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		Thoughts on the Nightingale legacy* Francis C. Biley Centre for Qualitative Research, Bournemouth University, United Kingdom Mail delivery: Centre for Qualitative Research. Bournemouth University, Royal London House, Christchurch Road, Bournemouth, Dorset BH1 3LT, United Kingdom Manuscript accepted by 3.8.2010 Temperamentvm 2010; 12 *I gave this presentation at the yearly general meeting of the Nursing Society of Honor of England, during which our group was subscribed to the Sigma Theta Tau of Nursing. We hope to become full members of Sigma Theta Tau in May 2011. This presentation took place at the University of Bournemouth on 21st July 2010
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    It is with some trepidation that I confronted the topic of Florence Nightingale and her nursing legacy. Some trepidation, because as I completed more preparative reading, I realised that in reality, it could be argued that Florence Nightingale left us with very little in the terms of a nursing legacy, and I say the term nursing as if it should be in italics; I'll explain that more later on. I realise that to say such a thing may be bordering on some form of blasphemy, but there you are, I've said it now, I'm going to have to defend myself, probably poorly.

Over the next few minutes, I'm going to try to make things interesting and might introduce you to some lesser known Nightingale facts, but I realise that many if not all of you, may know them already. At the same time, I will try to explore a number of aspects and issues that have made me come to the conclusion that in nursing at least, there is little more to the Nightingale legacy than a celebration of her past life and achievements and some controversies and morbid curiosities, many of which may have relevance to and may inform nursing, but in reality, could have little to do with nursing at all.

There is no need to remind you that Florence was born on the 12 May 1820, and died on the 13 August 1910. In 1844 she began her nursing career. In 1854 she travelled to Scutari in the Crimea with 38 Nightingale trained nurses. Contrary to popular belief, the death rate of the wounded soldiers did not drop on Nightingale's arrival, indeed it initially increased. Although it could be said that Nightingale was a disciple of Edwin Chadwick, the great Victorian sanitarian who was instrumental in formulating the Public Health Act of 1848 (that probably had a greater impact on the health of the nation than any medical intervention), it was not until the Sanitary Commission arrived from Britain to clean the drains did the death rate begin to fall. Point number one - it was Edwin Chadwick's work that inspired Nightingale to bring about sanitary reform, and not Nightingale herself.

Although she believed that cleanliness was important, Nightingale believed that it was nutrition and exhaustion, rather than insanitary conditions, that killed the soldiers.

After Nightingale had been at Scutari for about a year, the Nightingale Fund for the Training of Nurses was established in London. With £45,000, she established the Nightingale Training School in July 1860, shortly after the first publication of Notes on Nursing in December 1859 in which Nightingale wrote:

"Every day sanitary knowledge, or the knowledge of nursing, or in other words, of how to put the constitution in such a state as that it will have no disease, or that it can recover from disease, takes a higher place. It is recognised as the knowledge which every one ought to have - distinct from medical knowledge, which only a profession can have".

Now for me, this is real nursing, in order to paraphrase that oft quoted line by Nightingale "the role of the nurse is to place the patient in the best possible environment for nature to act upon him". In recent correspondence with the great Felicity Stockwell, she has quoted, or probably paraphrased, again from Notes on Nursing that:

"The art of cultivating good health is as important as the art of sick-nursing - with stress on prevention rather than cure - nursing proactive rather than reactive. Also note, it is nursing the sick person, and not nursing sickness. Nature attempts to cure, and nursing must put the patients in the best possible conditions for nature to restore health".

In order to achieve this, Nightingale, as expressed in Notes on Nursing identified, for example, the importance of cleanliness (brought to an abrupt end by the Salmon Report perhaps), fresh air, reducing extraneous noise to a minimum, that a carefully placed aspidistra can have healing qualities, and that a gentle aire played on the piano, can sensibly "soothe the sick". But is this what nurses, nowadays, do? It is perhaps what they should do, but is it what they actually do?

In examining the nurses' role, that is, what nurses actually do, Davina Allen, an ex-colleague of mine, defined contemporary nursing activity as being no more or less than one of mediation. In a paper published in Nursing Inquiry in 2004, entitled "Re-reading nursing and re-writing practice: towards an empirically based reformulation of the nursing mandate", Allen concludes that:

"A decade of ethnographic research reveals that, contrary to contemporary theories which promote an image of nursing work centred on individualised unmediated caring relationships, in real-life practice the core nursing contribution is that of the healthcare mediator".

Allen defined eight "bundles of activity" that nurses perform, including:

1. Prioritizing care and rationing resources.
2. Maintaining a record.
3. Obtaining, fabricating, interpreting and communicating  information.
4. Mediating occupational boundaries.
5. Managing the work of others.
6. Bringing the individual into the organisation.
7. Circulating patients.
8. Managing multiple agendas.

Now this is somewhat ironic. Allen describes contemporary nursing in a way that cannot be recognized from the way that it is described in Notes on Nursing, or indeed, by most modern nursing textbooks, or as it is taught in most if not all nursing curricula in the UK and throughout the Western World (on how many required or recommended reading lists is Notes on Nursing, I wonder? And who has read Cassandra? I, for one, have to admit that I haven't). However, a close reading of Nightingales nursing activities, not how its described in Notes on Nursing, nor how it was taught in Nightingale's Training School for Nurses, but how nursing was practiced by her and her team in Scutari, reveals that Nightingale's definition of nursing might be more closely associated with Allen's definition that might first be thought. I don't have the time to provide extensive evidence of this, but in order to make a point, Gill and Gill, in the journal Clinical Infectious Diseases, 2005, in a paper entitled "Nightingale in Scutari: her legacy re-examined", list Nightingale's "nursing" activity that...

"Brought her skills as a nurse. But she also brought prodigious managerial skills, an obsession with meticulous record keeping, and a deep faith in the Sanitarian movement... She helped establish a rational system for receiving and triaging the injured soldiers. She set up huge boilers to destroy lice and found honest washerwomen who would not steal the linens. She shamed hospital orderlies into removing buckets of human waste, to clean up the raw sewage that polluted the wards, and to unplug latrine pipes. At her behest, new windows capable of opening were installed to air out the wards. She established a separate kitchen in Barracks Hospital. In response to rampant petty corruption that was siphoning off medical supplies, she established a parallel supply system for critical materials and food. And, significantly, she kept meticulous records of everything she saw or did".

In addition to this of course, we all know about her relationships with the doctors at Scutari, with was one very much based on negotiation.

As you can see, altogether, this maps pretty closely onto Allen's definition of the nurses' role. When I recently confronted Davina Allen with my conclusions, she said that was perfectly understandable, the Nightingale Model of Care was a managerial model, and not a professional one.

The Nightingale Training School produced nurses who went on to establish their own schools and practice, essentially throughout the United Kingdom and some of the rest of the world, notably Australia. However, her influence wasn't universal.

I will give just two examples of this. Although it is widely thought that Linda Richards trained under Nightingale, she only visited her briefly after completing her nurse training in the US, but did spend some time elsewhere in the UK (a total of seven months). Linda Richards, was a pioneering US nurse, among other things night superintendent at New York's Bellevue Hospital and founder of the nursing school movement in Japan from 1885 onwards In a recent STTI page, IYNurse 2010 it is stated that "Japanese nursing has strong ties with Florence Nightingale and the United States" but this is clearly not the case. Anna Maxwell, was another pioneering American nurse, of Scottish decent, who was night superintendent at New York's Presbytarian Hospital. As far as I can establish, she had no Nightingale connections but and went on to form Columbia University's School of Nursing; founded the American Journal of Nursing (or did she,...perhaps it was Mary Davis) and became known as the American Florence Nightingale. I have no time here to mention other famous American nurses, such as Isabel Hampton or Lavinia Dock.

So what am I trying to say here? Well, it might be poorly argued, but I suppose I am saying that as her legacy Nightingale might be considered to have had little impact on contemporary nursing clinical practice, and in addition, that she did not revolutionize nurse training worldwide. These are then, points two and three.

Point one, was that she did consider the Sanitary Movement as significant, but drew her inspiration from Chadwick, rather than generate these insights herself. As a reviewer of Mark Bostridge's Nightingale biography acknowledged, she did little more than "she assisted reform, and outshone others owing to her fame". Point two, is that contemporary clinical practice is rarely influenced by Notes on Nursing and her other related writing, many will never have heard of her concepts of 'sanitary' and 'handicraft' nursing; and point three is that she alone was not solely responsible for the worldwide emergence of issues related to nurse training.

There can be few people in history who have had their lives examined in as much detail as Nightingale. Lynn McDonald, in her recent book Florence Nightingale at First Hand: Vision, Power, Legacy (where interestingly, she called Nightingale a radical religious fundamentalist of the intelligent design type), her other work and in her extensive and comprehensive series of collected works is one such historian.

Another is Barbara Dossey, who's Nightingale Initiative for Global Health perhaps does little more than exploit Nightingales name (albeit with good intentions), but who has written a range of publications that exhibit careful historical scholarship and analysis. Notably, her book.

But also numerous other publications. I am not sure what is to be gained from calling Nightingale a Mystic, or by investing in her strange healing and other powers as the title suggests (although I must admit I've not read the book). However, another recent publication of hers, in the JHN, examines Nightingale's health, fascinatingly examining the issue of whether she had Brucellosis or not. This is not a new idea of course, but has been identified for many years (primarily in a source that Dossey does not reference). This has little to do with her legacy of course, but what so what... its interesting...

Nightingale experienced a debilitating illness for at least 32 years, from the time of her arrival in the Crimea. Thought to be Crimean Fever, perhaps depression and even a variety of other things, Dossey seems to prove that Nightingale had chronic brucellosis, a disease characterized by a range of severe symptoms, including joint degeneration and mental fatigue rather than any neurotic complaints.

But here I am, getting diverted from my topic, and diverted towards the woman, not the work, but there may be a message I that. It could be said that Nightingale the woman, has eclipsed Nightingale's work. Her fame, of course, has lead her to be called, by Lytton Strachey, the second most eminent Victorian woman. This might be point number four.

Before I begin to run out of time, I want to end on an up note, or rather three up notes. On her arrival in Scutari, Nightingale realised that many medical interventions the "heroic medicine of the day, which was based on infusions of arsenic, mercury, opiates, and bleeding, hastened the deaths of many more patients than it saved" (Gill and Gill). Nightingale began to look after those patients for which there was little hope and who had been abandoned by the medical system. By keeping patients clean and as comfortable as possible, she improved the hygiene and sanitisation of her patients and hospitals, thus perhaps laying the foundations not only of infection control (is this point number five?), but also hospice, or end of life care (point number six). Indeed, to quote Gill and Gill again in relation to infection control:

"Many of our current health care practices, such as isolation of patients with antibiotic-resistant pathogens, avoidance of cross-contamination, routine cleansing of all patient areas, aseptic preparation of foods, ventilation of wards, and disposal of human and medical wastes, trace their origins to practices enacted by Nightingale at Scutari".

And in relation to hospice care, she used to make sure to communicate with the relatives of dying soldiers, and she would ritually walk the five miles of the Barracks Hospital wards every night, with one soldier writing:

"What a comfort it was to see her pass even. She would speak to one, and nod and smile to many more; but she could not do it all you know. We lay there by hundreds; but we could kiss her shadow as it fell and lay our heads on the pillow again content".

And finally, you may be relieved to hear, comes the final point seven; and here, before I go, I really I do have to mention statistics and hospital epidemiology.

In order to convince people of the terrible conditions and mortality figures that soldiers had been exposed to in the Crimea and later in India, Nightingale developed what might be know as the Cox Comb or polar area representation of figures and statistics. Nightingale drew inspiration from and wrote in her copy of Quételet's Essaie de Physique Sociale that:

"All Sciences of Observations depend upon Statistical methods - without these, are blind empiricism. Make your facts comparable before deducing causes. In complete, pell-mell observations arranged so as to support theory; insufficient number of observations; this is what one sees".

She was clearly an advocate of statistics, however she was not unchallenged. John Stuart Mill objected to the use of statistics in the social sciences, and Charles Dickens (as expressed in Hard Times) thought them dehumanising. But again, it was not particularly Nightingale who developed hospital statistics, but drawing on the work of Quételet, and under the direction of William Farr, a physician and statistician (she was still working in very much the same way as she did being influenced by Edwin Chadwick in sanitation), but she was a pioneer in the representation of statistical material. She developed, with Farr, the Model Hospital Statistical Form, which indicated to hospitals what sort of data should be collected. Her statistics were incorporated into various Government reports, and she also publicized this material, privately printing pamphlets and distributing them to, for example, the Houses of Parliament (this might be point eight, I'll come to that in just a moment). Nightingale asserted that statistics would "enable the value of particular methods of treatment and of special operations to be brought to statistical proof"; and this, along with other material, has prompted McDonald to claim that Nightingale may well have been responsible for the initial development of evidence-based medicine movement.

I need to wrap up. And to do so I will use more statistics. In 1861 the British census listed 27,618 nurses in Britain, and it listed that figure in the tables of occupations under the heading "Domestics"; by 1901 the number had increased to 64,14, and it was listed under "Medicine".

I have listed a total of eight points to consider when examining Nightingale's legacy, which I will recap. These are:

1. The sanitation movement, emerging out of the work of Chadwick.
2. That current theory is not directly informed by Nightingales model, or is it?
3. That nurse training around the world was initiated independently by a number of individuals.
4. That we tend to remember the woman, not the work.
5. She laid the foundation for infection control.
6. She laid the foundation for end of life care.
7. She developed hospital statistics, or at least ways of collecting and reporting them, inspired by Quételet and Farr.
8. Almost tongue in cheek, she was a Victorian Max Clifford...

I'm going to leave you with that thought.

And finally, I want to let you have the opportunity to read an abstract from Nightingale's fitting obituary:

"When I am no longer even a memory, just a name, I hope my voice may perpetuate the great work of my life. God bless my dear old comrades of Balaclava and bring them safe to shore". Florence Nightingale.