Born on 12 May 1820, Florence Nightingale left a formidable legacy for nursing and healthcare.
This year we celebrate that legacy in the 200th anniversary of Nightingale’s birth.
In 1854 Nightingale arrived in Scutari, Turkey, during the Crimean War with a group of 38 nurses to take charge of a British military hospital. She found injured soldiers festering in unsanitary conditions and set her charges to work scrubbing the hospital clean.
With germ theory yet to be proven, the fact that the hospital was on top of a cesspool of sewerage was considered relevant only in terms of the smell or ‘miasma’ entering the building (1).
Nightingale introduced laundered bedclothes and better food, no doubt improving the patients’ lives and reducing contamination via bedclothes. Nevertheless, thousands of soldiers continued to die at the hospital. It wasn’t until the following year, when the British Government sent a Sanitary Commission to investigate conditions that the reason for the rising death toll was discovered: patients were drinking contaminated water. The death rate began to fall when the hospital’s sewerage system was flushed out.
Nightingale’s nightly rounds at the Scutari military hospital led her to be lauded by the English press as ‘The Lady with the Lamp’ but this sentimental portrayal of Florence Nightingale obscured the bulk of her legacy to nursing and healthcare according to biographer Mark Bostridge, author of Florence Nightingale: The woman and her legend. Nightingale herself deemed her ‘Lady with the Lamp’ public image ‘all that ministering angel nonsense’. (2)
Bostridge says Nightingale was ‘a great nursing theoretician’ who used her considerable intellect to produce and analyse statistical data to influence healthcare reform. (3)
Nightingale’s experience of the thousands of disease-related deaths of soldiers in the British military hospital in Scutari inspired her to take aim at hospital-acquired infection, which remains a contemporary risk in hospitals. In her 1859 work Notes on Hospitals, Nightingale wrote: ‘It may seem a strange principle
to enunciate as the very first requirement in a hospital that it should do the sick no harm.’(4)
Gathering the data: an evidence-based approach to health reform
On her return to the UK, Nightingale took to her bed with a mysterious disease but continued to campaign for public health reform, writing thousands of letters and more than 200 books and pamphlets in her lifetime.
Nightingale met with Queen Victoria and persuaded the government to set up a royal commission into the health of the army. With statisticians from the Sanitary Commission, including William Farr, Nightingale analysed army data which revealed that 16,000 of 18,000 deaths were due to preventable diseases.(5)
Nightingale developed survey instruments and used bar and pie charts to effectively present data, most famously in the rose or ‘Coxcomb’ diagram she produced in her 1858 report Mortality of the British Army. She believed in the effectiveness of visual communication to “affect through the Eyes what we may fail to convey to the brains of the public through their word-proof ears”.(6)
The diagram (above) showed deaths due to disease and wounds during the Crimean War, and how the introduction of improved sanitation greatly reduced the deaths of hospitalised soldiers. Nightingale’s diagram influenced the introduction of the Public Health Act which required property owners to connect their sewage lines to main drain pipes, controlling the dumping of human waste onto the streets (7). This was a major development for people living in the crowded cities of industrialised England and extended the average lifespan by 20 years.
‘Nightingale was keen not only to get the science right but also to make it comprehensible to laypeople, especially the politicians and senior civil servants who made and administered the laws.(8)
In 1860 Nightingale successfully advocated to the International Statistical Congress for the uniform collection of hospital statistics and tried to have the census modified to ask questions about housing and health status, to better demonstrate the link between the two.(9)
Patient-centred care and nursing as a profession
Nightingale applied her knowledge to hospital design; introduced professional rather than untrained nurses into workhouse infirmaries; laid the foundations of Britain’s National Health Service; and enshrined the principle of humane care for those who were unable to pay for it.(10)
In 1860, she established the world’s first secular nursing school, which still exists as the Florence Nightingale Faculty of Nursing and Midwifery at King’s College, London.
While Nightingale adhered to the theory that poisonous vapour or ‘miasma’ was the cause of disease decades after germ theory was proven, the pure air, pure water, efficient drainage, cleanliness and light she prescribed as essential for health and patient recovery in her 1860 bestselling book Notes on Nursing: What it is and what it is not would today be called ‘the determinants of health’.
Her recommended practices to remove bad smells and ‘miasma’, such as ventilating sickrooms and removing chamberpots, also removed the bacteria that caused disease.(11) And Nightingale’s notes on the importance of hygiene at home continue to be relevant in a world where millions die of preventable diarrhoeal diseases.
Notes on Nursing reveals a woman of empathy who encouraged nurses to think of their patients’ feelings as well as their medical conditions.
‘I have often been surprised at the thoughtlessness (resulting in cruelty, quite unintentionally) of friends or of doctors who will hold a long conversation just in the room or passage adjoining to the room of the patient, who is either every moment expecting them to come in, or who has just seen them, and knows they are talking about him.’ (12)
Australia has Nightingale to thank for introducing professional nurses. In 1866, after the death of a patient who was ‘filthy and covered in vermin’ at the Sydney Infirmary, the MP for East Sydney Sir Henry Parkes – later to become the NSW Premier – wrote to Nightingale asking her to send nurses trained at her London school to the colony.
Nightingale insisted that the nurses be supervised not by the doctors of the hospital but by a matron – and sent five probationary nurses to Sydney, and Lucy Osburn to oversee them.(13) Parkes ensured that Lucy Osburn and the Nightingale-trained nurses were paid. Osburn went on to establish the first secular nurse training facility in Australia.