T • W • O

Florence Nightingale: Where Most Work Is Wanted

Frances Ward

Bank of England £10 note issued 1975–1992 honoring Florence Nightingale.

Thomas Chenery, a graduate of England’s Eton College and a diplomatic correspondent for London’s The Times, reported events of the Crimean War from his post in Istanbul. Often, he reported from the front lines. On October 12, 1854, he shocked Victorian England with his scathing criticism of the abysmal medical services provided to wounded soldiers at the British military hospital at Scutari, located on the edge of Constantinople. One of the first embedded reporters writing during wartime, he awoke the conscience of the British people. He also fueled national humiliation with his comparisons between the exceptionally poor care given to British heroes and the well-planned and executed care given to French soldiers, stating that “here the French are greatly our superiors.” Purposefully accentuating his point, Chenery lauded the French Sisters of Charity, who “accompanied the [French] expedition in incredible numbers. These devoted women are excellent nurses” (Royle, 1999, p. 247).

The Times’ readers responded, among them Florence Nightingale (1820–1910). A wealthy, educated, deeply rebellious individual frustrated by the Victorian ethos that shaped social customs and mores constraining contributions to society by women, Nightingale played on her countrymen’s indignation surrounding events at Scutari hospital. Capitalizing on her father’s relationship with Sidney Herbert, the British secretary of war, she requested that Elizabeth Herbert, his wife, influence her husband to support her proposal and to offer introductions for her party to the appropriate authorities at Constantinople. Using whatever means necessary to advance her goals, Nightingale was keenly aware that men held power and that power was the sine quo non for change and social reform.

Concurrently, and independent of Nightingale’s approach of Elizabeth Herbert, the secretary of war requested that Nightingale head an official party of nurses to Scutari as a government entourage. Recognizing this as an opportunity to model the way and lead change, Nightingale galvanized 38 women volunteer nurses she had trained, along with 15 Catholic nuns, and sailed to the maelstrom within the Ottoman Empire (Dossey, 1999). While at the military hospital for only a relatively short period—approximately 2 years—as the official superintendent of nurses charged to craft solutions to the debacle that was Scutari, Nightingale was credited with reducing the obscenely high death rate to a much lower figure. Once at Scutari, Nightingale became a national heroine in her early 30s.

Nightingale’s launch to celebrity status was propelled by the British public’s acclaim for the outcomes of her work at Scutari: decreased death rate, stabilization of the nursing staff, environmental improvements by the Sanitary Commission, and increased order and discipline at the hospital, irrespective of the medical staff’s disdainful dismissiveness for the changes she instituted. Her administrative craftsmanship evolved from a complex web of values and behaviors antithetical to women in Victorian England. Significantly, Nightingale occasionally referred to herself as a male. As she noted in an imaginary conversation with her mother in 1851–1852, “I shall go out and look for work.… You must look upon me as your son.… You must consider me married or a son” (Woodham-Smith, 1983, p. 66).

Enraged at her culture’s dismissal of women as vehicles for reproduction and pleasure, Nightingale achieved great social reform, designed hospitals, created medical recording systems, developed statistical approaches for public health management (in wartime as in peacetime), and designed a standardized nursing curriculum eventually used in training schools internationally. Defying categories of gender, Nightingale’s public leadership was founded on her desire for a meaningful life, one lived in opposition to the oppressive social code of 19th-century England. In a private note dated March 1852, she wrote:

That same year, she wrote: “In my thirty first year I see nothing desirable but death” (Baly, 1991, p. 15). Denying death, yet aware of its presence, that which she did constitutes a leadership narrative of nursing’s dark angel.

RADICALIZATION

Florence Nightingale’s father, William Edward Shore, acquired great wealth from a relative, Peter Nightingale, on his mother’s side of the family, after which he changed his last name to Nightingale (Gill, 2004). Early in life, becoming quite learned by the teachings of her father, Florence was rankled by the purposeless lives expected for women. She had early exposure to influential thinkers and leaders of her era, including politicians, government officers, and educators. One such influence was Adolphe Quetelet, the Belgian statistician, mathematician, and astronomer who applied statistical methods in the social sciences (Diamond & Stone, 1981). Contrary to the upbringing of her older sister, Florence’s education, through her father and the influence of those who frequented their home at Embley Park, radicalized her as a woman, providing her skills atypical of ladies of her time. A complex spiritual being, Nightingale was a religious eclectic, influenced primarily by her family’s Unitarian views as well as the tenets of the Church of England (Widerquist, 1992). Driven, Nightingale assumed the role of friendly visitor to neighbors requiring assistance (Whelan, 2001; Williamson, 1911, 1914/1999). Rescuing a baby owl, she named her Athena; the pet remained at her side until war broke out in the Crimea (Dossey, 1999). Nightingale’s Christian spirituality framed her behaviors toward those in need, shaping her singular focus on improving the care provided to others, including both direct care (nursing care) and indirect care (design of hospital structure, organizational models, medical documentation, and statistical reporting).

Tension between mother and daughter over marriage and work was intense for many years, particularly after Florence announced that God had called her in early 1837 to a life of service to others. She was 16 years old. Believing that service to God meant service to humanity, Nightingale searched for meaningful options. She wrote a friend, Christian von Bunsen, asking “What can an individual do, towards lifting the load of suffering from the helpless and the miserable?” (Calabria, 1997, p. 2). Bunsen advised Nightingale to visit the institution of the deaconesses in Kaiserswerth, Germany, to witness how care was given to ill patients. Forbidden by her mother to become a nurse, Nightingale turned to ill relatives to exercise her calling to care for people. In her early 20s, despondency overwhelmed Nightingale as she became desperately anxious to engage in a meaningful life of service. At a crisis point, she beseeched God to end her life:

Determined to live, Nightingale survived this crisis of spirit. Choosing the road less traveled by women in the early 19th century, Nightingale waited until 1844, when she was 24 years old, to announce her intent to become a nurse. Commonly considered as work generally undertaken by drunkards, prostitutes, or criminals in workhouse infirmaries for the indigent, nursing in Great Britain was embodied in Sairey Gamp, the infamous nurse-midwife character imagined by Charles Dickens in Martin Chuzzlewit (Dickens, 1844). Rapid growth of cities in the burgeoning modern era driven by exponential industrialization and capitalism, however, demanded a change from the unregulated friendly visiting to systematized care in hospitals. Such care demanded obedient, trained attendants.

Forever proud of his unusual, misfit daughter, William Nightingale supported her from her early childhood, eventually accepting her choice of nursing as a career. William shaped his daughter’s values for social reform through his own political career and views drawn from the Liberal wing of the Whig party. Although defeated in 1834 as the Whig candidate for a Parliament seat representing Andover in Hampshire, William Nightingale supported the 1832 Reform Act, legislation aimed at eliminating corruption in the electoral system in England (Gill, 2004). Growing up, Nightingale was immersed in British politics, conversing in her Embley Park drawing room with politicos over social reform. Her activities, successes, and national reputation as a social reformer both during and after her Crimean War efforts were highly correlated with her ability to speak directly with, and thus influence, her network of Parliament friends. Binding these influences to her alliances with popular press journalists, Nightingale succeeded in introducing social reform in England and India. As a woman, she could not hold a seat in Parliament, much to her frustration and chagrin. Nightingale thus labored harder and more painstakingly to use influence to model the way and lead change—a very exhausting process, fraught with political intrigue and lacking in objectivity. Through such processes, Nightingale focused objectively on her goals of social reform, first for British army and military health reform, and then for similar goals in India. When the Liberal wing of the Whig party lost power in Britain in the late 19th century, Nightingale retreated to her home, her bedroom, and continued political influence, albeit in a more indirect manner.

William Nightingale provided Florence with an annual annuity of 500 pounds in 1853, a sum that enabled her to move away from home, travel, and pursue her goals in rooms of her own (Dossey, 1999). Rejecting male suitors and marriage proposals, Nightingale had taken a vow of chastity at age 30, thus freeing herself from the constraints of Victorian life and liberating herself to pursue her goal to become a nurse. Husbandless, educated, and equipped with a generous annual annuity, Nightingale would undertake her own grand tour of Europe, exploring Greece, Germany, and Egypt, conducting medical and hospital tourism while documenting as much as possible about the structure, administration, functions, and personnel in these facilities. In Thebes, she claimed to have conversed with God, responding to his call for her to do good on his behalf, without public knowledge of her efforts (Nightingale, 1849–1850/1987).

When in Germany, Nightingale visited Kaiserswerth, where Theodor Fliedner, a Lutheran minister, had established a hospital and the Lutheran Deaconess Institute for the training of women in theology and nursing. Employing ideas borrowed from the Mennonites, Fliedner planned for young women to learn to care for the sick at the Institute. Nightingale joined the Institute as a student in July 1851; in October 1851, she finished her course of study (Dossey, 1999). Impressed by the steadfast devotion of the deaconesses, Nightingale’s German experiences framed her later work both in direct nursing care as well as in administration. In 1850, on return from her first visit to the Institute and prior to her subsequent 4-month nursing training, Nightingale wrote a 32-page informational pamphlet at the request of Theodor Fliedner. Recognizing that the written word is a powerful tool for persuasion, Nightingale used the pamphlet—The Institution of Kaiserswerth on the Rhine, for the Practical Training of Deaconesses under the Direction of Rev. Pastor Fliedner, Embracing the Support and Care of a Hospital, Infant and Industrial Schools, and a Female Penitentiary—as a vehicle to dismiss a popular myth that nursing was a Catholic institution, one loyal to Rome (Nightingale, 1851). Nightingale reviewed the importance of deaconesses, or nurses, in all divisions of Christianity, existing free from vows prior to the existence of the Sisters of Mercy in the mid-17th century (O’Brien, 2010). By extension, Nightingale reasoned that women could have a professional nursing career in a nonreligious institution. Although Nightingale held a spiritual view that nurses served as handmaids of the Lord, she deeply appreciated the practical necessity of separating nursing from religion in England. If viewed as a by-product of Catholic monasticism, nursing in Protestant England would simply not thrive. Written anonymously, this pamphlet served as a vehicle for clarification of thought and realization of the power of publication. Florence keenly sensed this period as a pivotal point, as her life and her career became one.

Nightingale’s training at Kaiserswerth was more than, and quite different from, nursing care of sick patients. She induced best care practices from individual cases, documenting all the while. She also deduced patterns of effective administration, noting central administration methods driven down to hospital units. Voluminous reports on efficient hospital administration, staff motivation and delegation, controls for extraneous factors, and replicable quality care outcomes were compiled; descriptions of the nursing superintendent, a central control officer, were detailed in Nightingale’s reports. She was learning to turn personal observations onto the page, refine them, and offer them publically to her peers.

MODELING THE WAY IN PRACTICE

A Kaiserswerth graduate deaconess, Nightingale struggled with self-definition on her return to England. In a 3-volume, 829-page work entitled Suggestions for Thought to the Searchers after Religious Truth (1860), Nightingale undertook a self-exploration on true spiritual experience and the emancipation of women from the dull tyranny of mindless drawing rooms (Poovey, 1993). In her essay Cassandra, Nightingale passionately decries the imprisonment of women’s minds within trivial pursuits, stating that women needed meaningful employment or vocations, similar to men. “Why have women passion, intellect, moral activity—these three—and a place in society where no one of the three can be exercised?” (O’Malley, 1934, pp. 109–110).

In 1853, Nightingale assumed the role of superintendent of the Institution for the Care of Sick Gentlewomen in Distressed Circumstances in Upper Harley Street, London. In response to her call from God, she was now free to execute her ideas for compassionate nursing care as well as efficient hospital administration. Equipped with powerful writing abilities, she was free to explore, implement, and publicize her ideas on health care administration and nursing care so carefully culled from her experiences in medical tourism trips throughout Europe, Greece, and Egypt. Respecting only her male role models throughout her life and maintaining what would become her lifelong disdain for women (whom she viewed as not as capable as men), Nightingale executed a plan, her plan, the only plan worthy of implementation.

Connections continued to provide opportunity. In the economically stressed years of the 1830s–1840s, there developed an oversupply of governesses. In the 1851 British census, governesses were known as “excess women,” with work conditions reflective of a near-slave lifestyle (Neff, 1929/2006). The Institution for the Care of Sick Gentlewomen in Distressed Circumstances managed large numbers of these severely debilitated, chronically ill governesses, an emotionally and physically complex group. As was common in this era of industrialization, urbanization, and poverty, women’s groups—usually wives of affluent families—managed care facilities for the poor. Social reform organizations, such as the National Association for the Promotion of Social Science and the International Congress for Charities, Correction, and Philanthropy, boosted women members and focused on solutions for public health, the penal system, and educational problems. At Nightingale’s request prior to her coming on board as superintendent, a committee of ladies managed the institution that relocated to No. 1 Upper Harley Street, London.

Consistent with other hospitals of the era, the Institution was very modest, housing only 27 beds in a three-floor building. Nightingale’s friend Elizabeth Herbert, the wife of Sidney Herbert, English statesman and the secretary of war from 1845 to 1846, 1852 to 1855, and 1859, had recommended Nightingale for the position of superintendent. In her April 29, 1853, acceptance letter to Lady Canning of the women’s committee, Nightingale requested that the committee consider the terms under which “volunteer Nursing Sisters shall be received into the institution, should any such offer themselves” (Dossey, 1999, p. 87). Three months and 2 weeks later—August 12, 1853—she began her career as nursing superintendent. Florence was 33 years old.

By the end of her first day as superintendent, Nightingale knew that she was no longer in Embley Park. With the building still undergoing renovation and chaos being the order of the day, Nightingale wrote to her friend Mary Clarke explaining her decision to leave her Embley Park home to live at Upper Harley Street, despite her mother’s and sister’s objections:

Chapter one of Nightingale’s freedom from home, her emancipation, had begun.

With incomplete renovations, an operating budget in the red, incompetent staff, and poor environmental conditions, Nightingale developed administrative knowledge from her own meager experiences in nursing, as well as from her past friendly visiting of ill neighbors and her experiences abroad. She reorganized patient spaces, insisted on sanitary room and patient conditions, developed nurse teams consisting of one or two probationary pupils to one nurse, fired drunken or unhygienic nurses and house staff, wrote job descriptions and daily work assignments, and maintained a clean kitchen with nutritious food and drink (Goldie, 1987). Air-filled, bright, quiet, and peaceful spaces conducive to mind and body recovery were mandatory in what was rapidly becoming Nightingale’s Institution.

A superb businesswoman, Nightingale brought change through political prowess. Her technique was self-effacement: Let the Institution’s governing committee and medical staff believe that the best ideas for change were theirs. Caring more for the success of her vision than for personal attribution, she worked tirelessly, earning respect from the staff. In a letter to her father, Nightingale wryly noted:

Becoming accustomed to winning, she barreled through religious bias and swept the facility clean of prejudice when confronted by the committee of ladies who refused to admit Catholic patients. Risking dismissal, Nightingale scandalously claimed, “I might take in Jews and their Rabbis to attend them” (Cook, 1914, pp. 134–135). Her ploy was successful; all religious denominations were now allowed into the institution. Ever alert to the parodic power of language, she recalled this tense situation to her friend Mary Clark: “Amen. From Committee, Charity, and Schism—from the Church of England and all other deadly sins—from philanthropy and all the deceits of the Devil, Good Lord, deliver us” (Cook, 1914, p. 135).

Criticized in her early years as being incapable of successfully managing staff, Nightingale matured as a human resource manager with progressive experience (Goldie, 1987). In 1872, in an address to nurses and probationers at St. Thomas Hospital, Nightingale advised these novice students that the

On August 7, 1854, Nightingale completed her first year as the Institution’s nursing superintendent. She had not established a training school for nurses, but she summarized in her final quarterly report that “as to good order, good nursing, moral influence and economy, the result has been to me most satisfactory” (Dossey, 1999, p. 95).

In 1854, as Nightingale prepared to leave the Institution, a cholera outbreak occurred in London. Nightingale assumed the nursing superintendent position of cholera patients at Middlesex Hospital in London. There she worked with John Snow, a physician who provided detailed street maps of cholera deaths in 1854. His cholera street cartography pointed to one common source of contamination—the handle of the Broad Street water pump (Hempel, 2007). Nightingale’s working relationship with Snow taught her epidemiologic tools that were objective in their power to change health indices of whole populations. She retained this experience and used this new technique of medical disease mapping in future military health challenges during wartime.

MODELING THE WAY IN WAR

By March of 1854, Great Britain had entered the Crimean War. By November, eight Anglican Order sisters accompanied Nightingale to Scutari, including Sarah Anne Terrot. Sarah, a Sellonite sister of the Anglican Order, had cared for patients in a Plymouth cholera epidemic. She was thus considered a valuable, seasoned nurse. Five Catholic nuns were also in Nightingale’s nursing party; however, as they had only cared for orphan children in London, they were considered less useful in the care of complex cholera patients. A journal writer, Sarah documented her Scutari experiences, living in the Barrick Hospital alongside Nightingale (Richardson, 1977, p. 85):

Sarah reported to Nightingale, a fact that pleased her, since she did not wish to report to a Catholic nun. Nightingale, a focused charge nurse, instructed Sarah and the other nurses to thoroughly clean their rooms, sew sacks of straw together to serve as beds for wounded soldiers, keep a healthy kitchen, and generally maintain a sanitary, uncluttered environment for healing. The filth was overwhelming; most of Nightingale’s party invariably fasted rather than become ill from poor, rotten food. Sarah was impressed by Nightingale, stating that while she looked tired, her appearance and manner “impressed me with a sense of goodness and wisdom, of high mental powers highly cultivated and devoted to highest ends” (Richardson, 1977, p. 66).

Nightingale was indeed fatigued, but perhaps as much from political maneuvering as from sickness. The physicians at Scutari did not want, nor had they sought, the services of Nightingale and her party. Despite clashes with medical authorities, Nightingale doggedly aligned with rank-and-file physicians, assisting them with their patients as needed. She also assumed firm control and command of her nursing party. As their advocate, Nightingale jockeyed resources to obtain materials for wound dressings, water basins, clean clothing, and food and fluids for soldiers—and for her nurses. Some nurses vehemently rankled at Nightingale’s spartan discipline, lamenting their original decision to join the party. Nightingale ordered nurses to enter wards only on the request of the medical officer of the day. As wounded soldiers increasingly poured into Scutari hospitals, Nightingale realized that deference to physicians—as a strategy to gain access to patients—would inevitably be successful. Nightingale weathered her nurses’ dislike of this policy in order to secure the physicians’ full capitulation to the obvious need for nurses. She encouraged surgeons to use chloroform as a surgical anesthetic, quite contrary to the orders of Dr. John Hall, inspector-general of hospitals, who preferred no anesthesia: “The smart of a knife is a powerful stimulant, and it is much better to hear a man bawl lustily than to see him sink into the grave” (House of Commons, 1854–1855, p. 56).

As the wounded grew exponentially, Nightingale documented relentlessly. She recorded individual patients’ wound status and care, death rates, types of diseases and symptoms managed, availability of supplies and lack of specific supplies, contaminated food and water, and organizational management. She was an early proponent of data-based decision making. Trends in data unveiled patterns, which, as evidence, could sway even the most recalcitrant of physicians or politicians. To effect large-scale change in military care practices, well-documented patterns of data must be thrust onto the public stage, especially to the government. Given her experiences with documentation and Snow’s epidemiologic methods of mapping cases, Nightingale appreciated the large public health issues at play at Scutari, equal to her understanding of practical daily details of patient management. Sanitation, to Nightingale, was an obvious solution to the morbidity and mortality experienced at Scutari. Facilitating health by preventing contact with hazardous waste, human and otherwise, was the cornerstone of Nightingale’s action plan at Scutari. By November 14, 1854, Nightingale wrote to her friend Dr. William Bowman at the Institution at Upper Harley Street:

Nightingale dismissed the popular notion of contagion—the belief that disease is passed from one person to another by touch. Sanitation and hygiene were Nightingale’s essential pillars of public health. She and her nurses meticulously swept, scrubbed, laundered clothes, made bandages from clean cloth, and managed safe food supplies, as there was, as Snow had argued, no such thing as miasma. Understanding point of contact from Snow, Nightingale championed sanitation, particularly environmental control. As she wrote in Notes on Nursing: What It Is, and What It Is Not, Nightingale claimed that the “very first cannon of nursing … [is] to keep the air he [the patient] breathes as pure as the external air, without chilling him” (Nightingale, 1860/1969, p. 12).

Nightingale supervised sanitary measures at Scutari as well as the renovations of patient units for maximum light and airflow. Concurrently, she struggled to create a new order of military nurses, women professional in demeanor and skilled in caregiving to those entrusted to them—a radically different orientation from those who cared for ill, impoverished patients in English almshouse infirmaries. Through her efforts in Scutari’s military hospitals, Nightingale relentlessly, painstakingly staked out a nursing work culture. In peacetime, her task would have been difficult; in wartime, the spirit of patriotism fueled well-intentioned volunteers. She demanded women who could nurse well—ability, not birth, was her critical criterion. A competent nursing staff was equally essential to a sanitary environment; the former was responsible to ensure the latter.

Unrelenting, Nightingale concurrently nursed patients and administered the entire hospital enterprise. Nightingale’s efforts were widely published; she was a ministering angel, the heroine of Scutari. In 1855, Queen Victoria sent Nightingale a brooch designed by Prince Albert as a sign of her appreciation. Depicting a St. George cross, the letters “VR,” and the royal cipher, the brooch was inscribed with the following on the back: “To Miss Florence Nightingale, as a mark of esteem and gratitude for her devotion toward the Queen’s brave soldiers—from Victoria R, 1855” (Gill, 2004, p. 401). The brooch became known as the Nightingale Jewel.

So popular was Nightingale that Henry Wadsworth Longfellow’s 1857 poem “Santa Filomena,” published in the Atlantic Monthly, referenced the Lady with the Lamp:

In the winter of 1855, a confluence of factors catapulted Nightingale to fame in Britain. Already gifted by Queen Victoria and beloved as the “Lady with the Lamp,” a phrase first coined in London’s The Times to symbolize her practice of moving through rows of patients at the Scutari hospital at night with her lamp swaying at her side, she became known for exposing the government’s sluggish response to the inhumane care provided soldiers at the front line. In January 1855, the army numbered 11,000 soldiers; the sick and injured numbered 23,000. Determined to bring order to the hospital system, Nightingale devised a basic triage system for incoming wounded soldiers, demanding that they be thoroughly washed and wounds cleaned and dressed, with each soldier receiving fresh, new bandages. She set up a laundry system, contrary to the common practices on the wards—with resultant resentment from intransigent medical officers. She ordered food to be allocated according to patients’ needs, with the sickest receiving broths and extra fluids (Gill, 2004). “Nothing which the ‘Times’ has said has been exaggerated of Hardship,” Nightingale wrote in her notes (Goldie, 1987, p. 130).

Maneuvering and influencing her political allies behind the scenes, she demanded a government response. Because of family connections, it was to come from the very highest level. Lord Palmerston, who retained a parliamentary seat largely due to the influence of Nightingale’s father and other family members, became prime minister in 1855. Noted as a shrewd manager of public opinion through skillful use of the press, Lord Palmerston’s first effort was to regain order in the Crimea—and accolades from his public. First, Lord Palmerston constituted a royal Sanitary Commission, comprising two physicians and an engineer. The charge to this Commission, consistent with the nation’s growing embrace of sanitation and hygiene, was to immediately improve hospital conditions and thus save lives otherwise at high risk resulting from impure air and preventable sanitary problems. Nightingale applauded the work of the Sanitary Commission, whose flushing of water pipes, unclogging of sewer drains, improved airflow and ventilation in roofs, removal of debris, disinfection of walls, and other improvements cleared the detritus symbolic of death in Scutari (Dossey, 1999). Mortality had begun to decline after Nightingale initiated her sanitary, dietary, and laundry measures; after the efforts of the Sanitary Commission, mortality continued to decline exponentially following aggressive sanitary public health action.

In 1855, Lord Palmerston also created the royal Commissariat Commission, a two-man team led by Sir John McNeill, a surgeon, and Colonel Alexander Tulloch, an army officer trained in law and internal affairs. Both men were passionate about sanitation and public health reform, with Tulloch an advocate of data collection of the health status of soldiers. The Commissariat report emulated Nightingale’s reports regarding problems with food, supplies, and hospital and other equipment (Dossey, 1999). Because Lord Palmerston authorized the two commissions with power to act, changes occurred quickly. Deliveries of fresh food began; processes for purchasing and storing of foods were established. For Nightingale, her many letters to her political friend Sidney Herbert and to the press had finally borne fruit—death from poor sanitation and poor hygiene was decreasing. The men in these two royal commissions and Nightingale remained colleagues for years, long after the commissions completed their work and the men involved suffered blocked professional advancement in their fields from jealous colleagues. Her association with these commissioners renewed Nightingale’s zeal and passion; she became increasingly determined to heal soldiers, and to do so well.

This same year Nightingale saw an opportunity in war to train a new breed of physicians who would elevate the role to a higher level as a result of improved knowledge to be gained from postmortem examinations and dissections, new therapeutics, and the collection of data and use of statistics. Nightingale saw opportunity for important secondary gains culled from war—new surgical techniques and increasingly intricate knowledge of human anatomy to be learned from the detritus of war. Nightingale appreciated that the morbidity and mortality associated with war offered opportunities to advance anesthetics and surgical techniques. Additionally, regular collection of data illustrated by statistics could provide evidence to document the need for change. Planning to use her own money to renovate a building in Scutari, Nightingale decided in 1855 to begin a medical school, given the large patient population and supply of corpses for dissection (Cook, 1914). Easily able to separate emotion from objectivity, Nightingale was quick to appreciate secondary gains to be accrued from war.

Irrespective of these dramatic improvements, a cholera outbreak subsequently ravaged the hospital, its patients, physicians, and nursing staff. Nightingale fell ill with Crimean fever in May 1855 and only rallied after several months of rest. Encouraged to recuperate at home in Embley Park, Nightingale refused, preferring instead to stay in the Crimea with the soldiers. After several months, Nightingale returned to the bedside, to supervision of care, and documentation of the debacle symbolized by Scutari. She inundated government officials with information from the front, appreciating fully that public sentiment was on her side. Her adoring public lavished Nightingale with gifts following her illness, as her political colleagues and confidantes in London schemed to create a more permanent testament of their devotion. In November 1855, high-ranking public officials met to create a voluntary national fund, to be called the Nightingale Fund, to support nurses’ training in England (Gill, 2004). The resolution drafted by the organizing committee paid tribute to Nightingale’s contributions to her country, for which the Fund would serve as a symbol of the public’s appreciation:

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