Abigail Richardson
Sheffield, UK

Florence Nightingale (1820–1910), the British nurse who became known as the “Lady with the Lamp,” is remembered for her work during the Crimean War and as a statistician and public health advocate.¹ Her lifelong dedication to nursing led to her being the first female Fellow of the Royal Statistical Society (1858) and honorary member of the American Statistical Association (1874), as well as being awarded the Order of Merit by King Edward VII (1907).¹ She was the founder of the first school of nursing (1860) and published many books that helped shape modern medicine.²

Born in Florence, hence her name, she was raised in Derbyshire and Hampshire to William and Frances Nightingale, who were wealthy landowners.^3,4 Florence and her sister were educated by her father and private tutors. She studied modern languages, mathematics, literature, and philosophy, skills that would benefit her in later life.^5,6 From a young age Florence attended the sick in Derbyshire, and by the age of sixteen she had felt a “call to service.”^4,5 Her family did not support a career in nursing as it was seen as a lower-class occupation and not appropriate for her. She was instead encouraged to tour Europe, which she used as an opportunity to observe different medical institutions and also to practice nursing in Kaiserwerth Hospital, Germany, in 1850 and again in 1851.^4,6,7 While abroad in 1847, she met Sidney Herbert (the Secretary of War), and on returning to Britain in 1853, he arranged for her to be appointed as superintendent of the Establishment for Gentlewomen During Illness, where she inspected hospitals, lobbied to reform hospital nursing, and worked to promote the idea of opening nursing schools to government circles.^4,6

During the Crimean War (1854–1856), Britain and France sent troops to Crimea in support of the Ottoman Empire against Russia.⁶ Reports came of ill and sick British soldiers being transported by boat from the Crimean battlefield to Scutari, many not surviving the trip, and met there by appalling hospital conditions.⁸ One in five men sent to Scutari died there, predominantly from infectious diseases such as typhoid, relapsing fever, malaria, dysentery, and pneumonia.⁸ It was reported that the French Army was better equipped and cared for their troops better than their British allies.⁶ This put considerable pressure on the British government to improve the hospital conditions for the wounded, and it also led Sidney Herbert to ask Florence to travel to Crimea.⁸

In November 1854, Florence Nightingale arrived at the British Army hospital in Scutari with thirty-eight volunteer nurses.⁹ She was met with a hospital in disrepair, contaminated water sources, short supplies of medicines and essential items, and infestations of rats, bugs, and lice.^9,10 At this time infection was not properly understood but was believed to travel through bad air—miasmas.¹¹ Florence asked for a sanitary commission to help improve the hygiene in the hospital.² The commission unblocked the sewers and water tanks and also cleaned and painted the hospital walls.¹¹ Clean, warm clothing and adequate nutrition and shelter were provided for the wounded men.² Nightingale and her nurses worked hard, focusing on “diet, drains and dirt,”⁹ and were able to reduce the mortality to 2.7% in just a few months.⁶ Also, Florence created a triage system for the injured soldiers and reported statistics and collected data that showed more men died from infection than from their battle wounds.¹¹ She standardized recordkeeping in hospitals and presented data in polar area charts, which were a fairly new concept.¹⁰ Florence was then able to apply this data to military hospitals, an effort which resulted in her induction into the Royal Statistical Society and later recognition by the American Statistical Association.^2,10

When Florence and her nurses arrived at the Army hospital, they were at first met with resistance from the doctors.¹⁰ However, by rigidly following regulations and through her team’s hard work, Florence was able to improve the relationships between the doctors and the nurses, forming arguably one of the earliest multidisciplinary teams.^4,10

In May 1955, Florence collapsed from “Crimean Fever” (brucellosis), and although she returned to work by August 1955, her health was affected for the rest of her life.¹² It has been argued that she may have suffered from either bipolar disorder or PTSD, but this did not affect her post-war contributions.¹² Returning home, she was received as a hero and was able to bring topics such as public health, nursing, and statistical analysis to the public’s attention.⁵

Because of her ill health, she spent most of her time confined to her room, where she published Notes on Matters Affecting Health, Efficiency and Hospital Administration of the British Army and in 1859 Notes on Nursing and Notes on Hospitals.^6,13 Most of her work focused on health reform, but she also covered a range of other topics, such as public health in India, workhouses, and hospital construction and management.¹⁴ She promoted the pavilion hospital method, which aimed to maximize ventilation and reduce cross-infection.^6,15 She suggested adapting large buildings into new hospitals by widening corridors and adding separate wings and improving ventilation by increasing windows.¹¹ This style of hospital was used by William Alexander Hammond in the US Civil War, and Florence was frequently consulted on how to best manage field hospitals.^1,14 The design was also implemented in the new St Thomas’ Hospital, and the model is still used today.^6,14

In 1855 Queen Victoria set up a Nightingale Fund, and in 1860 this fund was used to open the first nursing school, the Nightingale Home and Training School, at St Thomas’ Hospital in London.^6,10,11 Before Florence Nightingale, there had been little training for nurses, and they were often regarded as incompetent and as individuals who could not be employed in other professions.⁴ Her work during the Crimean War changed the public perception of nursing and inspired many other women to pursue nursing.¹ Her book Notes on Nursing was used in the nurses’ educational curriculum.^4,15 Nightingale aimed to produce academic, moral, and professional women who would work in public institutions and hospitals.⁴ Students from the school were encouraged to teach others and set up other Nightingale schools, and Florence pioneered the system of matrons in charge of junior nurses, with both working together as a team.^11,15 Much of her work contributed to modern nursing and changed the public view of the profession.¹⁶ It was the first attempt at professionalizing nursing and was holistic and based on health promotion and disease prevention.¹⁵

In later life, Florence went blind and likely suffered from dementia.^6,12 She died at age ninety in 1910.⁶ Up to her death, she continued to have an active role in nursing, and her impact on sanitation and ventilation, evidence-based practice, multi-disciplinary teams, and statistical analysis of hospitals continues to the present day.¹⁵

References

1. “Florence Nightingale.” History. November 9, 2009. Last updated January 10, 2023. Accessed March 14, 2023. https://history.com/topics/womens-history/florence-nightingale-1.
2. McDonald L. Florence Nightingale: The making of a hospital reformer. Health Environments Research & Design Journal 2020;13(2):25-31. doi:10.1177/1937586720918239
3. Matheson A. Florence Nightingale: A Biography. 1913. Project Gutenberg ebook published July 4, 2021. Available from: https://gutenberg.org/cache/epub/65762/pg65762-images.html.
4. Glasper A. Celebrating Florence Nightingale and her contribution to nursing. British Journal of Nursing 2020;29(13):790-1.
5. McDonald L. Florence Nightingale on Public Health Care. Waterloo, Ont.: Wilfrid Laurier University Press; 2001. Available from: https://ebookcentral.proquest.com/lib/sheffield/reader.action?docID=685772.
6. Ellis H. Florence Nightingale: Creator of Modern Nursing and Public Health Pioneer. Journal of Perioperative Practice 2019;30(5):145-6.
7. Nightingale F, McDonald L (ed.). Florence Nightingale’s European Travels. Waterloo, Ont.: Wilfrid Laurier University Press; 2004. Available from: https://ebookcentral.proquest.com/lib/sheffield/reader.action?docID=685773.
8. Gill CJ, Gill GC. Nightingale in Scutari: Her legacy reexamined. Clinical Infectious Diseases 2005;40(12):1799-805.
9. Fee E, Garofalo ME. Florence Nightingale and the Crimean War. American Journal of Public Health 2010;100(9):1591.
10. Malpas P. Florence Nightingale: Appreciating Our Legacy, Envisioning Our Future. Gastroenterology Nursing 2006;29(6):447-52.
11. McEnroe N. Celebrating Florence Nightingale’s Bicentenary. Lancet 2020;395(10235):1475-8.
12. Meissner T. Shimmering Somberness: The Lady with the Lamp. CME (Berlin, Germany). 2015;12(6):32-3. doi:10.1007/s11298-015-1.
13. Nightingale F. Florence Nightingale’s Notes on Nursing and Notes on Nursing for Labouring Classes: Commemorative Edition with Historical Commentary. Skretkowicz V, ed. New York: Springer; 2010.
14. Lescott C, Jumah F, Raju B, Gupta G, Nanda A. The contributions of William A. Hammond (1828–1900) to Civil War Medicine & Modern Neurology. Clinical Neurology and Neurosurgery 2021;208:106867.
15. McDonald L. Florence Nightingale’s nursing and health care: The worldwide legacy, as seen on the bicentenary of her birth. SciMedicine Journal 2021;3(1):51-8.
16. Hogan S. Florence Nightingale (1820–1910) – what does history say about her feminism? Journal of Gender Studies 2020;30(8): 915-26. doi:10.1080/09589236.2020.1845627.