CREDENTIALS AND BACKGROUND OF THE THEORIST

Florence Nightingale, the founder of modern nursing, was born on May 12, 1820, in Florence, Italy, while her parents were on an extended European tour; she was named after her birthplace. The Nightingales were a well-educated, affluent, aristocratic Victorian family with residences in Derbyshire (Lea Hurst their primary home) and Hampshire (Embley Park). This latter residence was near London, allowing the family to participate in London’s social seasons.

Although the extended Nightingale family was large, the immediate family included only Florence Nightingale and her older sister, Parthenope. During her childhood, Nightingale’s father educated her more broadly than other girls of the time. Her father and others tutored her in mathematics, languages, religion, and philosophy (influences on her lifework). Although she participated in the usual Victorian aristocratic activities and social events during her adolescence, Nightingale developed the sense that her life should become more useful. In 1837, Nightingale wrote about her “calling” in her diary: “God spoke to me and called me to his service” (Holliday & Parker, 1997, p. 41). The nature of her calling was unclear to her for some time. After she understood that she was called to become a nurse, she was able to complete her nursing training in 1851 at Kaiserwerth, Germany, a Protestant religious community with a hospital facility. She was there for approximately 3 months, and at the end, her teachers declared her trained as a nurse.

After her return to England, Nightingale was employed to examine hospital facilities, reformatories, and charitable institutions. Only 2 years after completing her training (in 1853), she became the superintendent of the Hospital for Invalid Gentlewomen in London.

During the Crimean War, Nightingale received a request from Sidney Herbert (a family friend and the Secretary of War) to travel to Scutari, Turkey, with a group of nurses to care for wounded British soldiers. She arrived there in November of 1854, accompanied by 34 newly recruited nurses who met her criteria for professional nursing—young, middle-class women with a basic general education. To achieve her mission of providing nursing care, she needed to address the environmental problems that existed, including the lack of sanitation and the presence of filth (few chamber pots, contaminated water, contaminated bed linens, and overflowing cesspools). In addition, the soldiers were faced with exposure, frostbite, louse infestations, wound infections, and opportunistic diseases as they recovered from their battle wounds (Thomas, 1993).

Nightingale’s work in improving these deplorable conditions made her a popular and revered person to the soldiers, but the support of physicians and military officers was less enthusiastic. She was called The Lady of the Lamp, as immortalized in the poem “Santa Filomena” (Longfellow, 1857), because she made ward rounds during the night, providing emotional comfort to the soldiers. In Scutari, Nightingale became critically ill with Crimean fever, which might have been typhus or brucellosis and which may have affected her physical condition for years afterward.

After the war, Nightingale returned to England to great accolades, particularly from the royal family (Queen Victoria), the soldiers who had survived the Crimean War, their families, and the families of those who died at Scutari. She was awarded funds in recognition of this work, which she used to establish schools for nursing training at St. Thomas’ Hospital and King’s College Hospital in London. Within a few years, the Nightingale School began to receive requests to establish new schools at hospitals worldwide, and Florence Nightingale’s reputation as the founder of modern nursing was established (Lobo, 1995).

Nightingale devoted her energies not only to the development of nursing as a vocation (profession), but even more to local, national, and international societal issues, in an attempt to improve the living environment of the poor and to create social change (Isler, 1970). She continued to concentrate on army sanitation reform, the functions of army hospitals, sanitation in India, and sanitation and healthcare for the poor in England. Her writings, Notes on Matters Affecting the Health, Efficiency, and Hospital Administration of the British Army Founded Chiefly on the Experience of the Late War (Nightingale, 1858a), Notes on Hospitals (Nightingale, 1858b), and Report on Measures Adopted for Sanitary Improvements in India from June 1869 to June 1870 (Nightingale, 1870), reflect her continuing concern about these issues.

Shortly after her return to England, Nightingale confined herself to her residence in London, citing her continued ill health. Until age 80, she wrote between 15,000 and 20,000 letters to friends, acquaintances, allies, and opponents. Her strong, clear written word conveyed her beliefs, observations, and desire for change in healthcare and in society. Through these writings, she was able to influence issues in the world that concerned her. When necessary and when her health allowed, she received powerful persons as visitors in her home to maintain dialogue, plot strategies to support causes, and carry out her work.

During her lifetime, Nightingale’s work was recognized through the many awards she received from her own country and from many others. She was able to work into her 80s until she lost her vision; she died in her sleep on August 13, 1910, at age 90.

Modern biographers and essayists have attempted to analyze Nightingale’s lifework through her family relationships, notably with her parents and sister. Film dramatizations have focused frequently and inaccurately on her personal relationships with family and friends. Although her personal and public life holds great intrigue for many, these retrospective analyses often are very negative and harshly critical or overly positive in their descriptions of this Victorian leader and founder of modern nursing. Many biographies have been written to describe Nightingale’s life and work. Cook (1913) wrote the first original and comprehensive biography of Nightingale, which was based on her written papers but may have been biased by her family’s involvement in and oversight of this project. It remains the most positive biography written. Shortly thereafter, Strachey (1918) described her negatively as arrogant and manipulative in his book, Eminent Victorians. O’Malley (1931) wrote a more positive biography that focused on her life from 1820 to 1856; however, the second volume, which would have described the rest of her life and activities, was never published. Woodham-Smith’s book (1951) chronicled her entire life and was drawn primarily from original documents made available by her family. This is the biography with which most Americans are familiar; it has endured as the definitive biography of Nightingale’s life, and although it is more balanced, it maintains a positive tone. In 1982, F. B. Smith (1982) wrote Florence Nightingale: Reputation and Power, which is critical of Nightingale’s character and her work. Most recently, Small (1998) published yet another Nightingale biography titled Florence Nightingale: Avenging Angel. Although he is critical of specific aspects of her character and work, he is more balanced in his presentation. He notes that Nightingale’s life “is better documented than perhaps any previous life in history” because of the vast quantity of family and personal papers that remain available today (Small, 2000). His concerns and disagreements with other biographers have been noted in reviews (Small, 2008). Small continues to study Nightingale and updates his website with additional information about the Crimean War and Nightingale. The controversy and intrigue about Nightingale’s role, her status, and her confined lifestyle continue; a London newspaper recently reported on newly found letters related to the conflicts Nightingale had with Sir John Hall (chief British army medical officer in the Crimea) (Kennedy, 2007). Perhaps in this current time, one might consider a diagnosis of posttraumatic stress disorder (PTSD).

An Internet search reveals thousands of sites that provide various articles, resources, and commentaries about Nightingale. Clearly, the world still is fascinated by this unique woman.

The nursing community in the United States remains similarly fascinated by the life and work of Nightingale. During their professional careers, Kalisch and Kalisch (1983a, 1983b, 1987) published several critiques of media portrayals that provide a better understanding of the many histories of Florence Nightingale; their techniques may provide methods of analyzing more recent publications and events for persons interested in studying Nightingale’s life and work. Dossey’s (2000) comprehensive book, Florence Nightingale: Mystic, Visionary, Healer, provides the reader with another in-depth history and interpretation of Nightingale’s personal life and work. Using quotes from Nightingale’s own writings (diaries and letters) and from those of people with whom she interacted and corresponded during her lifetime, Dossey focused on interpreting the spiritual nature of her being and her lifework, creating yet another way of looking at her. In an introduction/prelude to her descriptions of spirituality for nurses’ lives based on Nightingale’s writings, Macrae (2001) explores Nightingale’s personal spirituality as she interprets it after review of writings and documents. Lorentzon (2003) more recently has provided a review and analysis of letters written between Nightingale and one of her former students that clearly demonstrate her role as mentor.

Finally, all of Nightingale’s surviving writings are in the process of being published as The Collected Works of Florence Nightingale. To date, ten of the sixteen volumes have been published under the leadership of sociologist Lynn McDonald (McDonald, 2001-present). This large project and other newly discovered/released documents will continue to spawn articles and books that will explore, interpret, and speculate on her life and work.

THEORETICAL SOURCES FOR THEORY DEVELOPMENT

Many factors influenced the development of Nightingale’s philosophy of nursing. Her personal, societal, and professional values and concerns all were integral to the development of her beliefs. She combined her individual resources with societal and professional resources available to her to produce change.

As noted, Nightingale’s education was an unusual one for a Victorian girl. Her tutelage by her well-educated, intellectual father in subjects such as mathematics and philosophy provided her with knowledge and conceptual thinking abilities that were unique for women of her time. Although her parents initially opposed her desire to study mathematics, they relented and allowed her to receive additional tutoring from well-respected mathematicians. Her aunt Mai, a devoted relative and companion, described her as having a great mind; this is not a description that was used at the time for Victorian women, but it is one that was accepted for Nightingale. It remains unknown whether or not Nightingale was a genius who would have been a great leader and thinker under any circumstance, or whether her unique, formal education and social status were necessary for this to occur at the time. Would Nightingale become such a leader if born today? What would nursing be today if she had not been born at that time and in that place?

The Nightingale family’s aristocratic social status provided her with easy access to people of power and influence. Many were family friends, such as Stanley Herbert, who remained an ally and staunch supporter until his death. Nightingale learned to understand the political processes of Victorian England through the experiences of her father during his short-lived political career and through his continuing role as an aristocrat involved in the political and social activities of his community. She most likely relied on this foundation and on her own experiences as she waged political battles for her causes.

Nightingale also recognized the societal changes of her time and their impact on the health status of individuals. The industrial age had descended upon England, creating new social classes, new diseases, and new social problems. Dickens’ social commentaries and novels provided English society with scathing commentaries on healthcare and the need for health and social reform in England. In the novel, Martin Chuzzlewit (Dickens, 1987), Dickens’ portrayal of Sairey Gamp as a drunken, untrained nurse provided society with an image of the horrors of Victorian nursing practice. Nightingale’s alliance with Dickens undoubtedly influenced her definitions of nursing and healthcare and her theory for nursing; that relationship also provided her with a forum for expressing her views about social and healthcare issues (Dossey, 2000; Kalisch & Kalisch, 1983a; Woodham-Smith, 1951).

Similar dialogues with political leaders, intellectuals, and social reformers of the day (John Stuart Mill, Benjamin Jowett, Edwin Chadwick, and Harriet Marineau) advanced Nightingale’s philosophical and logical thinking, which is evident in her philosophy and theory of nursing (Dossey, 2000; Kalisch & Kalisch, 1983a; Woodham-Smith, 1951). These dialogues likely inspired her to strive to change the things she viewed as unacceptable in the society in which she lived. No other nursing leader could better exemplify Chinn and Kramer’s statement that “When individual, professional, or societal values change, the potential exists for creating fundamental change in knowledge and practice” (2008, p. 69).

Finally, Nightingale’s religious affiliation and beliefs were especially strong sources for her nursing theory. Reared as a Unitarian, her belief that action for the benefit of others is a primary way of serving God served as the foundation for defining her nursing work as a religious calling. In addition, the Unitarian community strongly supported education as a means of developing divine potential and helping people move toward perfection in their lives and in their service to God. Nightingale’s faith provided her with personal strength throughout her life and with the belief that education was a critical factor in establishing the profession of nursing. Also, religious conflicts of the time, particularly between the Anglican and Catholic Churches in the British Empire, may have led to her strongly held belief that nursing could and should be a secular profession (Dossey, 2000; Helmstadter, 1997; Nelson, 1997; Woodham-Smith, 1951). Despite her strong religious beliefs and her acknowledgment of her calling, this was not a requirement for her nurses. Indeed, her opposition to the work of the nuns in Crimea (she reported that they were proselytizing) escalated the conflict to the level of involvement of the Vatican (Dossey, 2000; Woodham-Smith, 1951). As parish nursing has seen a resurgence in the United States and missionary work by nurses continues throughout the world, Nelson’s review of pastoral care in the nineteenth century provides an interesting historical view of the role of religious service in nursing (Nelson, 1997).

USE OF EMPIRICAL EVIDENCE

Nightingale’s reports describing health and sanitary conditions in the Crimea and in England identify her as an outstanding scientist and empirical researcher. Her expertise as a statistician is evident in the reports that she generated throughout her lifetime on the varied subjects of healthcare, nursing, and social reform.

Nightingale’s carefully collected information that illustrated the efficacy of her hospital nursing system and organization during the Crimean War is perhaps her best-known work. Her report of her experiences and collected data was submitted to the British Royal Sanitary Commission in Notes on Matters Affecting the Health, Efficiency, and Hospital Administration of the British Army Founded Chiefly on the Experience of the Late War (Nightingale, 1858a). This Commission had been organized in response to Nightingale’s charges of poor sanitary conditions. The data in this report provided a strong argument in favor of her proposed reforms in the Crimean hospital barracks. According to Cohen (1984), she created the polar area diagram to represent dramatically the extent of needless death in British military hospitals in the Crimea. In this article, Cohen summarized the work of Nightingale as both a researcher and a statistician by noting that “she helped to pioneer the revolutionary notion that social phenomena could be objectively measured and subjected to mathematical analysis” (1984, p. 128). Palmer (1977) described Nightingale’s research skills as including recording, communicating, ordering, coding, conceptualizing, inferring, analyzing, and synthesizing. The observation of social phenomena at both individual and systems levels was especially important to Nightingale and served as the basis of her writings. Nightingale emphasized the concurrent use of observation and performance of tasks in the education of nurses and expected them to continue to use both of these activities in their work.

Nightingale believed that every woman, at one time in her life, would be a nurse in the sense that nursing is being responsible for someone else’s health. Nightingale’s book Notes on Nursing was published originally in 1859, to provide women with guidelines for caring for their loved ones at home and to give advice on how to “think like a nurse” (Nightingale, 1969, p. 4). Trained nurses, however, were to learn additional scientific principles to be applied in their work and were to be more skilled in observing and reporting patients’ health status while providing care as the patient recovered.

THEORETICAL ASSERTIONS

Nightingale believed that disease was a reparative process; disease was nature’s effort to remedy a process of poisoning or decay, or it was a reaction against the conditions in which a person was placed. Although these concepts seem ridiculous today, they were more scientific than the prevailing ones of the time (e.g., disease as punishment). Nightingale did not provide a definition of nature. She often capitalized the word nature in her writings, thereby suggesting that it was synonymous with God. Her Unitarian religious beliefs would support this view of God as nature. However, when she used the word nature without capitalization, it is unclear whether or not the intended meaning is different and perhaps synonymous with an organic pathological process. Nightingale believed that the role of nursing was to prevent an interruption of the reparative process and to provide optimal conditions for its enhancement, thus ensuring the patient’s recovery.

Nightingale was totally committed to nursing education (training). Although she wrote Notes on Nursing (1969) for all women, her primary treatise was that women were to be trained specifically to provide care for the sick person, and that nurses who provide preventive healthcare (public health nursing) require even more training. Nightingale (1969) believed that nurses needed to be excellent observers of their patients and the environment; observation was an ongoing activity for trained nurses. In addition, she believed that nurses needed to use common sense, coupled with observation, perseverance, and ingenuity, in their nursing practice. Finally, Nightingale believed that people desired good health, that they would cooperate with the nurse and nature to allow the reparative process to occur, and that they would alter their environment to prevent disease.

Although Nightingale has been maligned or ridiculed often for not embracing the germ theory, she very clearly understood the concept of contagion and contamination through organic materials from the patient and the environment. Many of her observations are consistent with the concepts of infection and the germ theory, for example, she embraced the concept of vaccination against various diseases. Small (2008) argues that Nightingale did indeed believe in a germ theory but not in the one that suggests that that disease germs cause inevitable infection. Such a theory was antithetical to her belief that sanitation and good hygiene could prevent infection. Her belief that appropriate manipulation of the environment would prevent disease underlies modern sanitation activities.

Nightingale did not explicitly discuss the caring behaviors of nurses. She wrote very little about interpersonal relationships, except as they influence the patient’s reparative processes. She did describe the phenomenon of being called to nursing and the need for commitment to nursing work. From the perspectives of Victorian England and her religious beliefs, these descriptions may describe a caring component of her nursing theory. Her own example of nursing practice in the Crimea provides evidence of caring behaviors. These include her commitment to observing her patients at night, a new concept and practice; sitting with them during the dying process; standing beside them during surgical procedures; writing letters for them; and providing reading materials, including a reading room, during their recuperation. Finally, she wrote letters to their families following soldiers’ deaths.

Nightingale believed that nurses should be moral agents. She addressed their professional relationship with their patients; she instructed them on the principle of confidentiality and advocated for care for the poor to improve their health and social situations. In addition, she commented on patient decision making, a component of a relevant modern ethical concept. Nightingale (1969) called for concise and clear decision making by the nurse and physician regarding the patient, noting that indecision (irresolution) or changing the mind is more harmful to the patient than the patient’s having to make a decision.