RICHARD COLGAN, MD and DEBORAH COLGAN, RN, BSN
I always feel as if God had said: Mankind is to create mankind.
If asked to identify one woman throughout history whose name is synonymous with providing care to the sick, most people would likely answer: Florence Nightingale. A British nurse, pioneer of modern nursing, public health advocate, and noted statistician, Nightingale (1820–1910) dedicated her life to serving others. She truly stands out as one of the greatest healers history has known.
THE LADY WITH THE LAMP
Florence Nightingale was born in Italy into a well-to-do English family. Her parents named her after the city where she was born. Her family members were land owners, developers of mines and quarries, farmers, bankers, and members of parliament. Nightingale was raised in privilege, at a time when few women chose professions or social causes. She cared little for socializing (“a waste of time”) or suitors. Nightingale was born into a family where she was expected to live a life of gentility, yet such comforts meant nothing to her. From her teenage years until her twenties, she cared for people from nearby villages who worked or lived on her family’s estates. Serving many, she worked long hours without rest. Her father questioned her actions and asked why she did not act like other women who married and had a family. Her reply was forthright: “Father, the strong do not need my help. They can take care of themselves. I believe in doing religion, not talking it.”1
Nightingale was deeply religious, deriving strength from doing God’s work and caring for mankind. She honed these skills in serving British soldiers during the Crimean War. At a time when bureaucracy and red tape were rampant in the Department of War, she fought for the basic necessities for her country’s men in battle. “Save these soldiers’ lives and then talk army regulations,” she said. “Give me blankets, food, medicine. Give me more help. I do not care for your systems and regulations, but I do care for the wounded and the sick.” Spending her own money on supplies, she would make nightly rounds on the sick, with her lantern in her hand to light the way. According to one historian of the day, “she finally made the British soldiers of the Crimea healthier than the civilian population of England.” She earned the reputation for being a genius of organization, likely due in part to her sense of extreme confidence that she could accomplish most anything she set her mind to.
Upon her return from war, a great reception awaited “the lady with the lamp” and her shipmates. As the boat approached the dock on the Thames River, rather than accept the applause which was sure to be heard, she slipped away from the boat and quietly found her way to her home in London (and went to bed) rather than accept applause and attention on the dock. Thereafter, she used her organizational and networking skills to identify how she might bring the greatest good to the most people. She also used the knowledge she gained from the battlefields of the Crimea to pioneer the modern hospital. What we find commonplace in most hospitals today, she championed in London in 1856.
AN IMPRESSIVE LIST OF ACCOMPLISHMENTS
Nursing historian Barbara Montgomery Dossey’s comprehensive text Florence Nightingale Today attributes the following list of accomplishments to her: the Pavilion system of buildings, isolation of communicable diseases, personal comforts for patients, cleanliness to an extreme degree, and the well-trained nurse. Dossey notes in this text, “Both the patients’ internal and external environment was viewed by Nightingale to be important. This included their bed and bedding, food, light, the patients’ cleanliness as well as that of the room.”2 Nightingale taught her nurses to avoid unnecessary noise, as well to not give false hope, promises, or advice. She had a holistic perspective to include not only mind, body, and biosocial but the spiritual element of each patient as well. This advice need not apply to just nurses.
Before the bacterial origin of infectious disease was known, at a time when bacteria were killing more people than those dying on the battlefields, Florence Nightingale fought for improved sanitation and the conversion of hospitals from “pesthouses” to wards with proper sanitary conditions. “It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm,” she noted.3 In Notes on Nursing, she identified the following five items as being important to the “health of houses”: pure air, pure water, efficient drainage, cleanliness, and light. Nightingale advocated for “total healing environments.” This entails observing the patients’ problems and managing well their care. She also promoted cleanliness and how to avoid disease outside of the hospital.
She worked to develop uniform systems for hospital statistics as well as disease classification. She created a novel pie chart–like descriptor, the Coxcomb diagram, to present statistics in a clearer manner. Working with William Farr, the founder of medical statistics, she created applied statistical tables listing the numbers of soldiers who had died, where they had died, and their cause of death. Using these tools, she was able to show that in peacetime, English soldiers were twice as likely to die compared to the rate of civilians. Because of this work, she is credited with persuading Queen Victoria of the need to improve sanitary conditions in military hospitals.4 Her contributions to public sanitation, public health, and statistics are beyond the scope of this book, yet are some of her greatest accomplishments. We mention them here to highlight her far-reaching efforts to improve the human condition.
LESSONS ON THE ART OF CARING
A working premise of my book Advice to the Healer: On the Art of Caring is that clinicians in the caring professions can learn from others outside of their own respective discipline. Physicians, dentists, and pharmacists can learn from nurses, social workers, and psychologists. To do so, we must recognize the value each contributes in caring for the total patient and believe that together we function best as a team. Some of the lessons taught by Florence Nightingale on how to care for the patient are worth noting because we can modify them to our own respective disciplines. To follow are some specifics on the art of caring as taught by this matriarch of nursing.
Florence Nightingale’s Notes on Nursing Which Apply to the Art of Caring
Observe the sick.
Never let a patient be waked out of his sleep.
Avoid unnecessary noise: Whisper outside the room.
View and sunlight are matters of first importance to the sick.
Leading questions are useless or misleading.
Obtain accurate information.*
Children are much more susceptible than grown people to noxious Influences.†
*Nightingale tells the story of a “clever” physician who began taking a history of those with abdominal pain with the question “point your finger where you be bad.”
†“They are affected by the same things, but much more quickly and seriously.”
Florence Nightingale, a woman of small stature and sick much of her life, was a visionary leader and a great healer. She was periodically confined to bed rest during the Crimean war yet would not let this deter her from helping the English troops. These soldiers were so touched by her dedication that they had to be given turns in sharing the privilege of carrying the “Lady-in-Chief” from hospital to hospital on a stretcher. She is described by the British physician and biographer Mosby as a rugged individual, not in stature but in her spirit and courage.1
Nightingale was chosen to exemplify the art of caring for many reasons. She was a selfless nurse who realized that the only thing that mattered was the patient. She fought stereotypes and societal pressure and identified what was needed, both on the battlefield and in the City of London. She then committed herself to improving the public’s health. Like many of the great healers described in my book Advice to the Healer: On the Art of Caring, she is remembered more than 100 years after her death for how she lived her life. Like Avicenna, Nightingale was someone who took care of patients, one at a time, while appreciating the importance of caring for the masses. Like Maimonides, she referred to her vocation as a calling and worked tirelessly. Like Schweitzer, she dedicated her life to service because of a conviction that it was how to best serve God. Dossey notes, “To Nightingale, nursing was service to God and service to humanity. She believed that the aim of human life was to create heaven here and now on earth.”2
Medical historian Dr Phillip Mackowiak offers the possibility that her periods of boundless energy alternating with extreme fatigue which caused her to “take to the bed” might have been due to posttraumatic stress disorder after returning from the Crimea.5 A cogent argument is also made for the possibility that she also suffered from what is now called bipolar disorder.
Florence Nightingale died at the age of 90. While the exact cause of her death has been debated, her death certificate lists old age and heart failure.
Nightingale turned down an offer of burial at Westminster Abbey. Instead, it was her wish that she have a quiet burial and be interred next to her father and mother at Embley with the simple inscription “F.N.” on her tombstone.
Reprinted with permission by Springer from Advice to the Healer: On the Art of Caring.
1. Mosby CV. A Little Journey to the Home of Florence Nightingale. St Louis, MO: The Press of CV Mosby Company; 1938.
2. Dossey B, Selanders L, Beck D, Attewell A. Florence Nightingale Today: Healing, Leadership, Global Action. Silver Spring, MD: American Nurses Association; 2005.
3. Nightingale F. Notes on Nursing and Hospitals. Birmingham, AL: The Classics of Medicine Library; 1982.
4. Pennock MR. Makers of Nursing History. New York: Lakeside Publishing Company; 1940.
5. Mackowiak P. Post Mortem: Solving History’s Great Medical Mysteries. Philadelphia, PA: American College of Physicians; 2007.