Florence Nightingale’s Nursing and Health Care: The Worldwide Legacy, As Seen on the Bicentenary of Her Birth

Aim: The aim of this article is to articulate the distinctive features on the Nightingale School of Nursing on the occasion of the 2020 bicentenary of her birth. Design: This is a historical study, based on all the available printed and archival sources of Nightingale’s writing. Methods: The article draws on Nightingale sources (full books, articles, chapters, pamphlets and unpublished letters in more than 200 libraries and archives worldwide) published in The Collected Works of Florence Nightingale, 16 volumes, peer-reviewed; transcriptions are available on its website [1]. Results: Nine key findings are discussed in the article: (1) how different Nightingale’s nursing was from what was called ‘nursing’ at the time; (2) that the central role of training allowed nursing to move from being a women’s profession to being open to all qualified; (3) the evolution of Nightingale nursing as medical science and public health advanced; (4) the academic content in her training; (5) team building in her system; (6) her (often misrepresented) views on germ theory; (7) her late work on preventing cholera; (8) the worldwide influence of her work; (9) her work upgrading workhouse infirmaries and advocacy of what would be later called universal access to health care. Conclusion: Nightingale’s ongoing relevance is evident in many of today’s concerns, such as lack of access to quality health care; the shortage of nurses in the United Kingdom’s National Health Service (and in some other countries) and inadequate wages and salaries of nurses and nurse practitioners; the ongoing dangers in nursing and the need to give nurses a safe working environment (the coronavirus is an extreme example); and inadequate data for health care planning purposes.


Introduction
In 2020, on the celebration of the bicentenary of Florence Nightingale's birth in 1820, it is timely to give an assessment of the significant long-term contribution she made to the creation of the modern nursing profession and to the advancement of health care more generally. The World Health Organization named 2020 the 'Year of the Nurse and Midwife' in recognition of Nightingale's enormous contribution to the founding of the modern professions of nursing and midwifery. Yet she continues to be misunderstood, misrepresented, and, in some places, attacked. The Commonwealth Nurses and Midwives Federation, for example, celebrates the Year of the Nurse and Midwife on its website, but declines to recognize the bicentenary. Nightingale, it says, was 'controversial.'

The Originality of Nightingale Nursing
While Nightingale is typically recognized as the 'founder' or 'major founder' of the modern nursing profession, some sources have her drawing on earlier sources, implying she was not so original:  The Anglican nuns at University College Hospital did provide some training before Nightingale's school, but only for the lower ranks; full-fledged nuns were assumed not to need it. Moreover, the care they gave was more spiritual than physical [6]). As well, there is no information on what the training entailed: no books, lecture notes, or examinations.
The principles and key elements of Nightingale nursing came from the lessons she learned during the Crimean War (1854-56). Notes on Nursing, 1860, is a positive statement of all the things required to prevent and treat disease and promote health. Its chapters methodically set out the need for ventilation and warming, food, bed and bedding, light, cleanliness of rooms, and personal cleanliness, all defects in the war hospitals [7]. Nightingale had seen first-hand the terrible condition of the soldiers coming into her hospital from the camps, which themselves were grossly defective in lodging and sanitation, while the food provided was inadequate (many soldiers arrived with scurvy).
Then, with the massive renovations and cleaning up achieved by the Sanitary Commission, and camp conditions improved with the work of the Supply Commission, death rates declined to no more than those in peacetime army hospitals in England. This convinced Nightingale of the efficacy of what would later be known as 'evidence-based nursing' or health care [8]. That her nursing theory took environmental conditions into account stems from the horrendous environmental conditions she had to contend with in the Crimean War hospitals.
Death rates, it must also be realized, were then high even in the best teaching hospitals in London, roughly 10 percent of admissions [9]. While Nightingale insisted that all nurse training take place in hospital, she gave much attention to the development of 'district' or 'home visiting' nursing. Such nurses had to be trained in hospital to see an adequate range of cases (this applied also to army nursing). They then required supervision in the field by an experienced district nurse. District nurses had to be of a higher standard than hospital nurses, for they did not have a doctor close by to call on in an emergency. District nursing had another obvious advantage: the avoidance of hospitals, which remained dangerous places.
Notes on Nursing was written before Nightingale's school opened, and was not intended to be a textbook, although it was assigned by the second medical instructor to the probationers at her school at St Thomas' Hospital, John Croft. Moreover, nurses cannot do all the things set out as their duties in it. Obviously, if the windows of a hospital do not open, the nurse cannot open them. Nightingale published two later editions of Notes on Nursing, both of them reflecting the low state of the health sciences of the time. All pre-date Joseph Lister's paper on antiseptic surgery (1867) [10] and Robert Koch's publication of the four postulates of germ theory in 1879 [11]. The rudimentary level of medical practice must not be forgotten: leeches were still applied (from the ancient four humours theory), and cholera belts, to dry up sweat, were used by the army.
Nightingale's vision of nursing was always holistic, featuring health promotion and disease prevention. She always factored in environmental conditions. How she incorporated motivation by religious faith into professional nursing also deserves attention. She was herself motivated by a religious 'call to service,' as were many of the nurses who trained at her school. However, she insisted on nursing being open to members of any faith or none at all. At that time nursing in many countries was provided by members of religious orders, and open only to them, not secular women. The Nightingale School was the start of professional nursing; that is, the creation of a profession-when women were allowed in no others-that provided decent salaries and opportunities for promotion, and did not require any specific religious commitment, let alone being a nun.
Nightingale was also firm that nursing itself was the goal with its object the physical body, albeit one that had a mind/soul interacting with it. She permitted nurses of religious faith to say a word 'in due season' about their faith, but did not want more. Chaplains were appointed to hospitals to deal in detail with patients who wanted to pursue faith issues.

Gender and Nursing
The fact that Nightingale nursing was based on training made it possible to incorporate men as nurses when improved education for women opened other professions to them and various social changes made nursing a good choice for men. Certainly, Nightingale's new profession was for women only, at a time when they were permitted in no other profession such as the armed forces, Parliament, civil service, or the clergy. However, she never considered that gender made anyone a nurse, and acknowledged the nursing skills (notably observation) of several men. The famous General Gordon claimed nursing skills and interests, and Nightingale said in a letter of 30 August 1886 that 'his love of the sick, his experience, made him of the same profession as I am' [1].
Ann Oakley argues, like many feminist commentators and nursing leaders, that if Nightingale 'had trained her pupils in assertiveness rather than obedience, perhaps nurses would be in a different place today' [12]. However, it is more likely that if Nightingale had encouraged assertiveness, doctors would not have accepted her nurses at all, and why should they have? The requirement to enter her training school was mere literacy and good character. There was no educational qualification at all, for few women then had the equivalent of secondary-school education, let alone university or medical school. It is remarkable that Nightingale went ahead when demographics provided such a challenge.

Nightingale's Revisions to Her Nursing Model
Nightingale's views on nursing evolved largely from contacts with professionally active nurses , for she herself did not nurse after 1856, apart from making referrals for her 'caseload' of relatives, friends, employees, and villagers. Beginning in 1872, Nightingale undertook systematic meetings with the senior staff of the school and probationers (some, not all) after their first year. She continued such meetings for nearly 30 years, all the while liaising with medical instructors on nursing, midwifery, and hospital care. Her writing in the 1880s and 1890s is scarcely known by academic nurses, even nursing historians, but it reflects advances in the health sciences and the consequent increase in requirements for nurse training.
Nightingale's famous definition of health appears only in these later writings, not in her 1860 Notes on Nursing: 'Health is not only to be well, but to be able to use well every power we have to use' [13] .The similarity with the definition of health adopted by the World Health Organization is 1948 is obvious: 'Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity' [14].
Nightingale continued to stress a holistic approach in her later writing. In 'Nursing the Sick,' in Quain's Dictionary of Medicine, she wrote, 'all that is wanted to enable Nature to set up her restorative processes, to expel the intruder disturbing her rules of health and life. For it is Nature that cures, not the physician or nurse.' The physician or surgeon gave the instructions for treatment, but 'the nurse carries them out' [13].

Academic Content in Nightingale Training
The secondary literature is often wrong on the academic content of Nightingale nursing; however, Seymer's book on the centenary of the School`s founding (1960) remains a good source [15]. Nursing was basic at first, when nurses and nursing students were not allowed even to take a patient's temperature. The criticism of F.B. Smith, the highly inaccurate author of Florence Nightingale: Reputation and Power, was not off the mark when he called this no more than 'applied housekeeping' [16]. However, what was taught at the School was soon updated to include 'elementary instruction in chemistry, physiology, anatomy, surgery, medicine' [1]. Nightingale was sent information on potential medical appointees to St Thomas', and she met with some of them. We know what the probationers were taught, for the (second) instructor, John Croft, with a grant from the Nightingale Fund, published his lectures [17]. For no other school was there any comparable publication. Dr Joseph Bell published his lectures to probationers at the Royal Edinburgh Infirmary in 1887 [18] and dedicated the volume to Nightingale-the Edinburgh school was in effect a second Nightingale School. Only qualified medical doctors were allowed to teach the probationers at St Thomas' throughout Nightingale's lifetime. At other schools, the matron or superintendent began to give lectures from the 1890s at least.

Team Building in the Nightingale System
Nightingale was conscious of the need to change the culture at a hospital when bringing in trained nursing. A trained nurse should never be sent alone to a hospital, but go with a team of nurses, desirably trained at the same school, with a matron from it as well. Otherwise, the lone nurse would likely succumb to the prevailing low standards rather than bring others up to hers. This was, in fact, done, at least for the early, carefully planned

Misinterpretations of Nightingale's View of Germ Theory
Contrary to much nursing secondary literature, Nightingale did not oppose germ theory all her life, but it appears only in her late writing. In a paper she published in an Indian public health journal in 1891, she called for slides to be included in village lectures to show 'the obnoxious living organisms in foul air and water,' which she thought would motivate people to clean up their water supply ('Sanitation in India,' [1]). Still, she preferred to emphasize dealing with the habitat of germs, the assault on them, as opposed to their identification, the task of bacteriologists. This seems not to have caused any offence at the time, as doctors understood that knowledge of bacteriology did not necessarily lead either to prevention or effective treatment. Clearly, such knowledge is essential for developing vaccines and assessing treatment results, but there was a long gap in the production of results. The eminent Russian bacteriologist Dr Waldemar Haffkine, later Nobel laureate for his vaccines for cholera and plague, notably wanted to meet Nightingale when he was in England on India work. They probably did not meet, but he sent her a copy of his book on inoculation for cholera, with a respectful dedication (1895), now housed at the Wellcome Library [19]. Koch's definitive work on the identification of cholera dates to 1883 and was published in 1884, but that did not make him an expert on prevention [20]. Nightingale learned of his research later, when Dr Sutherland bought 'a beautiful Vienna microscope' to show the cholera bacilli, and was convinced, as related by Cook [21].

Nightingale's Late Work on Cholera Prevention
Nightingale continued to be a source of practical information on disease prevention in times of epidemic. She was asked by the New York Herald to provide advice when a cholera epidemic was expected. Her 'Scavenge, Scavenge, Scavenge' (1884) was the result, reprinted in an American public health journal, The Sanitarian, A Monthly Magazine Devoted to the Preservation of Health, Mental and Physical, founded by a leading American public health expert, A.N. Bell [22]. 'Scavenge' gave some historical background and exploded several common myths about the disease, ending with: 'Vigorously enforce sanitary measures, but with judgment, e.g., scavenge, scavenge, scavenge; wash, cleanse and lime wash; remove all putrid human refuse from privies and cesspits and cesspools and dustbins.' Specifics she gave included 'stables and cowsheds and pigsties,' 'crowded places, dirty houses and yards.' In the UK in 1892, when another epidemic was expected, Dr Ernest Hart (1892) quoted 'Scavenge' at a special meeting of the National Health Society [23]. The society would supply cheap handbills with directions, advice repeated in The Times (1892) [24]. It is not known whether Nightingale or someone else added the crucial advice: 'boil water.'

The Worldwide Influence of Nightingale Nursing
Nightingale's influence on the development of the modern nursing profession is generally well known, but probably what is not so familiar is the diversity of countries where it was felt. From her school at St Thomas' Hospital, the new system spread throughout England, Scotland, and Ireland (beginning in Belfast, then moving to Dublin), Australia, Canada, the United States, and Europe (related in Florence Nightingale: Extending Nursing [1]). She provided leadership in nursing to the end of her working life (roughly 1900), mentoring nurses from her own school, intervening with authorities when they were in trouble, sending them care packages when they were despondent, and receiving aspiring nurse leaders from other countries at her home for mentoring. This included protracted meetings with the first trained nurse in the United States, Linda Richards, who in turn shaped nursing in many hospitals/states in America and later in Japan. Nightingale mentored Isabel Hampton, later Robb, who became the most influential nursing leader in the late nineteenth and well into the twentieth century through her books [25]. Nightingale's influence was felt even when she was not directly involved, such as with the earliest Cuban nurses. She was the inspiration for the nurse who led in the establishment of professional nursing in Nigeria, Kofoworola Abeni Pratt. Pratt trained at the Nightingale School in London and was the first black nurse in the NHS [26].
What Nightingale did to introduce and support nursing beyond her own hospital is abundantly clear in letters sent to her from nurses around the world. Nightingale kept their letters, as she did letters from inquiring would-be nurses and their mothers, as well as vicars and their wives looking for a trained nurse or midwife for their parish, and hospital authorities wanting trained nurses from her school. Very often Nightingale's reply is not extant, but there is a wealth of social and public health history in the material she kept, all available on the website of the Collected Works [1].
Nightingale's influence on the introduction of professional nursing in Australia has been given much negative coverage, as evident in a major journal article by Judith Godden, 'A Lamentable Failure: The Founding of Nightingale Nursing in Australia' [27]. The title of Godden's full-length book treatment of the first matron, Lucy Osburn, a Lady Displaced [28], is misleading, given that Osburn had held the post for 17 years, when she was replaced by an Australian nurse she had trained. Newspaper accounts of Osburn's departure show that she left with full honours.
It became fashionable to assert that the Nightingale School did not have much influence on the development of nursing. Yet, while it is true that the numbers it trained were not large, and other schools, like the London School, were much larger, its actual influence was enormous, by its sending out nursing leaders who inaugurated trained nursing in so many hospitals, in many countries. Table 1 presents a list of hospitals, of various kinds, that got a matron or superintendent from the Nightingale School between 1861 and 1899, the effective end of Nightingale's supervisory role.

From the Reform of the Workhouse Infirmaries to Universal Access to Health Care
Nightingale's concerted efforts at transforming the workhouse infirmaries into regular hospitals is arguably her greatest contribution to heath care. At the time, workhouse infirmaries had only rudimentary medical attendants and nursing only by 'pauper nurses,' untrained and notorious for drinking their meagre wages. Bed sharing was common, soap was not provided, and towels were shared. Thanks to the support of Liverpool philanthropist William Rathbone and the leadership given by Nightingale nurse Agnes Jones, Liverpool made the crucial breakthrough in 1865 in providing trained nurses. Other improvements were brought in gradually. The Highgate Infirmary, London, became in 1870 the second to get trained nurses, a development made possible by the passing of the Metropolitan Poor Act in 1867. Nightingale wrote a brief for the committee studying the issue (1: CW 6:367-90). Thanks to an amendment made by her brother-in-law, Sir Harry Verney, who chaired the Nightingale Fund, the law also made it possible for workhouse infirmaries to form training schools. Trained nurses were gradually employed at them, and nursing schools were established; some even got state-of-the art, pavilion-style buildings.
The establishment of the National Health Service in 1948 would not have been possible without these improvements, for more than 80 percent of the 'hospitals' of the United Kingdom were those dreaded workhouse infirmaries. Name changes also helped to remove the workhouse stigma when the 'Poor Law Board' became the 'Local Government Board' and the Metropolitan Asylums Board was formed with no association with the old workhouses. Nightingale fully understood the stigma of the Poor Law, obvious especially when most of the workhouse infirmaries were physically located on the same premises as the workhouse itself. Gradually, top trained nurses took positions at them, such as Elizabeth Vincent at St Marylebone Workhouse Infirmary. Edith Cavell was night superintendent at the St Pancras Workhouse Infirmary.
Baly suggested that if Nightingale's advice on the Poor Law been taken, 'there might have been a universal health service before 1948.' Further, 'had health been taken out of the "hideous system," preventive medicine would not have been tarred with the Poor Law brush.' She noted also that 'Nightingale was a prime mover in the reform of midwifery services' [29] Certainly no one else had as bold a vision as had Nightingale, who had to bring along allies whose aims were limited to visiting the sick in workhouses, as were Rathbone's initial motivation and Louisa Twining's. Changes in names of reform organizations show Nightingale's influence: Twining founded the Workhouse Visiting Society in 1858, the Workhouse Infirmary Nursing Association in 1879. Doctors initially concerned to get drugs provided to workhouse patients formed the Poor Law Medical Relief Association. Then, when Nightingale showed, in Liverpool in 1865, how much further reforms could go, they upped their goal to form the Association for the Improvement of the Infirmaries of the London Workhouses.
The National Health Service Act, adopted in 1946, provided for the first single-payer system in the world, to establish what would later be called 'universal access to health care.' It provided, right in the first paragraph, 'a comprehensive health service designed to secure improvement in the health of the people of England and Wales and the prevention, diagnosis and treatment of illness.' In other words, health promotion and disease prevention are right up there with treatment services themselves, as Nightingale had always advocated. Those provisions, of course, have been modified over time, and a large measure of private care brought in. As well, advances in the health sciences and related technological developments have massively increased the demands made on the system. So many more diseases and injuries can now be successfully treated than Nightingale ever anticipated, but the tough work of providing for treatment, health promotion, and prevention, with budget cuts and environmental challenges, make her a useful model, and indeed one that continues to inspire.

Conclusion
Given the great gap in time between Nightingale's period of writing and today, her core principles are remarkably relevant. Medical science, public health, and nursing practice itself have all changed radically, but the coronavirus pandemic, which emerged in early 2020, shows how many of the problems she had to confront have reappeared: the need for timely, accurate, data for responding; the principle of access to quality care for all, including the poorest; the importance of housing as it affects disease and death, for how can the homeless 'go home and stay home'? Nurses, since Nightingale's time, have become the largest health care profession in the world, yet there are serious shortages in some countries, notably the UK. She, from early on, called for better measures to ensure the safety and well-being of nurses as well as of doctors, clearly an ongoing issue.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval
Not applicable.