Florence Nightingale, an Englishwoman, developed the foundational philosophy of modern nursing and was a Victorian leader in sanitation reform. Her most famous position was as superintendent of female nursing in the military hospitals in Turkey based at Scutari during the Crimean War. The time in the Crimea provided Nightingale with the experience, political contact, and public fame to create significant and lasting social reform following the war.
Nightingale was born to William Edward and Frances Smith Nightingale on May 12, 1820, in Florence, Italy, and named for the city of her birth. Her father, through his Unitarian beliefs, supported schooling for women and provided Florence and her sister Parthenope with a broadly based curriculum. Florence proved to be an exceptional student, excelling particularly in languages, mathematics, and philosophy. As a young woman, she traveled widely in Europe, meeting the socially prominent. At 18, she was presented at court to Queen Victoria.
Nightingale was driven by a strong sense of spirituality and Christian service, believing that she had a duty to serve mankind. As a young woman, she displayed an early interest in nursing, caring for aging relatives and household staff. Despite family objections, she obtained minimal nursing experience through two visits in 1850 and 1851 to Kaiserswerth in Germany, a Protestant institution that trained governesses, nannies, and nurses. There she learned basic nursing skills, the value of patient observation, and fundamental hospital design.
Nightingale's passion for nursing led her to seek employment. In 1853, her father provided her with an annual allowance, permitting her some freedom. She was offered the superintendency of the Institution for the Care of Sick Gentlewomen in London, partially through the efforts of Elizabeth Herbert, a member of the Ladies' Committee of the Institution and a family friend. The 14 months Nightingale spent in this position provided her with practical experience in nursing practice and administration.
In 1854, Britain had entered the Crimean War. Telegraphed reports from the front by William Howard Russell, a reporter for The Times, described the poor medical care for the injured, the lack of appropriate purveyance of supplies, and the suffering of the British soldiers. Public outrage demanded change. Sidney Herbert, then Secretary at War in the Victorian government, and husband of Elizabeth Herbert, wrote to Nightingale requesting that she become superintendent of a group of nurses who were to be based at the Barrack Hospital at Scutari across the Bosphorus from Constantinople. Nightingale herself had considered organizing a small group of women to assist the war effort. The letters suggesting these plans to each other crossed in the mail.
Nightingale accepted Herbert's offer to head a group on behalf of the British government. She immediately set about organizing supplies and identifying the 38 women who would travel with her to serve as nurses, including 14 Anglican sisters, 10 Roman Catholic nuns, and 14 women without identified religious affiliation. On October 21, 1854, the party departed London and arrived at Scutari on November 4 in driving rain and fog.
On her initial inspection, Nightingale found the hospital to be overcrowded, filthy, understocked, and sorely lacking in administrative organization. Wounded were arriving by ship following the Battle of Balaclava by the hundreds to add to the more than 1,700 patients in residence. Nightingale estimated that there were 4 miles of beds 18 inches apart lining hallways and wards. Many patients were on the floor on straw pallets. Although Nightingale had instructions from the British government, her presence was initially ignored by the Inspector-General of Hospitals and the Chief Medical Officer in the East, Dr. John B. Hall, who seemed oblivious to the situation and was dismayed at her presence.
As Nightingale was allowed access to the wards, she began to address the most serious problems—the dirty environment and the lack of supplies—as well as establishing the operational rules for the nurses. She kept exceptional records of causes of death of the soldiers that revealed the predominant reason was from “preventable” causes, primarily contagious disease. Through her improvements and administrative skill, the death rate declined as the hospital was cleaned, adequate nutrition was provided, and the nurses met basic care needs of clean dressings and adequate clothing. Despite friction between the various groups of nurses and discipline and doctrinal disputes, Nightingale was able to establish elevated standards of care.
The British had also established a number of hospitals on the Crimean Peninsula. Nightingale visited the Crimea on three occasions in 1855 to inspect the institutions and to evaluate the nursing staff. On the first visit she contracted “Crimean Fever,” most probably brucellosis. Although seriously ill, she did recover, but suffered from residual chronic sciatica for another 40 years. Nightingale remained at the hospital in Scutari until the conclusion of the war in August 1856. She had set the example for the importance of military nursing, adequate purveyance, administrative reorganization, and maintenance of records.
The Crimean experience is often regarded as Nightingale's crowning achievement. However, it was the agenda of innovation and restructuring that she designed and implemented for the next 40 years that has distinguished her as a social reformer. Although chronically ill when she returned to England, she immediately sought to improve the hygiene of the military hospitals. She published a private report based on statistical data that demonstrated hygienic deficiencies in the hospital were the main cause of death of the British soldier, far exceeding war wounds. The highest rate of death had, in fact, been at Scutari, probably caused by the closure of several hospitals in the Crimea, which caused overcrowding at Scutari. Although Nightingale wished to make these data public, she was refused permission. She privately printed and circulated the report that demonstrated the faults of the British government's handling of medical care, purveyance of supplies, and resistance to change.
The results of two Royal Commissions supported by Nightingale promoted sanitation and hygiene in military housing and hospitals worldwide. The Royal Commission on the Health of the Army established in 1857 addressed the deficiencies experienced by the soldiers in the Crimea. The sanitary improvements were extended to hospitals and barracks in England when it was confirmed that the British soldier at home died at a much higher rate than the general population. The India Sanitary Commission, completed in 1863, sought to rectify the deplorable conditions of the military in India. The sanitary recommendations were extended to the general population, saving untold lives.
Nightingale established standards and outcomes for nursing, demanding that applicants have educational potential and dedication to the profession. Her war experiences caused her to focus nursing on altering the environment to maximize patient outcomes. Based on these principles, she established the Nightingale School of Nursing at St. Thomas' Hospital in 1860. Further, she worked to extend nursing through the development of educated midwifery, district nursing, poorhouse nursing, and nursing in the military. Her experiences and vision moved nursing from an underpaid and apprenticed occupation to a profession that has become an educated and necessary component of modern health care. Florence Nightingale died on August 13, 1910, in London. She is buried in the family plot at St. Margaret's Church, East Wellow, Hampshire, England.
SEE ALSO: Crimean War (1853–1856).
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