In 2009, the one hundred and fiftieth anniversary of
the publication of the seminal work ‘Notes on Nursing’ passed more or less
un-remarked across the planet. This lack of interest, particularly when
compared with the global interest that has been focused upon ‘Origin of
Species’ (which shared a similar anniversary), raises the question – is
Florence Nightingale’s still relevant to nursing?
Historically, Nightingale’s theories formed the
foundation of nurse education systems in countries from China and Japan to
America and Australia. A brief examination of the literature suggests that,
although the debt owed to Nightingale is often acknowledged by nurse
educationalists, there is little evidence to show if (or how) these theories
are ever deliberately reviewed or consciously incorporated into contemporary
nursing curricula. What is clear is that Nightingale holds an unassailable role
as the creator of modern nursing, and this role is rarely if ever questioned.
Nightingale’s
life reconsidered
Without doubt it is clear that Nightingale was born
into a wealthy and highly privileged environment, spending her early years touring Europe with her
parents and her older sister. Just how
wealthy and comfortable Nightingale’s life was up is best illustrated by the small
fact that she dressed herself and fashioned her own hair for the first time in
1853, when she was in her early thirties.
Nightingale
was extended a degree of autonomy that was unusual in Victorian gentlewoman in
that her parents appeared to hold a relaxed attitude towards matrimony for
their youngest daughter. Women of the upper middle classes depended heavily on
marrying "up" into the upper classes, therefore gaining social
prestige as well as a great deal more worldly goods (Rowbotham, 1989). However
Nightingale refused to marry, keeping one suitor Richard Moncton Mills waiting
seven years for an answer to his marriage proposal, finally rejecting him on
the grounds that she could not have “work” of her own if she chose to follow
her heart into a society marriage. Marriage would destroy her chance of serving
God’s call.
Thus
Nightingale is perceived as a force for good and change agent from whom all modern
nursing flows. However excavation of an almost archaeological nature can
present a slightly different picture of “The lady of the Lamp”. The image of a
solitary woman making her way through the wards of Scutari watching over the
sick and injured also underlines the fact that Nightingale did not work well
with other people, for example
- She rejected Mary Seacole’s offer
of help when the Cholera epidemic was at it’s worst even though Seacole was an
acknowledge expert in the disease (Simkin 2003)
- She displayed
considerable resentment towards people, Crimean doctors in particular, who had
dared to rise above their station (Williams 2007)
- She was noted for her exaggerated statements and
vituperative asides in relation to the senior medical staff, even going to far
as to assert that John Hall (Principal
Medical Officer in the Crimea) had no adequate medical qualification, when in
fact he was an FRCS, by examination, and had an MD from St Andrews (Williams 2007)
It is unlikely that Nightingale would have achieved what she
did in the Crimea and afterwards without having a strong personality.
Nonetheless she wasn’t averse to using the achievements of others to further
her own ambition:
- Nightingale publically stated that she regarded
the establishment of a medical statistical branch as one of her most
important proposals adopted by the Royal Commission in 1857. When, in fact
been Andrew Smith (director general of the army medical department)
proposed in 1855 that a board for medical statistics be established
formally within his office, a function that it was already performing
- She took credit for the idea of the need for an
army medical school although the idea had been proposed some 50 years
previously
- St Thomas’s was selected by Nightingale to host
the first nurse training school as this allowed her to to capitalise upon the work of Mrs Wardroper, the Matron, who
had already initiated a programme of reform in 1855
(Williams, 2008)
Even Nightingale’s own sister, Parthenope with whom Florence
had a stormy relationship at best noted that Florence was 'a shocking nurse’,
arguing that;
“She has little or none
of what is called charity or philanthropy, she is ambitious - very, and would
like... to regenerate the world... I wish she could be brought to see that it
is the intellectual part that interests her, not the manual.'
(Cited by Bostridge, 2005)
Nightingales
actions on arrival in Scutari would also suggest that she had no real “feel”
for nursing; one of her first actions being to dismiss the nurses that were
already working in the military hospital. This caused two main problems,
firstly it removed a number of effective nurses from the caring arena and
secondly it left 38 nurses, the women Nightingale had taken to Crimea with her,
the unenviable task of caring for over 3,000 patients. Within a few months of Nightingale’s arrival,
patient numbers had risen to 5,000 but no extra nurses were requested (Williams,
2008). Indeed, when Mary Stanley, a long standing friend and admirer, met with
Nightingale in December 1855 to offer the services of 21 Catholic nurses whom,
inspired by Nightingale she had bought to Turkey to nurse the injured and sick,
the offer was curtly rejected (Baylen 1974).
It is not inappropriate to suggest that the opportunities
afforded to Nightingale by the public engagement with the Crimean war, it was
after all the first war to be fully reported in the national press, allowed her
to promote herself and her activities in a remarkable manner. The emotive and
evocative picture of “The Lady with the Lamp” only came about because
Nightingale herself had banned all women from the wards at night (Cohen, 1984)
on the grounds of alleged immorality, although no one seems to have questioned
how an immoral environment could flourish with patients as sick and badly
wounded at those at Scutari. John Hall,
the Principal Medical Officer in the Crimea, denounced her
as a publicity seeking meddler (Williams 2008).
Regardless of the
subdued rumble of criticism, Nightingale managed the Victorian media with a
skill that would be recognisable to a number of ‘celebrities’ today. Such was
the level of public adoration for this woman – evidenced by paintings, poetry
and even a fan club - that experienced and skilled nurses who took issue with
her approach to care felt unable to express their approbation in the public
domain. Baylen (1974) cites a letter from Mary Stanley, written in 1855 in
which she notes;
“I came out loving
Florence [Nightingale] … I was long and loth (sic) to believe she was not as
great as I believed her to be. If you
knew what it was to me to hear every one complaining of her and to feel that
the blessing given by the nurses is so immense, and that so few comparatively
enjoy it.”
(Baylen, 1974 p 189
Nightingale’s strangle hold on the organisation and
delivery of care upset a number of experienced nurses who felt their only
option was to return to England. In the
same letter cited above Stanley goes on to complain;
“Miss
Emily Anderson has been for a fortnight at the General Hospital, but she has
sent in her resignation for she felt she could not work with Florence.
And further notes that,
Miss
Tebbutt has I believe written to you. She, I think, will wish to go home, she
is so miserable. … the work they are allowed to do is so very small compared
with what might be done, or what they could do at home. The Irish nurses feel
this especially.”
(Baylen, 1974 p 189)
It is clear that Nightingale did not appear to have the
skill of friend making, although she never hesitated to exploit the influence
of acquaintances to further her own ends.
Rajabally (1994) suggests that Nightingale’s judgmental attitude made
her an unsympathetic character even though her public manner was gentle and
unassuming. Elizabeth Gaskell, a contemporary of Nightingale’s
wrote that under her charming exterior there existed a hardness and singleness
of purpose which had developed through years of frustration. Nightingale’s remaining letters illustrate her crushing sarcasm and how she plotted and
planned and subdued people to her will (Bishop, 1960) Rajabally (1994) goes fso
far as to suggest that her controlling
and manipulative behaviour whilst at
Scutari and her reclusive behaviour following her return from the Crimea was symptomatic
of narcissism and self-hatred.
Nightingale
on the World Wide Web.
Nightingale
maintains her presence on the World Wide Web – A search on Google Scholar using
the Search term “Florence Nightingale” shows 33,700 hits, using the search term
“Florence Nightingale and Nurse Education” provides some 21,500 hits and the
search terms “Florence Nightingale in the 21st Century” gives 2, 860
hits. That implies that in excess of 33,000scholarly papers focused upon or
quoted from Florence Nightingale’s works. These works are not confined to nursing
journals but cover medical, historical and philosophical journals also.
By
searching on the main Google web site, arguably the search portal that many
non-academics would use in preference to Google Scholar, the search term
“Florence Nightingale” brings up 1,150,000 web sites which include Wikipedia (http://en.wikipedia.org/wiki/Florence_Nightingale
), the Florence Nightingale Museum (http://www.florence-nightingale.co.uk
) and pages that are designed to appeal to school children who, clearly are
still being asked to investigate Nightingale as part of their studies (http://www.thekidswindow.co.uk/news/florence_nightingale).
Almost without exception, these pages perpetuate the Nightingale image as the
saintly and heroic “ Lady of the Lamp” and reiterate the same historical facts,
many of which show Nightingale in a highly positive light. Even the entries on
Google Scholar which, one would anticipate would show a higher degree of
critical appraisal, tend, in the main, to be laudatory.
Nightingale's Legacy
It is ironic that whilst Nightingale is widely held to
be the originator of the educated and professional nurses that practise today
it is the area of education that her ideas are most irrelevant. Whilst the
clinical concerns that she wrote of remain focuses of concern today her ideas
about education; no exams, no registration, the role of the nurse as a
subordinate care provider, are not. Whilst her legend is promulgated via the
World Wide Web she will be perceived as a selfless crusader and the less
positive aspects of the birth of the modern nursing will be sidelined. Although
teaching nursing history has, in many cases been sacrificed in order to focus
upon practical, care driven subjects, there is still a place for educators to
encourage nursing students to explore Nightingale’s actions and legacy and to
examine her motivations and decisions from a more balanced and critical
perspective than is currently the fashion. I'm not saying we should denigrate her undoubtedly spectacular achievements, but I am saying that for a profession that prides itself upon using evidence and subjecting ideas to critical appraisal we seem strangely reluctant to subject Miss Nightingales actions and legacy to such scrutiny. Nonetheless, however Nightingale is
viewed; saint or sinner, the contribution that she made to nursing cannot be
ignored. Making allowances for the style of writing of the time, her obituary
in the New York Times, perhaps sums up her current relevance best;
“Perhaps
the greatest good that has resulted from her noble life has been the setting in
motion of a force which has led thousands of women to devote themselves to
systematic care of the sick and wounded”.
New York Times, August 15th 1910
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There is a slide share presentation to complement this blog here
References
Baylen,
JO (1974) The Florence Nightingale-Mary Stanley
controversy: some unpublished letters. Med Hist 18(2): 186–193.
Bishop,
W. I. (1960). Florence Nightingale’s message for to-day. Nursing Outlook, 8,246-247.
Bostridge,
M (2005) Florence Nightingale: the Lady with the Lamp. Available at
Cohen, IB (1984) Florence Nightingale. Scientific American 250(3):128-137
Rajabelly,
M (1994) Florence Nightingale’s personality: a psychoanalytical profile Int. J. Nurs. Stud., Vol. 31, No. 3, pp. 269-278,
Rowbotham, J (1989) Good Girls make Good Wives. Blackwell. Oxford
Simkin, J (2003) Florence Nightingale. Available at
Williams,
K (2008) Reappraising Florence Nightingale. BMJ 337:a2889. 1461-1463
