Florence Nightingale’s Radical Approach to Public Health Care

by Lynn McDonald
Hannah Lecture, American Association for the History of Nursing with the Canadian Association for the History of Nursing: 20th Annual Congress, Milwaukee, Wisconsin, 19 September 2003

Five volumes have been published in the Collected Works of Florence Nightingale to date (2003). Two are in production. There will be full electronic publication of data bases, the original transcriptions, and lists of names of people with whom Nightingale corresponded or worked or read, a full chronology of Nightingale’s letters, visitors, reading, etc., which we hope will help facilitate further research on Nightingale.

When I refer to Florence Nightingale’s “radical approach” to public health care I mean the simple, etymological use of radical as going to the root of a matter. Nightingale was a systems thinker. Her approach to public health care reflects her faith-based philosophy, her understanding of God as a God of law, who created the world and runs it in a regular, orderly way that we can discover by conducting scientific research.

“God governs by His laws, but so do we, when we have discovered them. If it were otherwise we could not learn from the past for the future.” (“Essay in Memoriam,” in Society and Politics 5:60)

When we work with God to make the world better we become God’s “co-workers.”

Her faith and her social science constantly overlap. Her “call to service,” dated 7 February 1837 (when she was sixteen), led her or even drove her to equip herself for work, the work of saving lives, initially through nursing individuals, then increasingly toward administrative reforms that would save even more lives.

The work of course had to be well done. Nightingale always had a healthy respect for the power of unintended consequences from the best-intended actions. Her systems approach is a safe one, featuring positive methods for building health and preventing disease and warning of the risks of various treatments:

decent housing
clean water and air
nutrition
safe childbirth
good child care

All of these matters received her attention throughout her life, in papers and pamphlets, Notes on Nursing, especially the 1861 edition of Notes on Nursing for the Labouring Classes. All of these required many, broad social reforms, not only nursing. Some of this material (especially on housing and income security) has already appeared in the Collected Works of Florence Nightingale in volume 5, Society and Politics. For example, on the importance of decent housing, at a time when the vast mass of the population was very badly housed.

I believe that more moral and physical good is done by improving the dwellings of mankind than in almost any other way. And if all the money that is spent on hospitals were spent on improving the habitations of those who go to hospitals, and (on prisons) of those who go to prison, we should want neither prisons nor hospitals. (A letter 1868 to Sir Harry Verney, in Society and Politics 5:181)

We in vain labour at the moral progress of a population if we leave it festering in unhealthy dwellings. Probably there is no influence stronger than the buildings they live in, for bad or for good, upon the inhabitants. (Notes from Devotional Authors of the Middle Ages, in Mysticism and Eastern Religions 4:56)

In Notes on Nursing (first edition, 1860), Nightingale set out her underlying philosophy, a very holistic approach to health care.

All disease, at some period or other of its course, is more or less a reparative process, not necessarily accompanied with suffering: an effort of nature to remedy a process of poisoning or of decay, which has taken place weeks, months, sometimes years beforehand, unnoticed.

Medicine was not “the curative process.”

Neither medicine nor surgery “can do anything but remove obstructions; neither can cure; nature alone cures

Surgery removes the bullet out of the limb, which is an obstruction to cure, but nature heals the wound. So it is with medicine; the function of an organ becomes obstructed; medicine, so far as we know, assists nature to remove the obstruction, but does nothing more.

What nursing has to do in either case is to put the patient in the best condition for nature to act upon him.

For, “diet, not medicine, ensures health.” Nature’s “restorative processes” were “fresh air, light, warmth, quiet, cleanliness and care in diet.” This of course to be achieved required massive changes in how people live in their own homes (indeed in every class).

Notes on Nursing for the Labouring Classes (especially) gave advice to ordinary working class people, especially the rural poor cottagers (a subject to which Nightingale returned and gave much attention in the 1890s):

to teach “the art of health, which every mother, girl, mistress, teacher, child’s nurse, every woman ought practically to learn.”

However, even with the best of housing, diet, air and water, even with the safest childbirth and good, safe schools, some people would get sick. Hence the need for special measures to be brought in, always the most conservative, the safest. Hospitals would always be the place of last resort for Nightingale, necessary for some cases, of course, notably for surgery, but to be used as little as possible, especially for children, who were even more vulnerable than adults to nosocomial diseases.

Nightingale’s views here were statistically correct. Brian Abel Smith estimated that hospitals only began to be (relatively) safe places to be in the 1890s. Her own experience of the Scutari Barrack Hospital, with its high mortality rate from disease, no doubt also help to fuel this conviction.

Hence the emphasis in her system of medical attendance and nursing support at home:

home visiting by doctor and nurse
district nursing for those without private care
minimal use of hospitals because of their danger:
- hospitals (general, acute care), where necessary
- convalescent hospitals (preferably in the suburbs or country)
- seaside convalescent hospitals associated with regular, city, hospital

The dangers of hospitals were so great that Nightingale gave a great deal of her own scarce time to criticizing plans for hospitals—better to prevent mistakes than to have to deal with them afterwards. (This will be reported in a volume, Hospital Reform.) For the third edition of her Notes on Hospitals, she added a preface which suggested a Hippocratic oath for hospitals:

It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.

This was necessary, she explained:

because the actual mortality in hospitals, especially in those of large crowded cities, is very much higher than any calculation founded on the mortality of the same class of diseases among patients treated out of hospital would lead us to expect.

(Chapter 5) “It is a rule without any exception, that no patient ought ever to stay a day longer in hospital than is absolutely essential for medical or surgical treatment.”

In the case of children she revised this to “not an hour” longer than necessary. For both adults and children she recommended the use of convalescent facilities, out of the city (hence with better air).

Every hospital should have its convalescent branch, and every county its convalescent home.

Desirably hospitals would have seaside convalescent institutions affiliated with them. Nightingale herself often sent patients, especially convalescing nurses, to seaside places.

Nightingale’s Method

We can see a “Nightingale method” guiding her thinking on these and indeed all the subjects on which she worked. It is still good advice:

get the best information available
use government reports and statistics
read and interview experts
If the available information is inadequate collect your own:
- draw up a questionnaire (queries)
- consult experts on it, practitioners who use the material
- test it first (pre-test)

At the stage of report writing:

send out a draft or proofs to experts for vetting before publication.

All this is very clear when one looks at the mass of writing she did in the preparation of major papers and books: letters to sanitary experts, doctors, officials; notes on debriefing experts on their particular work; the amassing of books, reports and articles; draft questionnaires, begging letters to busy professionals to give her advice on the adequacy of her queries, did she leave anything out?

The purpose of all this was application, system change and development, but this had to be proceeded with very carefully and cautiously, because of the danger of unintended consequences. From Quetelet she had learned not only the possibilities for application but the dangers of wrongful acts, however benevolent the intention:

“The plan of God” is to teach us “by these results the laws by which our moral progress is to be attained, or rather explaining the road we must take if we are to discover the laws of God’s government of His moral world.” (Note, in Society and Politics 5:39)

Quetelet was:

the creator of a new science in which observation and calculation are allied to bring out the immutable laws which govern phenomena apparently the most accidental of our physical life to our least actions. (5:40)

But he warned cogently, giving several important examples:

“Consecrated blunders in medicine prove the need of statistics. Statistics must be made otherwise than to prove a preconceived idea.” (Comment of Physique sociale, in Society and Politics 5:30)

Quetelet gave examples of high infant mortality in foundling hospitals.

Nightingale’s work on maternal mortality in childbirth a later example (Introductory Notes on Lying-in Institutions, in Women)

Again, from Quetelet Nightingale learned that:

Different treatments [have but a] small influence on the death rate.

Hospital death rates depend:

“on the way they are kept more than on the treatment employed.”

“Administration saves more hospital patients than the best medical science.” (Comments on Physique sociale, Society and Politics 5:30-31)

Knowledge for application, but a healthy respect for the power of unintended results. So, great care was required.

New programs must be monitored statistically.

Statistics must be kept on a uniform basis so that comparisons can be made.

Nightingale’s “Hospital Statistics” and a further letter to the congress were pleas for uniform data collection by hospitals, precisely so that comparisons could be made and lessons learned from the better institutions (i.e., those with better results). (Paper given at the International Statistical Congress, 1860, in Society and Politics 5:83).

Nightingale, in other words, was a pioneer in “evidence-based health care,” both in developing the means by which it would be possible and in arguing the urgent need for its adoption.

Part 2, The Reform of Workhouse Infirmaries

The reform of the workhouse infirmaries was, I believe, the work Nightingale most wanted to do, the work most closely following from her “call to service,” the best opportunity to make a difference, that is, actually to save lives by carefully-thought out, well-applied hard effort. Nightingale had visited workhouse infirmaries when a young woman (when she was not allowed to nurse, or study nursing); visiting was an acceptable activity for a “lady.” But Nightingale was upset by her (apparently) few visits. To William Rathbone, when he made the offer of funding some improvements in care in Liverpool Workhouse Infirmary, she said:

In days long ago, when I visited in one of the largest London workhouse infirmaries [Marylebone], I became fully convinced of this. How gladly would I have become the matron of a workhouse. But, of a visitor’s visits, the only result is to break the visitor’s heart. She sees how much could be done and cannot do it. (5 February 1864, in Public Health Care)

This was twenty-seven years after her “call” and the work of workhouse infirmary reform did not start for yet another year. When the workhouse nursing was well alone in preparation (again before it started) she told Henry Bence Jones much the same thing, ending with:

I felt that visiting had no other effect but to break the visitor’s heart. To nurse efficiently is what is wanted. (Letter 13 October 1864, in Public Health Care)

I make something of this timing, for Nightingale is sometimes portrayed as a “military nurse,” as if the rest of her work were secondary. One commentator, the biographer of William Farr, even argued that it was Farr who got Nightingale to pay attention to the needs of civilian life, bribing her in effect with an offer to assist her with the health of the army if she would reciprocate with reducing civilian mortality (John M. Eyler, Victorian Social Medicine: The Ideas and Methods of William Farr 159). The evidence is very strong that Nightingale’s concern with the “sick poor” well antedates her involvement in the Crimean War. It is clear that she and Henry Bence Jones (an attending physician) discussed the defects of workhouse infirmaries while at the Establishment for Gentlewomen during Illness (1853-54). It appears in correspondence between them during the Crimean War. To Bence Jones, who had himself done a report on workhouses, Nightingale wrote from the Barrack Hospital, Scutari;

I shall certainly devote that life and health to the one object which we have talked about, and I shall certainly not spend any portion of that life in “training nurses for rich families,” except by parentheses, but shall begin in the poorest and most neglected institution I can find. This is the only plan I have. (in Public Health Care)

Yet the opportunity to act arose only in 1864, with the offer of William Rathbone to fund improved practices in the Liverpool Workhouse Infirmary. His proposal, alas was merely for:

a “lady visitor…one with tact, power and Christianity.”

For Nightingale, however, this opening was all that was needed. They had worked together earlier on district nursing and a home for nurses. Rathbone was much more conservative politically than Nightingale, sceptical about the involvement of central government (which Nightingale saw as essential for significant reform). But he was most amenable to taking direction. Nightingale’s reply (of 5 February 1864) laid out the case:

Workhouse sick and workhouse infirmaries require quite as much care as (I had almost said more than) hospital sick. There is an even greater work to be accomplished in workhouse infirmaries than in hospitals.

A draft reply is very clear indeed as to her goal:

There is no reason whatever why workhouse infirmaries should not be nursed and the sick cared for as efficiently as in the best nursed hospital. Liverpool would be a most excellent place to introduce this great reform on trial….

If Liverpool succeeds it will be the best argument for extending the system elsewhere.

Her recommendation was to begin with the fever wards:

the place for exhibiting the benefits of skilful nursing, and as the persons admitted are the poor who may not be paupers, you might prevent pauperism by saving the lives of the heads of families and helping the more speedy convalescence of hard working people. (in Public Health Care)

The introduction of nursing into the Liverpool Workhouse Infirmary entails too many complications to deal with in this paper. Suffice it say that professional nursing began May 1865, with Agnes Jones as superintendent of the Liverpool Workhouse Infirmary, and numerous structural problems to resolve:

Problems of her authority over her nurses, conflict with the traditional workhouse governor’s authority
Conflict over “pauper nurses”
Lack of beds, supplies

There was a shortage of nurses for any hospital nursing, let alone workhouse nursing, all matters that would be years in resolution.

This might be the place too to flag the work of Dr John Sutherland, Nightingale’s collaborator on so many issues. He did much of the drafting and generally assisted in all the machinations that went on to move the reforms forward.

In the meantime the opportunity arose to bring in the system to London, for Liverpool, sometimes referred to as an experiment, was to Nightingale merely the first stage. Lessons had to be learned there, but for her the issue was not whether or not to extend professional nursing, but how best to do so. The opportunity in London arose from a scandalous case, the death of an Irish migrant worker, Tim Daly, in the Holborn Union Workhouse. Nightingale, a systems thinker, was well aware of the need for good examples. Media attention to this death and a coroner’s inquiry (which exonerated the medical attendant) gave her the chance to make the general case.

When Nightingale actually began work on workhouse infirmary reform there were a number of people who were concerned, had conducted investigations, made recommendations and tried to raise public interest in the problems (notably Louisa Twining, Ernest Hart, Francis Anstie, Lancet and the British Medical Journal articles).

Numerous reformers concerned with abuses in workhouses and the need for more and better paid medical care, the provision of drugs and various supplements.

But Nightingale was the only person who made the case for:

the introduction of trained nursing
not merely the absence of abuses, but
quality care for all, on the same basis as in the civil hospitals.

For sick you want hospitals as good as the best civil hospitals. You want the best nurses you can find. You want efficient and sufficient medical attendance. You want an energetic and wise administration. (draft note ca. July 1865, in Public Health Care)

This required an administrative separation of the sick from other workhouse inmates.

When Nightingale took the initiative to write the president of the Poor Law Board (a Cabinet position), C.P. Villiers, she did not stress the particular scandal but the widespread, indeed general, problem:

My object in writing is quite different; it is to bring before you the whole question of hospital nursing in workhouses….

When the poor pauper becomes sick, from that moment he ceases to be a pauper and becomes brother to the best of us and as a brother he should be cared for. I would make this a cardinal distinction in Poor Law relief. (Letter 30 December 1864 in Public Health Care)

Nightingale further noted that the coroner’s evidence showed “no nursing in the case worthy of the name.” and “nearly every workhouse in England could tell a similar tale.” The Liverpool work was then about to start and she cited it as a positive example:

The improved nursing system is thus about to be initiated in one of the largest establishments in the kingdom and there is no reason why it should not in time be introduced in every workhouse.

Nightingale invited Villiers to “help in this great improvement by having a searching inquiry made into the nursing system in all workhouses.” (in Public Health Care).

But the fall of the Liberal government occurred before any legislation could be adopted (it seems there was nothing even drafted, whatever commitment Villiers might have made in principle). Thus, the legislation drafted by a less-concerned Conservative administration and Nightingale was forced, most reluctantly, to take half a loaf. With Lord Palmerston’s death Nightingale lost a key ally for reform (he got liberal measures through his Liberal Cabinet); now there was a full change in government.

Nightingale had been long concerned with workhouse reform more generally, the provision of appropriate asylum and care for the different categories of inmate (material reported in Society and Politics). She continued to make the case for workhouse infirmary reform in the context of the broader reforms needed:

The principles of reform:

A. To insist on the great principle of separating the sick, insane, incurable and children from the usual pauper population of the metropolis;
B. To advocate a general metropolitan rate for this purpose and a central administration;
C. To leave the pauper and casual population and the rating for under the boards of guardians, as at present.

These were “the ABC of the reform required. Centralize all the sanitary powers at present exercised by the guardians…provide a scheme of suburban hospitals and asylums.

For sick;

For infirm, aged and invalids;

For insane and imbeciles;

Industrial schools for children.

Pay for them by a general school and hospital rate.

All those classes which suffer from any disease, bodily or mental, should be placed under a distinct responsible administration amenable directly to Parliament. Uniformity of system in this matter is absolutely necessary in order that the suffering poor should be properly cared for. (in Public Health Care)

Nightingale noted further that economies could be made with the centralized system, waste reduced with centralized purchasing and duplication avoided, for example, patients could be moved to empty beds rather than having too many in any one place. Most importantly, of course, the sick, especially heads of families, could rejoin the paid labour force when well.

The principle:

Sickness, madness, imbecility and permanent infirmity are general afflictions affecting the entire community and are not (like pauperism) to be kept down by local knowledge or by hard usage.

The sick or infirm or mad pauper ceases to be a pauper when so afflicted and should be chargeable to the community at large, as a fellow-creature in suffering.

Hence there should be a general rate for this purpose to be levied over the whole metropolitan area, to be administered by the central authority. (in Public Health Care)

The results: “What might be done in the way of cure — I say nothing of prevention — must be at present quite unknown.”

Society was responsible:

Sick, infirm, idiots and mad persons require special construction arrangements, special medical care and nursing and special dieting. (Of all these they have little or none that is worthy the name in the present London workhouses.) They are not “paupers.” They are “poor and in affliction.” Society certainly owes them, if it owes anything, every necessary care for recovery. (in Public Health Care)

The Metropolitan Poor Bill of 1867 was in fact brought in by Gathorne Hardy, the new president of the Poor Law Board (a Cabinet position) and Villiers was now in opposition. Nightingale was invited to give a brief to the Cubic Space Committee, 1867, which Gathorne Hardy established. Its terms of reference were woefully limited, a challenge to the political activist of all times!

Cubic space be hanged! (excuse swearing — I spend my life in it.)

I don’t think the cubic space question the important one.

Nightingale further argued that “superficial space” was more important than cubic space for efficient nursing, and many other things even more so. Her priorities:

Adequate administration: “by placing the sick under a totally different management from the able-bodied, and after the buildings, i.e., the kind of buildings and sites required….then will be the time to consider what is the smallest cubic space you can work with for health, administration, nursing and economy. (From a letter to Douglas Galton 31 October 1866, in Public Health Care).

Nightingale’s brief to the Cubic Space Committee was entitled “Suggestions on the Subject of Providing Training and Organizing Nurses for the Sick Poor in Workhouse Infirmaries.” In it she promptly acknowledged that the definition of nursing was ever “improving”:

I will take for granted that the intention is now really to inquire into the best system of nursing (best as conducing to the cure of the sick), and how to obtain it.

Perhaps I need scarcely add that nurses must be paid the market price for their labour, like any other workers, and that this is yearly rising. Our principle at our training school at St Thomas’ is to train as many women as we can, to certificate them and to find employment for them, making the best bargain for them, not only as to wages, but as to arrangements and facilities for success. (in Public Health Care)

She explained the inadequacy of the supply of nurses for hospitals generally and outlined a method of improving supply.

She stipulated the need for a “competent training matron” and argued that “head nurses,” i.e., trained nurses, must also be training nurses.

She addressed the possibility of training pauper girls (daughters of inmates), always opposing the use of “pauper nurses.” She set out the structural requirements:

Relation of hospital management to efficient nursing

The administration required for curing the sick is a thing so totally different from the administration required for keeping down pauperism and poor rates, that it is simply impossible that they should both be carried out on the same principles.

Need for separate authority structure

Financial administration

Complaints procedure

Structural arrangements (housing) required for efficient nursing

(And then, finally, cubic space)

Nightingale frequently raised the issue of working conditions for nurses (already in Notes on Nursing). Here she made several key points:

Every employer of labour is bound to provide for the health of the workers. And any society which professes to provide for sick, and so provides for them that the lives of nurses and of medical officers have to be sacrificed in the discharge of their duty, gives sufficient proof that providing for the care of sick is not its calling.

For, as it happens, the arrangements required for the welfare of sick are the very same which are required for the health of nurses, nurses, that is, who are really discharging their duty in constant attendance on sick. (in Public Health Care)

In other words, nurses need adequate cubic space, too. She sought improvements in workhouse infirmaries in other respects as well:

There is no reason why workhouse infirmaries should be excluded from progress in improvements in such matters any more than other hospitals. (in Public Health Care)

Nightingale was well aware that conditions in workhouse infirmaries would be much less desirable that in the regular civil hospitals, but keen to establish the principle that improvements could be looked to.

The Metropolitan Poor Bill in fact was passed in 1867 with little amendment. The introduction of professional nursing in the London and other workhouse infirmaries began. It had to be won piecemeal, as the legislation was permissive, but did not require any workhouse infirmary to bring in trained nurses. This is too long and involved a story to be dealt with here, but I would like to stress one further, structural, point Nightingale insisted on, the use of teams of nurses, a matron or superintendent to go into a workhouse with a staff of nurses she had trained and knew.

Some workhouse infirmaries had already brought in a nurse or two, but these had little effect. Often they became the matron and were confined to counting the linen and such tasks. Worse, Nightingale thought they wrecked the women. School teachers could go out alone, but:

We deprecate sending one solitary nurse to a workhouse, which we think is only wasting her and breaking her heart. (in Public Health Care)

Issues of nursing practice and education are the subject of the two volumes specifically dealing with nursing, so there will be more on workhouse nursing in later volumes, and indeed in Hospital Reform, which will focus on hospital design.

Conclusion

A Collected Works permits quite a different look at a person from that gained from reliance on secondary sources, or use of only a restricted range of primary sources. In the case of Nightingale, because there is so much surviving material, scattered among so many archives and private collections (we now have material from about 200 sources worldwide) this is crucial. There is a great deal of bad secondary work on Nightingale, and it gets worse every year as new authors quote the growing number of bad sources. Some glaring errors may be citable from five or ten different sources (some of them quite respectable).

The work reported here on workhouse infirmary reform was pieced together from a large number of archival sources: apart from the British Library, the Wellcome Trust and the London Metropolitan Archives, there were key letters at Cambridge University, the Wiltshire County Archives, Liverpool Record Office, Columbia University, Boston University and the State Library of New South Wales. Sometimes Nightingale’s letter to someone was in one collection, the response in another collection on another continent. Sometimes the letter was addressed merely to “Sir” and the recipient could not be identified by the archive (but could be when the sequence is put together).

The Collected Works data bases as well as the print volumes will assist other scholars to address issues in their own areas of interest and expertise and I look forward to seeing the next round of work on Florence Nightingale and your participation in it. I will be glad to answer questions about the Collected Works of Florence Nightingale generally, as well as today’s subject in particular.

Sources Cited

References are all to print volumes, with the short title and volume number; all published by Wilfrid Laurier University Press, Waterloo ON.

Eyler, John M. Victorian Social Medicine: The Ideas and Methods of William Farr. Baltimore: Johns Hopkins 1979.

Lynn McDonald, Professor, Dept. of Sociology and Anthropology, University of Guelph, Director, the Collected Works of Florence Nightingale. Website: sites.uoguelph.ca/cwfn/