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A time to celebrate: Florence Nightingale.

Spring is recognized as a special time for planting seeds in anticipation of flourishing flora that sustain life. During this commemorative time of year, nurses also recognize Florence Nightingale (1820-1910) for her many years of planting and nurturing seeds of a different nature that changed nursing forever. Florence (a pioneer of nursing and hospital reformer) spread numerous seeds of experience, wisdom, understanding, and reform that would later blossom into the profession of nursing. She cultivated an environment that would not only change the world of nursing, but also that of healthcare. In commemoration of her many contributions, May 12th is designated as a day to remember and honor Florence Nightingale (see Figure 1).

On May 12, 2016, I had the opportunity to attend a commemorative ceremony for Florence in Great Britain and stand before her grave. Her final resting place is in an ancient courtyard cemetery outside the Church of Saint Margaret of Antioch Darenth (Church of England), established around the 11th century (Wellow History Society, 2002). Her initials are the only form of identification on her grave stone (see Figure 2). As a nurse with more than 40 years in the profession, the experience was humbling and profound. I couldn't help but reflect on her life accomplishments, and the opportunities and experiences I have been afforded because of her legacy.

Florence Nightingale's Contributions

Florence's contributions to nursing were based on her deep-seated belief that nurses should maintain a leadership role in healthcare reform and not just accept the status quo (Nightingale, 1859). She believed nurses should not only be involved in caring for individuals during sickness, but also during times of wellness. For much of Florence's adulthood, her impressive mission in life was to serve humankind by promoting wellness and preventing senseless morbidity and mortality. She tenaciously pursued this aspiration by taking on various administrative roles in a variety of settings, including the British military healthcare system.

Florence is best known for her contributions toward the reformation of the British military healthcare system during the 19th century (Cohen, 1984, Sarmadi, 2014). This reformation occurred through Florence's relentlessness to convince others to implement many of the basic health and hygiene principles that are now taken for granted in present day healthcare systems. This undertaking was a monumental endeavor because during this time in history, nurses were not considered professionals, and women in general were evaluated against contextual social restraints of Victorian England. Florence was keenly aware of these barriers. As a result, she knew that in order to implement changes to the British healthcare system, she would need effective administrative skills and a considerable amount of evidence to persuade skeptical men in power (Ulrich, 1992).

Crimean War

Florence experienced firsthand the complexities of improving healthcare and conditions of the sick and wounded during the Crimean War (1854-1856). In September 1853, thousands of British and French troops deployed to Crimea to join Turkey in its war against the Russian Empire for control of the Ottoman Empire (Sarmadi, 2014). By early 1854, military hospitals had admitted more than 18,000 soldiers. It was not long before word came back from Crimea that the healthcare and hospital conditions for the sick and wounded soldiers were disgustingly inhumane. In response to these reports, Sidney Herbert, the Secretary at War, recruited Florence to be chief nurse of a military hospital at Scutari, Turkey. At this time, British military hospitals in support of the Crimean War did not employ female nurses. With official backing by the government and private financial funds, Florence and a team of 38 trained nurses traveled to the Scutari military hospital in Turkey.

Upon arrival to Scutari, the team of nurses found a dilapidated, filthy, quadrangle building that was overcrowded, unsanitary, and infested with rodents and bugs. Many of the sick and wounded were on dirty floors or harsh straw mats. Other soldiers were on cots with rank soiled sheets because laundry facilities for patients were nonexistent there. There was no clean running water, and most drains and sewers were clogged with feces and filth. A putrid stench circulated among the rooms and throughout the corridors. Essential surgical and medical equipment were scarce due to impeded distribution from "military red tape." The overcrowded, unsanitary, and poor patient care resulted in 90% of the soldiers dying from diseases, such as typhus, typhoid, cholera, and dysentery, rather than battle wounds (Stanley, 2007).

This horrendous scenario represented a complete antithesis of Florence's beliefs about proper nursing and patient care. She believed that nursing "ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet and the proper selection and administration of diet--all at the least expense of vital power to the patient" (Nightingale, 1859, p. 8). Nightingale understood that many health problems were related to diet, dirt, and drains. She arranged for food to be sent from England. She had the kitchens cleaned and had her team of nurses scrub the hospital wards. She purchased clean linen and blankets, and made arrangements for a laundry facility to be installed on the premises. She contacted the British government and orchestrated the arrival of Sanitary Commission administrators to come onsite to repair the sewers, provide clean running water, and improve ventilation (Fee & Garofalo, 2010).

Leader of Change

The blatant, callous, and unwelcoming attitude of physicians and staff who perceived the nurses as being in their way was another complication. As the chief nurse, Florence faced many frustrating obstacles, but rather than blaming and oppressing the current hospital administration or taking it all on herself, she appropriated a more calculated approach. Her approach was based on her convictions about what it meant to be in charge. According to Florence (Nightingale, 1859):

To be in charge is certainly not only to carry out the proper measures yourself but to see that everyone else does so too; to see that no one either willfully or ignorantly thwarts or prevents such measures. It is neither to do everything yourself nor to appoint a number of people to each duty, but to ensure that each does that duty to which he is appointed. (p. 25)

Florence's efforts for change were challenged every step of the way by military authorities who resisted any modification that could potentially indicate their own errors or incompetence. Despite overwhelming barriers, she convinced leaders to make significant changes by collecting and providing statistical data based on the hospital's medical records. Florence discovered the hospital's medical records were not being accurately recorded and maintained. Fortunately, in her earlier years, she had experience with a form of qualified inquiry of social facts and forces that could be numerically represented. She invented a polar-area chart, in which the statistic being represented was proportional to the area of a wedge in a circular diagram (see Figure 3). She used these diagrams to present reliable data on the incidence of preventable deaths at Scutari to the military leaders (McDonald, 2010). Florence was able to show that within six months after the team of nurses arrived at Scutari, the hospital mortality rates plummeted from 42.7% to 2.2% (Cohen, 1984; Nightingale, 1858a; b). Her polar-area chart convinced military leadership to not only accept nurses as an asset, but to value Florence's recommendations for healthcare reform on a much greater scale.

Florence's success as a leader was also due to her ability to be flexible. Florence was extremely insightful about implementing change and its relationship to leadership and management, as can be seen in her following notes: "Look for the ideal, but put it into the actual" (Barritt, 1975, p. 38). "Do not be fettered by too many rules at first. Try different things and see what answers best" (Barritt, 1975, p. 14). Although Florence spent long hours conducting administrative duties, she managed to visit the sick and wounded soldiers most evenings. Alone, she wandered among the soldiers providing care, holding a lamp in her hand. The carrying of her lamp on endless rounds at night gave rise to the "lady with the lamp" legends (Stanley, 2007).

Contributions to Nursing Education

Florence is also well known as the founder of nurse training programs that provided a sound foundation for nursing as a profession. In 1859, she wrote the first modern nursing curriculum for St. Thomas Hospital in London. Her book, titled Notes on Nursing (Nightingale, 1859), was the first published nursing text book. Her endurance and need to provide consistency in nursing care resulted in the development of the first standards of care for nurses. Many of these early standards of care remain relevant today as the profession of nursing continues to integrate her early perceptions of health promotion, risk reduction, and disease prevention.

Conclusion

Florence laid down the foundation for the profession of nursing that we know today. She left nurses so many precious seeds for education, practice, and research. Like most professionals, nurses face many disruptions and distractions at work and home. As a result, there is a tendency to get lost in our own struggles and forget why we became nurses. During this celebratory time of year, take time to remember Florence as the person who encountered conflict and suffering to make nursing a profession that you can be proud of.

doi:10.7257/1053-816X.2017.37.2.57

Editor's Note: After completion of one year as a member of the Urologie Nursing Editorial Board, Nancy Steele has resigned her position due to health issues. I will miss her deep understanding of research methods and ability to work with authors to complete necessary edits for manuscript publication.

--Jane Hokanson Hawks, PhD, RN-BC, FAAN, Editor

References

Barritt, E.R. (1975). Florence Nightingale: Her wit and wisdom. Mount Vernon, NY: Peter Pauper Press.

Cohen B. (1984). Florence Nightingale. Scientific American, 250(3), 128-137.

Duyckinick, E.A. (1873). Portrait gallery of eminent men and women in Europe and America. New York, NY: Johnson, Wilson & Company.

Fee, E., & Garofalo, M.E. (2010). Florence Nightingale and the Crimean War. American Journal of Public Health, 100(9), 15-91.

McDonald, L. (2010). Florence Nightingale: Passionate statistician. Journal of Holistic Nursing, 28(1), 92-98. doi:10.1177/ 0898010109358769

Nightingale, F. (1858a). Notes on matters affecting the health, efficiency and hospital administration of the British Army. London, United Kingdom: Harrison.

Nightingale, F. (1858b). Mortality of the British Army at home, at home and abroad, and during the Russian War, as compared with the mortality of the civil population in England. London, United Kingdom: Harrison.

Nightingale, F. (1859). Notes on nursing: What it is and what it is not. London, United Kingdom: Harrison & Sons.

Sarmadi, M.T. (2014). Florence Nightingale who raised nursing as a highly profession International Journal of Nursing Science, 4(3), 33-36. doi:10.5923/j.nursing.20140403.01

Stanley, D. (2007). Lights in the shadows: Florence Nightingale and others who made their mark. Contemporary Nurse, 24(1), 45-51.

Ulrich, B.T. (1992). Leadership and management according to Florence Nightingale. Norwalk, CT: Appleton & Lange.

Wellow History Society. (2002). The Parish Church of St. Margaret of Antioch. East Wellow, United Kingdom: St. Margaret's Parochial Church Council.

<ADD> Nancy M. Steele, PhD, WHNP-BC, RNC-BC Urologie Nursing Editorial Board Member </ADD>

Caption: Figure 1. Portrait of Florence Nightingale Source: Duyckinick, 1873. (U.S. public domain tag: {{PD-US}}--Published in U.S. before 1923 and public domain in the U.S.)

Caption: Figure 2. Florence Nightingale's Grave at St. Margaret's Church, Wellow, UK Source: Photograph by Dr. Nancy Steele.

Caption: Figure 3. Florence Nightingale's Polar-Area Diagram: Causes of Mortality During the Crimean War Notes: Published in Notes on Matters Affecting the Health, Efficiency, and Hospital Administration of the British Army and sent to Queen Victoria in 1858. U.S. public domain tag: {{PD-US}}--Published in U.S. before 1923 and public domain in the U.S.
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Author:Steele, Nancy M.
Publication:Urologic Nursing
Date:Mar 1, 2017
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