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Florence Nightingale – A Strong Woman Making Hand Hygiene History

Nightingale has forever earned her place in the history books as the founder of modern nursing. Nightingale quite literally invented the profession, stating in her book, Notes on Nursing, “Everyday 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 recognized as the knowledge which everyone ought to have, distinct from medical knowledge, which only a profession can have.” Nightingale understood what others before her had failed to realize – sanitation saved lives. During her time leading a field hospital for the British army during the Crimean War, she managed to reduce death rates from 42% to 2% through the implementation of hand hygiene protocols in her hospital. 

Nightingale became a Victorian culture icon, also known as “the lady with the lamp”, as she was busy caring for the wounded even at night. Even though her most known work took place during the Crimean War where she led the care for wounded soldiers in Constantinople, Nightingale didn’t stop there. She was a social reformer through and through, a gifted statistician, and lobbied for the sanitary design of hospitals and sanitation in working-class homes.

Florence Nightingale, an angel of mercy. Scutari hospital 1855. Butterworth. Tomkins. Lettering continues: “when all the medical officers have retired for the night, and silence and darkness have settled down upon thosse miles of prostrate sick, she may be observed alone, with a little lamp in her hand, making her solitary rounds”.

“Well-behaved women rarely make history”

Florence was born in 1820 in Florence, Italy – hence her name. When she was 1 year old, the family moved back to England. Florence’s family was wealthy and affluent, and her father took both her and her sister’s education upon himself. He taught them history, mathematics, languages, classical literature, and philosophy. Florence especially shone in her mathematics abilities, a skill she would use often in her professional life in preparing and displaying hospital reports so that they were easily understood by people in power. She was said to have a radiant smile that warmed those around her to her immediately.

Nightingale, c. 1858, by Goodman

When Florence was 18 she followed her family on a trip to Europe, where she met Mary Clarke, a feisty Parisian hostess. The two became fast friends. Clarke introduced Florence to the innovative idea that women could be equal to men, and just as successful. Clarke, or as Nightingale called her, Clarkey, often said she pitied the English noblewomen due to the constraints and expectations of society and that she would much rather be a slave if given the choice – as they had much more freedom. She was impossible to ignore, stood her ground in intellectual debates, and had a bubbly, mischievous disposition. Florence and Mary remained close friends for the 40 years to come. 

Florence’s mother and sister seemed horrified by this turn of events, and the “ridiculous” ideas Florence got from Clarkey. They urged Florence to take her “rightful” place in society, as a wife and a mother, and the fact that Florence refused to surrender to the restrictive social code dictated for women distressed them greatly. Florence felt a calling to do so much more, often describing it as a “calling from God” to the nursing profession. She turned down several suitors, choosing to focus on nursing. She independently schooled herself on the medical profession and traveled across the world, learning and taking notes from different healthcare practices in different countries to improve her understanding of the subject.

After traveling to Rome and Egypt, Nightingale traveled to Greece. There she found a juvenile little owl being beaten by local children – she saved it and named it Athena. Curiously enough, the miniature owl became her close companion and she often carried it in her pocket. 

Later, in Germany, she visited the church led by Pastor Fliedner and witnessed his work caring for the sick. This was one of the turning points in her life, and where she would receive her first real medical training for several months.  

At 33, in 1853, Nightingale was made the superintendent at the Institute for the Care Of Sick Gentlewomen in London. Her father supported her career endeavors and provided her with a comfortable annual income that allowed her to focus on the nursing profession without reserve. However, Nightingale couldn’t stay there long – she was called to help with the war endeavors just a year later. Shortly before departing to help in the war, securely in Nightingale’s pocket as always, Athena the owl passed of old age.

A depiction of what the hospital Florence Nightingale worked at may have looked like

“If we don’t end war, war will end us”

In 1854 Nightingale trained 38 volunteer women as nurses, and together with 15 Catholic nuns, they were sent to the Ottoman Empire to support Britain, France, and the Ottomans in the fight against Russia. On the way to Constantinople (today’s Istanbul), the women stopped in Paris and were assisted by Nightingale’s longtime friend, Mary Clarke.

Nightingale utilized her gift for statistics and math to convey the dire conditions of the wounded in the military hospital she was in charge of at Constantinople, Istanbul. Nightingale was even proclaimed “a true pioneer in the graphical representation of statistics”, as she invented a form of the pie chart to ensure her reports were understood by members of parliament who did not know how to read traditional statistical reports.

This “Diagram of the causes of mortality in the army in the East” was published in Notes on Matters Affecting the Health, Efficiency, and Hospital Administration of the British Army and sent to Queen Victoria in 1858.
War-time soldiers were overworked in crowded spaces

Despite the general notion at the time that the simple soldier was a replaceable commodity, Nightingale had an overwhelming appreciation for the soldiers who were wounded at battle. She cared for them deeply and did everything within her power to ensure they had a better chance at survival. This was where Nightingale earned her nickname, “the lady with the lamp”, as she traveled from bed to bed in the darkness, lamp in hand, to check on the sick soldiers.  

Her reports alerted Britain to the state of the soldiers – overworked, underfed, turning to alcohol to drown the horrors of war. Back then, there was little the medical staff could do to help the wounded, and it was even described how the hospital was laden with straw to soak up the blood. The staff was overworked as well, medicine was scarce, and most importantly – the hygiene conditions were dreadful and hand hygiene was neglected, which led to mass infections inside the hospital. This is one of the things that haunted Nightingale the most upon her return to Britain – the thought that many of the soldiers died in vain, due to hospital-acquired infections. 

Popular lithograph reproduction of a painting of Nightingale by Henrietta Rae, 1891.

The war scarred Nightingale’s heart and strengthened her belief that sanitation was vital to maintain a healthy body. According to her observations, ten times more soldiers died from contaminable illnesses such as typhoid, cholera, and dysentery than from their battle wounds. The hospital was overcrowded, had defective sewers, and lacked ventilation. Nightingale urged the Sanitary Commission to help, and upon their arrival, they indeed made the structural changes needed in the hospital, which led to a sharp reduction in death rates. Thanks to Nightingale’s reports, changes were made by the British Government in other war hospitals as well, and the death rate dropped to 1\10 of the ones previously held. 

Nightingale also mandated handwashing in the war hospital she worked in, which had an incredible effect on the health of the patients. According to Stephen Paget in the Dictionary of National Biography – Nightingale reduced the death rate from 42% to 2% by making improvements in hygiene herself and calling the Sanitary Commission.

This is what prompted Nightingale to advocate for sanitary living conditions. Thanks to her, peacetime deaths in the army were reduced, and she worked hard lobbying for the sanitary design of hospitals around the world.

Impact on the nursing profession  

Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care
King’s College London

While still in Crimea, the Nightingale Fund was established for the training of nurses, and thanks to donations, upon Florence’s return to Britain she set about to create the first nurses training school. In 1865 the first Nightingale nurses began work at the Liverpool Infirmary. The school, the Florence Nightingale School of Nursing and Midwifery, exists to this day! In 1859 Nightingale published Notes on Nursing, a book that detailed how to nurse the sick at home. It was the first of its kind and sold well to the general reading public. 

Before Nightingale, in the first half of the 19th century, “nurses” existed without the exact name, and they were untrained, uneducated, and merely followed orders. It was considered an undeserving profession, a job done by widows, former servants, or orphans that had to make a living somehow. Charles Dickens even created the figure of Mrs. Gamp in one of his books, a sad caricature that depicted the general public’s impression of those women nursing them. Mrs. Gamp was an incompetent drunkard, who cared more about her gin than her patients. 

Nightingale changed all that by introducing trained nurses to the workforce. Caroline Worthington, the director of the Florence Nightingale Museum said, “Florence transformed nursing when she got back from Crimea. She had access to people in high places and she used it to get things done. Florence was stubborn, opinionated, and forthright – but she had to be those things in order to achieve all that she did.”

Nightingale’s work inspired nurses caring for wounded soldiers in the American Civil War. Both the Union Government and the United States Sanitary Commission took her advice in organizing field medicine and war hospitals.

Around 1870, Linda Richards came to study under Nightingale and became America’s first trained nurse. Richards returned to the states and established nursing schools there, as well as doing prominent nursing jobs in Japan.

By 1882, less than 10 years after its establishment, Nightingale’s nursing school had produced several matrons for leading hospitals in London and Australia. For her work in the field, in 1883 Nightingale became the first recipient of the Royal Red Cross. Although Nightingale was modest in everyday life, she received many titles throughout her lifetime. For example, thanks to her work in statistical depiction in a way that was more intuitive and easier for others to understand, in 1859 she was elected as the first female member of the Royal Statistical Society, and in 1874 was made an honorary member of the American Statistical Association.

the medal Florence Nightingale received from Queen Victoria for her services in Nursing and care.

Her experience in the war had indeed settled deep within Nightingale’s heart, and from 1857 on she was intermittently bedridden having been diagnosed with depression. Her depression seemed to stem from the thought that she could have saved more lives in the war-hospital, her great admiration for the soldiers causing her to grieve the loss of their lives deeply. She was also diagnosed with a severe form of brucellosis and a following spondylitis. During her bedridden years, she readily continued to work in social reform from her bed, planning field hospitals to cater better to the sanitation and hygiene needs of the patients. However, her outputs slowed significantly in the last decade of her life, as she couldn’t write due to blindness.

Florence Nightingale died peacefully in her sleep at the age of 90 in 1910. She was buried in the churchyard of St Margaret’s Church in Hampshire, near her childhood home. Her grave simply has her initials, date of birth, and death. After her passing, several hundred unpublished notes were found in her belongings, showing how she was truly devoted to her work even in her later years.

An exceptional woman, Florence Nightingale is an inspiration to this day.

Florence Nightingale

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