wrote and published documents, articles, and
books on the topic. Besides her numerous other recognitions, she received the
Order of Merit in 1902, the first woman to receive this honor. She wrote over
100 combined books and official Army reports; her 10,000 letters now make up
the largest private collection of letters at the British Library with 4,000 family
letters at the Wellcome Trust in London.
Nightingale found another opportunity to achieve reforms during the 1860
International Statistical Congress, which was held in London and presided over
by the eminent Belgian statistician, Adolphe Quetelet. She sent a letter
advocating the uniform collection of hospital statistics, so that outcomes could
be compared by hospital, region, and country. The delegates took up her
proposal, adopted a resolution to that effect, and forms were duly drawn up.
Jocelyn Keith described the proposal as “the first model for the systematic
collection of hospital data using a uniform classification of diseases and
operations that was to form the basis of the ICD code used today.” Nightingale
sent a proposal for improved statistics of surgical operations to the International
Statistical Congress held at Berlin in 1863, which took the analysis a step
further.
Nightingale attempted unsuccessfully to have the census modified to
make it a more effective source of data for public policy. As the 1861 census
was being prepared, she tried to have questions on health status and housing
added, conscious that health outcomes were influenced by housing. A question
on health would provide information that mere mortality data did not: “We
should have a return of the whole sick and diseases in the United Kingdom for
one spring day, which would give a good average idea of the sanitary state of
all classes of the population.”
RECOGNITION AND ROLE IN NURSING EDUCATION
Nightingale was a nurse, an educator, administrator, communicator,
statistician, and an environmental activist. Her specific accomplishments
include establishing the model for nursing schools throughout the world and
creating a prototype model of care for the sick and wounded soldiers during the
Crimean War (1854–1856). She was an innovator for British Army medical
reform that included reorganizing the British Army Medical Department,
creating an Army Statistical Department, and collaborating on the first British
Army medical school, including developing the curriculum and choosing the
professors.
After the war she returned home to a hero’s welcome and was awarded
the “Nightingale Jewel,” a brooch with an engraved dedication from Queen
Victoria, for her service in the Crimea. She was also granted a prize of $250,000
from the British government and used the money to establish St. Thomas’
Hospital and the Nightingale Training School for Nurses. Her work lifted the
reputation of nursing from lowly and menial to a respectable profession to
which many upper-class women aspired.
Nightingale established nursing education by writing the first textbook
on the subject in 1960, entitled Notes of Nursing. This book outlined the
principles of the nursing profession, provided advice on how regular women
could care for their families, and how illness could be properly managed. In her
writing, Nightingale emphasized the importance of patient observation to figure
out their symptoms and needs, as to be able to provide the right care. The
importance of sanitary conditions was also stressed, as well as warmth, clean
air, light in rooms, and a nutritious diet.
Florence Nightingale opened the first nursing school in 1960, which was
the beginning of professional education and training in the field. Her school, the
Nightingale School for Nurses, was a part of St. Thomas’ Hospital in London,
and offered the first official training program for nurses so that they could work
in hospitals, help the poor, and teach others. The training emphasized the
important of patient home care and taught students how to care for the sick at
home and the practice of midwifery. Many of the students at the school
continued on to be matrons at major hospitals in England, as well as went on to
establish their own training programs throughout the world.
Florence Nightingale (1820–1910), the philosophical founder of modern
secular nursing and the first recognized nurse theorist, was an integralist. An
integralist is a person who focuses on the individual and the collective, the inner
and outer, and human and nonhuman concerns. Nightingale was concerned with
the most basic needs of human beings and all aspects of the environment (clean
air, water, food, houses, etc.)—local to global. She also experienced and
recorded her personal understanding of the connection and an awareness of the
Divine, which she knew to be something much greater than she was. This was a
major connecting link woven into the entirety of her life, work, insights and
vision. She clearly articulated and demonstrated the science and art of an
integral worldview for nursing, healthcare and humankind.
NIGHTINGALE, ADVOCACY, AND 21STCENTURY LEADERSHIP
Nightingale’s lasting legacy is a composite of her accomplishments and her
vision of what can and should be undertaken by the profession. She wrote
prolifically and demonstrated methods that were effective. Her lessons have
become the roadmap for future generations.Perhaps the most significant and
enduring of Nightingale’s contribution to nursing is learned not by reading one
document, but rather by synthesizing the entire body of literature that she wrote
regarding nursing. From this body of literature can be extracted nursing’s
foundational philosophical base . The Table summarizes the major referents
defined by Nightingale as essential to nursing practice, education, and
research.nightingale understood the value of and the methods for achieving
visionary leadership. She repetitively utilized techniques which have been
developed as the stair step leadership development model. This paradigm
blends the ideas of Nightingale with the current leadership terminology of Burn,
who identified the relative merit of leadership outcomes, with the ‘novice-to-
expert' concept which focuses on the necessity of building leadership skills.
The goal of this stair step leadership development model is to identify a
progression of stages through which individuals achieve positive leadership
behaviours over time. This model does not assume that an individual holds a
formal leadership position in order to demonstrate leadership; rather, it assumes
that all nurses are leaders by virtue of assuming the role of nurse. The ultimate
goal of this model is that leaders and followers achieve a mutually defined goal
with collective purpose and long-term effectiveness.
The first three steps of the model identify the progression from novice nurse to
someone who is experienced in a specific realm of nursing. This is consistent
with Benner’s model. This progression may be repeated multiple times as the
nurse moves from position to position. Additionally, it supports the idea that
leaders are developed rather than the belief that some have innate leadership
capabilities while others do not .
Expected outcomes of the model are that an individual ultimately will
assume the characteristics of either a transvisionary or transformational leader.
Burns has defined these levels. Transactional leaders tend to exchange valued
commodities, such as exchanging work for pay. This is often coercive in nature,
and while perhaps effective for the short term, does not achieve long-term
results. Conversely, transformational leaders seek to create long-term or
permanent change through the mutual identification of goals between
individuals and the organization. This is effective in achieving change that has
lasting value.
CONCLUSION
Today we recognize Nightingale’s work as global nursing where she
envisioned what a healthy world might be with her integral philosophy and
expanded visionary capacities. Her work included aspects of the nursing process
as well. Her work was social action that demonstrated and clearly articulated the
science and art of an integral worldview for nursing, health care, and
humankind.
In the 1880s Nightingale began to write that it would take 100–150 years
before educated and experienced nurses would arrive to change the healthcare
system. We are that generation of 21st-century Nightingales and health
diplomats. We must tell nurses’ stories beyond nursing and see ourselves as
health journalists and social media communicators to transform health care with
others and carry forth her vision of social action to create a healthy world.
Nightingale was ahead of her time. Her dedicated and focused 50 years of work
and service — still informing and impacting our nursing work and our global
mission of health and healing for humanity.
REFERENCES
BOOKS
1. Barbara Montgomery Dossey (2010). Florence Nightingale: Mystic, Visionary, Healer. Philadelphia, PA: F. A. Davis.
2. Benner, P. (2000). From novice to expert: Excellence and power in nursing practice. Upper Saddle River, NJ: Prentice-Hall.
3. Bostridge, M. (2008). Florence Nightingale: The woman and the legend. London: Penguin.
4. Dossey, B.M. (2000). Florence Nightingale: Mystic, visionary, healer. Springhouse, PA: Springhouse.
5. Glicken, M. (2005) Improving the Effectiveness of the Helping Professions: An Evidencebased Approach to Practice.Thousand Oaks, CA: Sage.
6. National League of Nursing League of Nursing Education. (1937). A curriculum guide for schools of nursing. New York: National League of Nursing Education.
7. Nightingale, F. Letter to the International Statistical Congress, 19 July 1860. In McDonald L, editor. Women theorists on society and politics. Waterloo: Wilfrid Laurier University Press.
JOURNELS
1. Stark, M. (1979). Cassandra: An essay by Florence Nightingale. New York: The Feminist Press.
2. Vaario, H. & Leino-Kilpi, H. (2004). Nursing advocacy – A review of the empirical research 1990-2003. International Journal of Nursing Studies
3. Notes on Nursing. Wikipedia. http://en.wikipedia.org/wiki/Notes_on_Nursing. Viewed 2/6/2015.
WEBSITE
1. Nightingale Declaration: http://www.nightingaledeclaration.net/the-declaration2. Nightingale Overview: http://www.nightingaledeclaration.net/why-florence-
nightingale3. Nightingale Moment: http://www.nightingaledeclaration.net/nightingale-moment