CHAPTER 6 Florence Nightingale 1820-1910 Modern Nursing Susan A. Pfettscher “Recognition of nursing as a professional endeavor distinct from medicine began with Nightingale” 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 Buropean 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’ father educated her more broadly than other girls of the time. Her father and (Chinn & Kramer, 2011, p. 26). 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. 491). ‘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 Uuaining 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 em- ployed to examine hospital facilities, reformatories, Previous authors: Susan A. Pfettscher, Karen R. de Grail, Ann Marriner Tomey, Cynthia L. Mossman, and Maribeth Slebodnik. 60CHAPTER 6 Florence Nightingale GI and charitable institutions. Only 2 years after com- pleting her training (in 1853), she became the super- intendent 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 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 mis- sion 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 dis eases as they recovered from their battle wounds. Nightingales 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 emo- tional 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's Hospital and Kings College Hospital in London, Within a few years, the Nightingale School began to receive requests to establish new schools at hospitals world- wide, and Florence Nightingales reputation as the founder of modern nursing was established 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. She continued to concentrate on army sanitation reform, the functions of army hospitals, sanitation in India, and sanitation and health care 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 Hospi- tals (Nightingale, 1858b), and Report on Measures Adopted for Sanitary Improvements in India, from June 1869 to June 1870 (Nightingale, 1871), 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 80 years of age, she wrote between 15,000 and 20,000 letters to friends, acquain- tances, allies, and opponents. Her strong, clear written word conveyed her beliefs, observations, and desire for change in health care 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, Nightingale received powerful persons as visitors in her home to maintain dialogue, plot strategies to support causes, and carry out her work, During her lifetime, Nightingales work was recog. nized 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 90 years of age. Modern biographers and essayists have attempted to analyze Nightingale’ lifework through her family relationships, notably with her parents and sister. Film dramatizations have focused frequently and in- accurately 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 biogra- phies have been written to describe Nightingale’ life and work. Cook (1913) wrote the first original and comprehensive biography of Nightingale, which was based on her written papers, but it may have been biased by her family’s involvement in and oversight of the 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62 un IT I_Nursing Philosophies from 1820 to 1856; however, the second volume, which would have described the rest of her life and activities, was never published. Woodham-Smith’ 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 defini- tive biography of Nightingales life, and although it is more balanced, it maintains a positive tone. E.B. Smith (1982) wrote Florence Nightingale: Reputa- tion and Power, which is critical of Nightingales character and her work. Small (1998) published yet another Nightingale biography titled Florence Night- ingale: Avenging Angel. Although he is critical of specific aspects of her character and work, Small is, more balanced in his presentation. He notes that Nightingale’ 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 life- style continue; a London newspaper recently reported on newly found letters related to the conflicts Night- ingale had with Sir John Hall (chief British army medical officer in the Crimea) (Kennedy, 2007). 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’ life and work. Dossey’s (2000) comprehensive book, Florence Nightingale: Mystic, Visionary, Healer, provides another in-depth history and interpretation of Nightingales personal life and work. Using quotes from Nightin- gales own writings (diaries and letters) and from 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 Nightingale. In an intro- duction/prelude to her descriptions of spirituality for nurses’ lives based on Nightingales writings, Macrae (2001) explores Nightingales personal spirituality as, she interprets it after review of writings and docu- ments. Lorentzon (2003) more recently has provided a review and analysis of letters written between Night- ingale and one of her former students that clearly dem- onstrate her role as mentor, Finally, all of Nightingales surviving writings are in the process of being published as ‘Ihe Collected Works of Florence Nightingale. To date, fourteen of the sixteen volumes have been published under the leadership of sociologist and Nightingale scholar Lynn McDonald (McDonald, 2001-present). ‘This large project and other newly discovered/released documents continue to spawn articles and books that explore, interpret, and speculate on Nightingale’ life and work. In addi tion, she has published a new biography of Nightingale (McDonald, 20102) Theoretical Sources for Theory Development Many factors influenced the development of Nightin- gale’ 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 immediate and long-term change throughout the world ‘As noted, Nightingales education was an unusual one for a Victorian girl. Her tutelage by her well- educated, intellectual father in subjects such as mathe- matics 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 re- ented 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 itis one that was accepted for Nightingale. It remains unknown whether or not Nightingale was a genius who wouldCHAPTER 6 Florence Nightingale 63 have been great leader and thinker under any circum- stance, 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 commen: taries and novels provided English society with scathing commentaries on health care and the need for health and social reform in England. In the serialized novel (1843 to 1844), 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’ alliance with Dickens undoubtedly in- fluenced her definitions of nursing and health care and her theory for nursing; that relationship also provided her with a forum for expressing her views about social and health care issues (Dossey, 2000; Kalisch & Kalisch, 1983a; Woodham-Smith, 1951) MAJOR CONCEPTS & DEFINITIONS Similar dialogues with political leaders, intellectuals, and social reformers of the day (John Stuart Mill, Benjamin Jowett, Edwin Chadwick, and Harriet ‘Marineau) advanced Nightingales philosophical and logical thinking, which is evident in her philosophy and theory of nursing (Dossey, 2000; Kalisch & Kalisch, 19834; 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. Finally, Nightingale’ 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 com- munity 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. Nightingales 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), Nelsons review of pastoral care in the nineteenth century provides an interesting historical view of the role of religious service in nursing (Nelson, 1997), Nightingale’ theory focused on environment, how- ever Nightingale used the term surroundings in her writing. She defined and described the concepts of ventilation, warmth, light, diet, cleanliness, and noise—components of surroundings usually re- ferred to as environment in discussions of her work. When reading Notes on Nursing (Nightingale, 1969) one can easily identify an emphasis on the physical environment. In the context of issues Nightingale identified and struggled to improve (war-torn envi- ronments and workhouses) , this emphasis appears to be most appropriate (Gropper, 1990). Her con- cern about healthy surroundings involved hospital settings in Crimea and England, and also extended to the public in their private homes and to the physical living conditions of the poor. She believed Continued64___ UNIT II_Nursing Philosophies MAJOR CONCEPTS & DEFINITIONS—cont’d that healthy surroundings were necessary for proper nursing care and restoration/maintenance of health. Her theoretical work on five essential components of environmental health (pure air, pure water, effi- cient drainage, cleanliness, and light) is as relevant today as it was 150 years ago, Proper ventilation for the patient seemed to be of greatest concern to Nightingale; her charge to nurses wwas to “keep the air he breathes as pure as the exter- nal air, without chilling him’ (Nightingale, 1969, p. 12), Nightingales emphasis on proper ventilation indicates that she recognized the surroundings as a source of disease and recovery. In addition to dis- cussing ventilation in the room or home, Nightingale provided a description for measuring the patients body temperature through palpation of extremities to check for heat loss (Nightingale, 1969). The nurse wwas instructed to manipulate the surroundings to maintain ventilation and patient warmth by using a good fire, opening windows, and properly posi- tioning the patient in the room. ‘The concept of light was also of importance in Nightingales theory. In particular, she identified direct sunlight as a particular need of patients. She noted that “light has quite as real and tangible effects upon the human body ... Who has not observed the purifying effect of light, and especially of direct sun- light, upon the air of a room?” (Nightingale, 1969, pp. 84:85). To achieve the beneficial effects of sun- light, nurses were instructed to move and position patients to expose them to sunlight. Cleanliness is another critical component of Nightingales environmental theory (Nightingale, 1969). In this regard, she specifically addressed the patient, the nurse, and the physical environment. She noted thata dirty environment (floors, carpets, walls, and bed linens) wasa source of infection through the organic matter it contained, Even if the environment ‘was well ventilated, the presence of organic material created a dirty area; therefore, appropriate handling 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, and disposal of bodily excretions and sewage were required to prevent contamination of the environ- ‘ment. Finally, Nightingale advocated bathing patients on a frequent, even daily, basis at a time when this practice was not the norm, She required that nurses also bathe daily, that their clothing be clean, and that they wash their hands frequently (Nightingale, 1968). This concept held special significance for individual patient care, and it was critically important in im- proving the health status of the poor who were living in crowded, environmentally inferior conditions with inadequate sewage and limited access to pure water (Nightingale, 1969). ‘Nightingale included the concepts of quiet and diet in her theory. The nurse was required to assess the need for quiet and to intervene as needed to maintain it (Nightingale, 1969). Noise created by physical activities in the areas around a patients room was to be avoided because it could harm the patient. Nightingale was also concerned about the patient's diet (Nightingale, 1969). She instructed nurses to assess not only dietary intake, but also the meal schedule and its effect on the patient. She believed that patients with chronic illness could be starved to death unintentionally, and that intelligent nurses successfully met patients’ nutritional needs. Another component of Nightingale’ writing was a description of petty management (nursing admin- istration) (Nightingale, 1969). She pointed out that the nurse was in control of the environment both physically and administratively. The nurse was to protect the patient from receiving of upsetting news, seeing visitors who could negatively affect recovery, and experiencing sudden disruptions of sleep. In addition, Nightingale recognized that pet visits (small animals) might be of comfort to the patient. ‘Nightingale believed that the nurse remained in charge of the environment, even when she was rot physically present, because she should oversee others who worked in her absence. Her expertise as a statistician is evident in the reports that she generated throughout her lifetime on the varied subjects of health care, nursing, and social reform.CHAPTER 6 Florence Nightingale 65 Nightingale’ 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 ofthe British Army Founded Chiefly on the Experience of the Late War (Nightingale, 1858a). This Commis- sion had been organized in response to Nightingales 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 revolution- ary notion that social phenomena could be objectively measured and subjected to mathematical analysis” (1984, p. 128). Palmer (1977) described Nightingales research skills as including recording, communicat ing, ordering, coding, conceptualizing, inferring, ana lyzing, and synthesizing. The observation of social phenomena at both individual and systems level 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, Major Assumptions Nursing ‘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, Nightin- gales 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. Person In most of her writings, Nightingale referred to the person as a patient, Nurses performed tasks to and for the patient and controlled the patient’ environment to enhance recovery. For the most part, Nightingale described a passive patient in this relationship. How- ever, specific references are made to the patient per- forming self-care when possible and, in particular, being involved in the timing and substance of meals ‘The nurse was to ask the patient about his or her preferences, which reveals the belief that Nightingale saw each patient as an individual. However, Nightin- gale (1969) emphasized that the nurse was in control of and responsible for the patient’ environmental surroundings. Nightingale had respect for persons of various backgrounds and was not judgmental about social worth, Health Nightingale defined health as being well and using every power (resource) to the fullest extent in living life. ‘Additionally, she saw disease and illness as a reparative process that nature instituted when a person did not attend to health concerns. Nightingale envisioned the maintenance of health through prevention of disease via environmental control and social responsibility What she described led to public health nursing and the more modern concept of health promotion. She distinguished the concept of health nursing as different from nursing a sick patient to enhance recovery, and from living better until peaceful death. Her concept of health mursing exists today in the role of district nurses and health workers in England and in other countries where lay health care workers are used to maintain health and teach people how to prevent disease and illness. Her concept of health nursing is a model employed by many public health agencies and depart- ‘ments in the United States, Environment ‘Nightingale’s concept of environment emphasized that nursing was “to assist nature in healing the patient, Little, if anything, in the patient's world is excluded from her definition of environment. Her admonition to nurses, both those providing care in the home and trained nurses in hospitals, was to create and maintain a therapeutic environment that would enhance the comfort and recovery of the66 un IT Il_Nursing Philosophies patient, Her treatise on rural hygiene includes an incredibly specific description of environmental problems and their results, as well as practical solutions to these problems for households and com- munities (Halsall, 1997) Nightingales assumptions and understanding about the environmental conditions of the day were most relevant to her philosophy. She believed that sick poor people would benefit from environmental improvements that would affect both their bodies and their minds. She believed that nurses could be instru- mental in changing the social status of the poor by improving their physical living conditions. Many aristocrats of the time were unaware of the living conditions of the poor. Nightingales mother, however, had visited and provided care to poor fami- lies in the communities surrounding their estates; Nightingale accompanied her on these visits as a child and continued them when she was older. ‘Thus Nightingale’s understandings of physical surround- ings and their effect on health was acquired through first-hand observation and experience beyond her own comfortable living situation. 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), 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’ recovery. Nightingale was totally committed to nursing edu- cation (training). She wrote Notes on Nursing (1969) for women caregivers, making a distinction between the role of houschold servants and those trained specifically as nurses to provide care for the sick per- son. Nightingale (1969) believed that nurses needed to be excellent observers of patients and the environ: ment; observation was an ongoing activity for trained nurses, In addition, she believed that nurses should ‘use common sense in practice, coupled with observa. tion, perseverance, and ingenuity. 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 ridiculed for say- ing she didn't embrace 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 observa- tions 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 sug- gests that disease germs cause inevitable infection, Such a theory was antithetical to her belief that sanitation and good hygiene could prevent infec- tion, Her belief that appropriate manipulation of the environment could prevent disease underlies modern sanitation activities. Nightingale did not explicitly discuss the caring behaviors of nurses. She wrote very litle about inter personal 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. Her own example of nursing practice in the Crimea provides evidence of caring behaviors. ‘These include her commitment to observing 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 a reading room and materials during their recuperation. Finally, she wrote letters to their families following soldiers’ deaths. Watson defines Nightingale’s descrip tions/behaviors as a “blueprint for transpersonal meanings and models of caring” (Watson, 2010, p- 107). Neils (2010) describes a nursing role of caring as a liaison nurse based on Nightingales description of rounding. She interprets this activity as a way ofCHAPTER 6 Florence Nightingale 67 expressing caring and spiritual support while also achieving other nursing observations, Straughair (2012) reports that a loss of compassion in nursing (as a component of caring) was identified by patients, in the National Health Service in England and pleads for nursing attention to this aspect of Nightingales Christian ideal of professional nursing. Similarly, both Burkhart and Hogan (2008) and Wu and Lin (2011) have conducted research to identify the spiritual care in nursing practice as first described by Nightingale. The settings of these stud- ies (US. and Taiwan) reflect the universality of Nightingales work. Straughair (2012) makes the case that there needs to be a rediscovery of compas- sion that appears to be diminishing in modern nursing. Finally, Wagner and White (2010) explore and analyze “caring relationships” in Nightingales own writings. ‘This historical study contributes to our understanding of how Nightingale described the modern concept of caring. Nightingale believed that nurses should be moral agents, She addressed their professional relationship with their patients; she instructed them on the prin- ciple of confidentiality and advocated for care of 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 deci- sion 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 having to make a decision. Hoyt (2010) analyzed how Nightingale defined nursing as an ethical profession and the ethical practices embedded in nursing, Logical Form ‘Nightingale used inductive reasoning to extract laws of health, disease, and nursing from her observations and experiences, Her childhood education, particularly in philosophy and mathematics, may have contributed to her logical thinking and inductive reasoning abili- ties. For example, her observations of the conditions in the Scutari hospital led her to conclude that the contaminated, dirty, dark environment led to disease. Not only did she prevent disease from flourishing in such an environment, but also validated the outcome by careful record keeping, From her own training, her brief experience as a superintendent in London, and her experiences in the Crimea, she made observations and established principles for nurse training and patient care (Nightingale, 1969). Acceptance by the Nursing Community Practice ‘Nightingales nursing principles remain the foundation of nursing practice today. ‘The environmental aspects ofher theory (ie. ventilation, warmth, quiet, diet, and cleanliness) remain integral components of nursing care. As nurses practice in the twenty-first century, the relevance of her concepts continues; in fact, they hhave increased relevance as a global society faces new issues of disease control. Although modern sanita- tion and water treatment have controlled traditional sources of disease fairly successfully in the United States, contaminated water due to environmental changes or to the introduction of uncommon contami nants remains a health issue in many communities. Global travel has altered dramatically the actual and potential spread of disease. Modern sanitation, ade- quate water treatment, and recognition and control of other methods of disease transmission remain challenges for nurses worldwide. ‘New environmental concerns have been created by modern architecture (eg., sick-building syndrome); nurses need to ask whether modern, environmentally: controlled buildings meet Nightingales principle of good ventilation. On the other hand, controlled environments increasingly protect the public from second-hand cigarette smoke, toxic gases, auto emis- sions, and other environmental hazards. Disposal of these wastes, including toxic waste, and the use of chemicals in this modern society challenge profes- sional nurses and other health care professionals to reassess the concept of a healthy environment (Butterfield, 1999; Gropper, 1990; Michigan Nurses Association (MNA), 1999; Sessler, 199). Shaner- ‘McRae, McRae, and Jas (2007) described environ- mental conditions of our hospitals that affect not only the individual patient environment but also the larger environment incorporating multiple environmental concepts identified by Nightingale. While they focus on Western hospitals, it is evident that this is a global challenge for nurses.6s un IT I_Nursing Philosophies In health care facilities, the ability to control room temperature for an individual patient often is increas- ingly difficult. This same environment may create great noise through activities and the technology (equipment) used to assist the patients reparative process. Nurses have looked in a scholarly way at these problems as they continue to affect patients and. the health care system (McCarthy, Ouimet, & Daun, 1991; McLaughlin, McLaughlin, Elliott, & Campalani, 1996; MNA, 1999; Pope, 1995). Monteiro (1985) provided the American public health community with a comprehensive review of Nightingale’s work as a sanitarian and a social re- former, reminding them of the extent of her impact on health care in various settings and her concern about poverty and sanitation issues. Although other disciplines in the United States have increasingly ad- dressed such issues, itis clear that nurses and nurs. ing have an active role in providing direct patient care and in becoming involved in the social and political arenas to ensure healthy environments for all citizens, McPhaul and Lipscomb (2005) have applied Night ingale’s environmental principles to practice in occu ational health nursing. These nurse specialists have increasingly recognized current environmental health, problems at local, regional, and global levels. Modern changes in travel, migration, and the physical environ- ment are causing health problems for many. Infectious diseases (e.g., HIV, TB, West Nile virus) are examples of these changes. In addition, nurses are confronted by an epidemic of toxic substances and nosocomial infections and the development of resistant organisms (eg, MRSA) in their patient care environments; first-line prevention measures of handwashing and environmental cleanliness harken back to Nightingale’s original environmental theory and principles. Other problems created by environ- mental changes and pollution might astound Night- ingale, but she would probably approach them in a typically aggressive fashion for control. As health care systems and providers struggle to promote patient safety through prevention of infection in health care facilites, this work can be framed in these words of Florence Nightingale: “It seems a strange principle to enunciate, as the very first requirement, in a hospital that it should Do the Sick No Harm” (Vincent, 2005). Although some of Nightingales rationales have been modified or disproved by medical advances and scientific discovery, many of her concepts have endured the tests of time and technological advances. Itis clear that much of her theory remains relevant for nursing today. Concepts from Nightingales writings, from political commentary to scholarly research, continue to be cited in the nursing literature. Several authors have analyzed Nightingales petty ‘management concepts and actions, identifying some of the timelessness and universality of her manage- ment style (Decker & Farley, 1991; Henry, Woods, & Nagelkerk, 1990; Monteiro, 1985). More recently, Lorentzon (2003) focused specifically on Nightingales role as a mentor to a former student in her review and analysis of letters written between her and her former student Rachel Williams. ‘This analysis provides a review of mentoring approaches based on Nightingale’s theories; her comments on management as offered to Rachel Williams would stimulate good discussion about the needs of nurses today for mentoring and professional development. Lannon (2007) and Naraya. nasamy and Narayanasamy (2007) based their exami nations of nursing staff and leadership development on Nightingale’ statements about the essential need for continued learning in nursing practice. Finally, several writers have analyzed Nightingales role in the suffrage movement, especially in the con- text of feminist theory development. Although she has been criticized for not actively participating in this movement, Nightingale indicated in a letter to John Stuart Mill that she could do work for women in other ways (Woodham-Smith, 1951). Her essay titled Cassandra (Nightingale 1852) reflects support for the concept that is now known as feminism, Scholars continue to assess and analyze her role in the feminist movement of this modern era (Dossey, 2000; Hektor, 1994; Holliday & Parker, 1997; Selanders, 2010; Welch, 1990), Selanders (2010) argues powerfully that ‘Nightingale was a feminist and that her belief as a feminist were integral to the development of modern professional nursing. Education ‘Nightingales principles of nurse training (instruction in scientific principles and practical experience for the ‘mastery of skills) provided a universal template for early nurse training schools, beginning with St. ThomassCHAPTER 6 Florence Nightingale 69 Hospital and King’s College Hospital in London, Using the Nightingale model of nurse training, the following three experimental schools were established in the United States in 1873 (Ashley, 1976): 1, Bellevue Hospital in New York 2, New Haven Hospital in Connecticut 3. Massachusetts Hospital in Boston “The influence of this training system and of many of its principles is still evident in today's nursing pro- grams. Although Nightingale advocated independence of the nursing school from a hospital to ensure that students would not become involved in the hospital's labor pool as part of their training, American nursing schools were unable to achieve such independence for many years (Ashley, 1976). Nightingale (Decker & Farley, 1991) believed that the art of nursing could not be measured by licensing examinations, but she used testing methods, including case studies (notes), for nursing probationers at St. Thomas’ Hospital. Clearly, Nightingale understood that good practice could result only from good education. This message resounds throughout her writings on nursing. Night ingale historian Joanne Farley responded to a modern nursing student by noting that “Training is to teach a nurse to know her business... . Training is to enable like an intelligent and responsible being” (Decker & Farley, 1991, pp. 12-13). Itiis difficult to imagine what the care of sick human. beings would be like if Nightingale had not defined the educational needs of nurses and established these first schools. the nurse to act for the best Research science and practice throughout the world. Most notable is her focus on surroundings (environment) and their importance to nursing, Finally, itis interest- ing to note that Nightingale used brief case studies, possible exemplars, to illustrate a number of the con- cepts that she discussed in Notes on Nursing (1969). Further Development ‘Nightingale’s philosophy and theory of nursing are stated clearly and concisely in Notes on Nursing (1969), Nightingale’s most widely known work. In this writing, she provides guidance for care of the sick and in so doing clarifies what nursing is and what it is not. The content of the text seems most amenable to theory analysis. Hardy (1978) proposed that Night- ingale formulated a grand theory that explains the totality of behavior. As knowledge of nursing theory has developed, Nightingales work has come to be recognized as a philosophy of nursing. Although some formulations have been tested, most often prin: ciples are derived from anecdotal situations to illus trate their meaning and support their claims. Her work is often discussed as a theory, and it is clear that Nightingale’s premises provide a foundation for the development of both nursing practice and current nursing theories. Tourville and Ingalls (2003) de- scribed Nightingale as the trunk of the living tree of nursing theories. Critique Clarity ‘Nightingale’ interest in scientific inquiry and statistics continues to define the scientific inquiry used in nurs- ing research, She was exceptionally efficient and resourceful in her ability to gather and analyze data; her ability to represent data graphically was first iden- tified in the polar diagrams, the graphical illustration style that she invented (Agnew, 1958; Cohen, 1984; McDonald, 2010b). Her empirical approach to solving problems of health care delivery is obvious in the data that she included in her numerous reports and letters. When Nightingales writings are defined and ana- lyzed as theory, they are seen to present a philo- sophical approach that is applicable in modern nursing. Concepts that Nightingale identified serve as the basis for research adding to modern nursing Nightingale’s work is clear and easily understood. It contains the following three major relationships: 1, Environment to patient 2, Nurse to environment 3. Nurse to patient Nightingale believed that the environment was the main factor that created illness in a patient and regarded disease as “the reactions of kindly nature against the conditions in which we have placed our- selves” (Nightingale, 1969, p. 56). Nightingale recog- nized the potential harmfulness of an environment, and she emphasized the benefit of a good environment in preventing disease. ‘The nurse's practice includes manipulation of the environment in a number of ways to enhance patient7 un IT I_Nursing Philosophies recovery. Elimination of contamination and contagion and exposure to fresh ait, light, warmth, and quiet were identified as clements to be controlled or manipulated in the environment. Nightingale began to develop relationships between some of these elements in her discussions of contamination and ventilation, light and patient position in the room, cleanliness and darkness, and noise and patient stimulation. She also described the relationship between the sickroom and the rest of the house and the relationship between the house and the surrounding neighborhood The nurse-patient relationship may be the least ‘well defined in Nightingale’s writings. Yet cooperation and collaboration between the nurse and patient is suggested in her discussions of a patient's eating pat terns and preferences, the comfort of a beloved pet to the patient, protection of the patient from emotional distress, and conservation of energy while the patient is allowed to participate in self-care. Finally, itis inter- esting to note that Nightingale discussed the concept of observation extensively, including its use to guide the care of patients and to measure improvement or lack of response to nursing interventions, Simplicity ‘Nightingale provides a descriptive, explanatory theory. Its environmental focus along with its epidemiological components has predictive potential. Nightingale could be said to have tested her theory in an informal manner by collecting data and verifying improvements. She intended to provide general rules and explanations that ‘would result in good nursing care for patients. Thus her objective of setting forth general rules for the practice and development of nursing was met through this simple theory. Generality Nightingales theories have been used to provide general guidelines for all nurses since she introduced them more than 150 years ago. Although some activities that she described are no longer relevant, the universality and timelessness of her concepts remain pertinent. Nurses are increasingly recogniz- ing the role of observation and measurement of outcomes as an essential component of nursing practice. Burnes Bolton and Goodenough (2003), Erlen (2007), Robb, Mackie, & Elcock (2007), and Weit-Hughes (2007) all have written about measure- ment of patient outcomes and methods of quality improvement based on Nightingales notions of observation. ‘The relation concepts (nurse, patient, and environment) remain applicable in all nursing settings today. Therefore they mect the criterion of generality. Empirical Precision Concepts and relationships within Nightingales the- ory frequently are stated implicitly and are presented as truths rather than as tentative, testable statements. In contrast to her quantitative research on mortality performed in the Crimea, Nightingale advised the nurses of her day that their practice should be based on their observations and experiences. Her concepts are amenable to studies with the qualitative approaches of today as well as quantitative methods. Derivable Consequence: To an extraordinary degree, Nightingales writings direct the nurse to take action on behalf of the patient and the nurse. These directives encompass the areas, of practice, research, and education. Her principles to shape nursing practice are the most specific. She ‘urges nurses to provide physicians with “not your opinion, however respectfully given, but your facts” (Nightingale, 1969, p. 122). Similarly, she advises that “if you cannot get the habit of observation one way or other, you had better give up being a nurse, for itis not your calling, however kind and anxious you may be" (Nightingale, 1968, p. 113). ‘Nightingale’ view of humanity was consistent with her theory of nursing, She believed in a creative, uni- versal humanity with the potential and ability for growth and change (Dossey, 2000; Hektor, 1994; Palmer, 1977). Deeply religious, she viewed nursing as, a means of doing the will of her God. The zeal and self-righteousness that come from being a reformer might explain some of her beliefs and the practices that she advocated. Finally, the period and place in which she lived, Victorian England, must be consid- ered if one is to understand and interpret her views. Nightingales basic principles of environmental ‘manipulation and care of the patient can be applied in contemporary nursing settings. Although subjected to some criticisms, her theory and her principles areCHAPTER 6 Florence Nightingale 71 relevant to the professional identity and practice of nursing, ‘As one reads Notes on Nursing, sentences and observations made by Nightingale can have great significance for the world of nursing today. Vidrine, Owen-Smith, and Faulkner (2002) have identified one of these observations as the guiding theory for their work with equine-facilitated group psycho- therapy: “a small pet animal is often an excellent companion for the sick, for long chronic cases espe- cially” (Nightingale, 1969, p. 102). Although a horse may not qualify as a “small animal in the sickroom,” these authors have found that their therapy is suc- cessful with their patients. Indeed, Nightingale is a testament to her own theory; it is reported that she had 60 cats over her lifetime (she was chronically ill for much of her adult life and lived to 90 years of age). Summary Florence Nightingale is a unique figure in the history of the world. Her picture appeared on the English 10-pound note for 100 years. No other woman has been and still is revered as an icon by so many people in so many diverse geographical locations. Few other figures continue to stimulate such interest in, contro- versy about, and interpretation of their lives and work, The nursing profession embraces her as the founder of modern nursing. Nightingale defined the skills, behaviors, and Knowledge required for professional nursing. Rem- nants of these descriptions serve the nursing profes- sion well today, although their origins probably are not known by today’s nurses, Because of scientific and social changes that have occurred in the world, some of Nightingale’s observa- tions have been rejected, only to find after closer analysis that her underlying beliefs, philosophy, and observations continue to be valid. Nightingale did not consciously attempt to develop what is considered a theory of nursing; she provided the first definitions from which nurses could develop theory and the conceptual models and frameworks that inform pro- fessional nursing today. Professionals increasingly identify her as their matriarch. Mathematicians revere her for her work as an outstanding statistician. Epidemiologists, public health professionals, and lay health care workers trace the origins of their disciplines to Nightingales descriptions of people who perform health promotion and disease preven- tion, Sociologists acknowledge het leadership role in defining communities and their social ills, and in working to correct problems of society as a way of improving the health of its members. A century after Nightingales death, nursing com- munities throughout the world gave special attention to her life and work. In particular, the Journal of Holistic Nursing published multiple articles (cited in this chapter). Of special note is Beck's (2010) article identifying Seven Recommendations for 21st Century ‘Nursing Practice based on Nightingales philosophy offering a clarion call for nurses throughout the world to emulate the work of Nightingale. ‘Nurses, both students and practitioners, would be wise to become familiar with Nightingales original writings and to review the many books and documents that are increasingly available (McDonald, 2001 to present). If you have read Notes on Nursing, rereading it will reveal new and inspirational ideas and provide a brief look at her wry sense of humor. The logic and common sense that are embodied in Nightingales ‘writings serve to stimulate productive thinking for the individual nurse and the nursing profession. To emu- late the life of Nightingale is to become a good citizen and leader in the community, the country, and the world. tis only right that Nightingale should continue tobe recognized as the brilliant and creative founder of modern nursing and its first nursing theorist. What ‘would Nightingale say about nursing today? Whatever she would say, she probably would provide an objec- tive, logical, and revealing analysis and critique. CASE STUDY mi | You are caring for an 82-year-old woman who has been hospitalized for several weeks for burns that she sustained on her lower legs during a cooking accident. Before the time of her admission, she lived alone in a small apartment. ‘The patient reported on admission that she has no surviving family. Her support system appears to be other Continued