The Nightingale System of Training

by Lynn McDonald
for a Conference September 14 2010, Windsor
American Association for the History of Nursing and European Nursing History Group

I thank the organizers of this discussion for the opportunity of presenting, but must regret that, in 2010, the hundredth anniversary of Nightingale’s death, the 150th anniversary of the founding of her school, and the 150th anniversary of the publication of her most famous book, Notes on Nursing, that the question has to be asked as to the distinctive nature of the Nightingale system of nursing (never her term) and its (considerable) influence.

Compare this with the celebration last year, on the 150th anniversary of the publication of Charles Darwin’s Origin of Species, which was a real celebration of accomplishment, including debate as to specific aspects of his work, but nary a question as to whether or not he had any distinctive ideas or whether or not they were influential.

The answer to both questions posed on Nightingale’s nursing is YES. Two volumes of the Collected Works of Florence Nightingale provide copious details:

The Nightingale School, volume 12, 934 pages
Extending Nursing, volume 13, 946 pages

Together these volumes cover the operation of the school from its founding, the development of other “Nightingale schools” at the Edinburgh Royal Infirmary, Highgate Workhouse Infirmary and St Marylebone Workhouse Infirmary, district and workhouse nursing, and the influence of Nightingale’s nursing over the rest of the 19th century across London, Britain, Europe, America, Australia and around the world.¹ Nightingale never set out a “Nightingale method of training,” but key elements can be discerned, as follows:

All nurses must be trained, in a regular civil hospital, regardless of social class or educational background, and regardless of where they would later nurse.
(Military hospitals did not have a sufficient number and diversity of serious cases for training purposes)
Training was fundamentally on the apprenticeship model: hands-on, in the wards, under the ward sister.
Classes, given by medical doctors, augmented training in the wards.
The “home sister” or “mistress of probationers” organized the training, under the matron; she was
- based at the Probationers’ Home
- acted as tutor for the classes given by doctors, and
- organized remedial classes as necessary.
District nurses had to be hospital trained (or they would not see enough serious cases), the training augmented by supervised district visiting.
Midwifery nurses had to be hospital trained (again, to ensure exposure to a sufficient number and diversity of serious cases) even if they were to be conducting home deliveries.
Training was required for administrative positions (ward sisters and matrons) as well as ordinary staff.
This training was also hands-on, e.g., by the trainee filling in for a sister or matron ill or on holiday, or a short-term appointment.
Probationers kept diaries and case notes of their work, examined by the matron and home sister, and often by Nightingale.
A major component of training was moral: ethical standards for patient care (although the term “ethics” was not used).
Technical training had to be updated as the requirements for nursing evolved, with advances in medical science and practice.² * Progress in training was tracked regularly by written reports.
(Moral fitness for nursing could not be ascertained by written examination.)
A Probationers’ Home should be provided, with a private room for each, comfortable (common) living and dining space, hot meals, adequate bathing and toilet facilities, a “home” atmosphere.
(Nightingale accepted that long hours would be the norm for nurses and probationers, but was insistent on good working conditions, breaks, holidays, etc.)
Responsibility for probationers’ health and safety, including rules to prevent septicemia and ongoing monitoring of probationers’ health.
Certificates and letters of reference had to be dated and were relevant only for a short time. (Nightingale opposed permanent certificates.)
A matron should have a housekeeper under her so that she could concentrate on the nursing and the nurse training.³
“The superintendent herself must have the highest knowledge of nursing, be herself resident in the hospital, make the training in nursing her first object, and be herself a trained nurse of the highest order.”⁴

While Nightingale did not anticipate nursing training at universities (when she started women were not allowed in any), she did look to “professors of nursing.”

“There is no professor of nursing, no organization of night nursing. There is a law of human energy of course, a law of nursing power. But the laws of nursing power are not known. There should be a professorship of hospital administration, hospital construction and hospital nursing.”⁵

Influence of the Nightingale Method in Britain and Worldwide

A list of hospitals to which the Nightingale School sent matrons or superintendents is available.⁶

London: St Mary’s, Paddington; St Bartholomew’s; Westminster; Middlesex; Guy’s; Charing Cross; King’s College; University College; St George’s; Soho Sq. Hosp for Women; New Hosp for Women; Royal Hosp for Incurables, Putney; Royal London Ophthalmic; Hosp for Consumption, Brompton; Royal Victoria Hosp for Children, Chelsea; Children’s Hosp, Shadwell; Children’s Hosp, Gt. Ormond St.; London Homeopathic; Royal Ear Hosp, Soho; Lewisham Inf; Haverstock Hill Inf; Shoreham Inf; Convalescent Home for Sick Children, St Pancras; Fulham Inf; Homerton Fever Hosp; Waterloo Rd. Hosp; Harrow Rd. Hosp for Women and Children;

Southern England: Radcliffe Inf, Oxford; Addenbrooke’s Hosp, Cambridge; Chichester Hosp; Royal Inf; Fever Hosp; Salisbury Inf; Norfolk and Norwich Hosp; Folkestone Hosp; Sussex County Hosp; Bristol: Royal Inf and Women’s Hosp; Royal Seabathing Hosp, Margate; Devon and Exeter Hosp; Ipswich Hosp; Croydon General; Smallpox Hosp, Croydon; Southend-on-Sea Sanitorium; Northampton Inf; Brighton and Sussex Inf, Brighton and Sussex Throat and Ear; Portsmouth Hosp; Kent and Canterbury Hosp; East Sussex Hosp, Hastings; Babies Castle, Kent; Royal Berkshire Hosp, Reading; Royal Hampshire County Hosp; County Hosp, Gloucester; Royal Inf, Cheltenham General; Darenth Asylum; Horton Inf, Banbury Inf; Halifax Inf; Mildenhall Hosp, Suffolk; Bedfordshire Hosp; Isolation Hosp, Wimbledon; Lowestoft Hosp; Shrewsbury Sanitorium; Bath Eye Inf; Taunton Somerset Hosp; Ashton-under-Lyme Inf; Chartham Sanatorium; Monkwearmouth Dispensary; Tetbury; Buchanan Hosp, St Leonards; Richmond Royal Hosp.

Midlands and North: Liverpool: Royal (Southern) Inf, Northern; Hosp for Infectious Diseases; Mill Rd. Inf; City Hosp, North Liverpool; Women’s Hosp, Shaw St., Children’s Hosp, Myrtle St.; Manchester: Royal Inf, Ophthalmic Hosp, Heaton Mersey, Monsall Fever Hosp; Lying-in Hosp; Lincoln Hosp; Royal Cumberland Inf, Carlisle; Royal Eye Hosp; Birmingham: General Hosp, Queen’s Hosp, Maternity Hosp; Newcastle-upon-Tyne: General Hosp and Children’s Hosp; Royal Orthopedic Hosp; Stafford Inf; Children’s Inf, Kirkdale; Leeds: Hosp for Women and Children, Infectious Hosp, City Hosp; Sheffield; Pendlebury Children’s Hosp; Stoke-on-Trent Inf; Coventry and Warwickshire Hosp; Worcester Hosp; Royal Northern Hosp; Bradford Eye and Ear Hosp; Warrington Isolation Hosp; Blackburn Inf; Wolverhampton Inf; Bradford Inf; Kidderminster Inf, Albert Inf, Cheshire; Chester General Inf; York County Hosp; Derby Royal Inf; Women’s Hosp, Nottingham; Salford Dispensary; Banbury; Bromsgrove and Redditch Isolation; St Monica’s Children’s Hosp, Kilburn.

Wales: Aberystwyth Inf; Cardiff Inf; Swansea Inf; Carnarvon Anglesea Inf.

Scotland: Edinburgh: Royal Inf, Hosp for Sick Children and Convalescent Home; Glasgow: Royal Inf, Western Inf; Aberdeen: Royal Inf and City Hosp; Dundee Royal Inf; Leith Hosp; St Andrews Hosp, Fife; Inverness Inf; Gartlock Lunatic Asylum;

Ireland, Dublin: Rotunda Hosp; Fever Hosp; City of Dublin Hosp; Dr Steevens’s Hosp; Sir Patrick Duns Hosp; Royal Hosp for Incurables; Belfast: Children’s Hosp, Lying-in Hosp and Nightingale Nursing Home; Thompson Memorial Home, Lisburn.

Military Hospitals: Royal Victoria Hosp, Netley; Naval Hosp, Haslar; Royal Victoria Hosp, Bournemouth; Herbert Hosp, Woolwich; Military Fever Wards, Royal Military Inf, Dublin; Female Garrison Hosp, Portsmouth; Portsmouth Lock Hosp; Military Isolation Hosp, Aldershot; Hosp for Paralyzed Soldiers, Nottingham; King Edward 7th Sanitorium, Midhurst; First Eastern General Hosp; Queen Alexandra Imperial Military Nursing Service;

Workhouse Infirmaries: London: Highgate; St Marylebone, Paddington; Hampstead; Whitechapel; Holborn. Southern England: Bolton Inf; Midlands and North: Liverpool; Birmingham; Warrington; Brentwood Infirmary, Isleworth;

District Nursing: Metropolitan and National District Nursing Assoc., Bloomsbury Sq. (headquarters); South London District, Battersea; Chelsea; Southwark, Newington and Walworth District; Liverpool; Edgeware Rd.; East London Nursing Society; and numerous districts

Sweden. Sabbatsbergs Hosp and Sophiahemmet Nursing School, Stockholm; Uppsala University Hosp;

Germany. City Hosp, Berlin; Darmstadt Hosp and Training School;

France. Ruffi Hosp, Nimes;

Finland. Helsinki: Kuopio University and Surgical Hosp;

Australia. Sydney Inf; Alfred Hosp, Melbourne; Brisbane Inf; Newport, Adelaide and Perth Colonial Hosp; Gladesville Hosp for Insane;

United States. Boston: Massachusetts General Hosp, Waltham Training School, City Hosp and New England Hosp for Women and Children; Philadelphia: Blockley Hosp and University of Pennsylvania; University of Maryland Hosp and Training School, Baltimore; Salt Lake City Hosp; Hosp for Women and Children, Roxbury, Mass; Taunton Hosp for the Insane, Mass;

Canada. Montreal General Hosp;

India. Calcutta: Eden Hosp and General Hosp; HH Nizam’s Hosp, Hyderabad;

Ceylon [Sri Lanka]. General Hosp, Colombo;

New Zealand. Masterton Hosp;

Africa. Albany General Hosp, Grahamstown; Transvaal and Grey Hosp, Kimberley Hosp; King Williamstown; Government Hosp, Mafeking, Basutoland; Government Hosp, Suez; Vincent Hosp, Nigeria;

South America: English Hosp, Buenos Aires; English Hosp, Rio de Janeiro;

West Indies: Cottage Hosp, St Lucia; Government Hosp, St Vincent;

Japan. Yokohama General Hosp; Mission Hosp, Kyoto.

Fiji. Suva Hosp.

I am not aware of any listing of training schools developed under Nightingale’s influence. Many examples appear in the two nursing volumes in the Collected Works, such as:

Edinburgh Royal Infirmary (in effect, the second “Nightingale School”) from 1872, which in turn influenced other Scottish training;
St Mary’s, Paddington (under Rachel Williams);
Glasgow Royal Infirmary and Dundee (under Rebecca Strong);
Highgate Workhouse Infirmary (but ended after 5 years);
St Marylebone Workhouse Infirmary (very successful under Elizabeth Vincent);
Liverpool Training School and Home for Nurses (from 1860s);
Liverpool Workhouse Infirmary (from the 1880s);
Manchester Royal Infirmary;
Belfast Nurses’ Home and Training School (from 1870s, A.L. Bristowe);
Dr Steevens’s Hospital, Dublin (under Louisa Franks);
St Lawrence’s Catholic Home, Dublin (under Margaret St Clair);
Stockholm, Sweden (under Sophie Leyonhufond);
Kuopio, Finland (under Ellen Ekblom);
Hesse-Darmstadt, Germany (under Princess Alice);
Baden, Germany (under the grand duchess of Baden);
Waltham Training School, Boston (under Charlotte Macleod);
Bellevue Hospital, New York City (various contacts);
University of Pennsylvania Hospital (under Linda Richards);
New England Hospital for Women and Children, Training School of the Massachusetts General Hospital (Linda Richards);
Illinois Training School, Cook County (Chicago) under Isabel Hampton Robb⁷;
New York Training School for Nurses, Blackwell Island (under Louise Darche);
Blockley Hospital, Philadelphia (under Alice Fisher);
Johns Hopkins University (under Isabel Hampton Robb);
University of Maryland Hospital (under Louisa Parsons).

Nightingale advised directly on the founding of training schools in several other countries:

Vienna, Austria
Padua, Italy, Florence and Rome⁸ Nightingale’s indirect influence, i.e., through her school, but without any personal involvement, can be seen in other examples: Kyoto (from 1886, through Linda Richards)
France (early 20th century, through Dr Anna Hamilton).

Sometimes the link ran from a matron trained at the Nightingale School at St Thomas’, who was then serving at another hospital. For example, Alice Fisher, when matron at Lincoln, trained nurses who led in the introduction of trained nursing in western Canada.⁹

Nightingale’s Mentoring Relationships

Nightingale acted as mentor to many matrons who were former probationers, and some who were not (notably Eva Lückes at the London Hospital), but who asked for her assistance. They reported to her regularly, by letter and occasional visits, asking for her advice both on practice and training. Nightingale kept copious notes from these meetings and shared information on advances, on topics ranging from:

Deployment of nurses, numbers, rank, schedules, number of probationers
Probationers’ classes (bedside instruction, practice bandaging)
Classes by medical doctors
Best practice (especially operating theatre preparation)
Sharing of ideas from other countries (e.g. Finland on aseptic surgical practices)
Books in different medical specialties and nursing
Nurses’ meals (and budgets)

Nightingale’s network of leading nurses and doctors provided information on best practice which she used in her own writing, and passed on in mentoring sessions.

For example, the matron at the Rotunda Hospital, Dublin, Sarah E. Hampson, made inquiries for her as to the best all-round book on midwifery (Lusk’s), and the best treatise on gynecology (Pozzi, translated by Spencer Wells).¹⁰ In advising the medical officer of health of Buckinghamshire on the prevention of infant blindness, Nightingale inquired of Dr Charlotte Smith, who sent her detailed advice and numerous documents.¹¹ In an interview with theatre sister Constance Herbert, Nightingale learned of the pioneering splenectomy operations being performed at St Thomas’. Herbert updated her with a report on three cases, with further information on them from The Lancet. These were the first successful cases on record of splenectomy for ruptured spleen.¹² When Ellen E. Moriarty was about to become matron of the newly built Brentwood (Workhouse) Infirmary at Isleworth, in 1896, Nightingale made sure that she got some further experience at St Thomas’ before she started. (She was then night superintendent at St Marylebone and thus had seen little recent surgery.)

Nightingale arranged for Moriarty to see the preparations for aseptic treatment of surgical wounds at St Thomas’. The theatre sister took her to observe the arrangement of the theatre and instruments, and then the surgery itself, to see how the work was divided.

Moriarty wrote back afterwards: “Such a difference since the time when I was at St Thomas’….It is such an improvement to have so few close round the patient.” She also reported that Dr Sharkey, from St Thomas’, was coming to examine the probationers at St Marylebone, and she was “working them up.”¹³ Margaret St Clair, a rare Roman Catholic who trained at the Nightingale School, became matron at the St Lawrence’s Catholic Home in Dublin, and kept in touch with Nightingale. After six years in the post she reported that they had seen the home, started as an experiment, flourish.

They had sent out 17 trained nurses to all parts of Ireland, and kept a staff of five in the home. “All have done well and are working loyally under the rules of the Jubilee Institute.”

In three months time they will have started three more districts.¹⁴ Correspondence to Nightingale sometimes came via the home sister, Mary S. Crossland, for example an 1894 letter from Florence Burt, then at the Albany General Hospital, Grahamstown, South Africa. Burt said that she was starting a training school for the colony, and hoped to get two of her second-year nurses into St Thomas’ for further training: “It is only right that I should tell you of my appointment as matron to this hospital, for I feel that I still belong to St Thomas’ and the Nightingale Home.”¹⁵ It is best to ignore the wildly inaccurate statements of F.B. Smith that Nightingale’s method of nursing never amounted to more than “common sense care,” and that “she added nothing to the details of technical proficiency required in a nurse’s daily tasks.”¹⁶ Nightingale’s articles in Quain’s Dictionary of Medicine (cited above) show the serious requirements by 1880, but Smith was wrong even for the earliest stages, when the requirements were much lower, but always far beyond “mere housekeeping.”

Time is lacking for any coverage of district nursing or military nursing (and related issues of training for orderlies and male nurses).

Workhouse infirmary nursing requires at least the comment that Nightingale’s contribution was immense. Social administration expert Brian Abel-Smith called the introduction of trained nursing at Liverpool a “spectacular success,” that is, “eventually,” with points as to how and why it took time.¹⁷ Remember that, when Nightingale started, there were five patients in a workhouse infirmary for every one in a regular civil hospital.

The National Health Service (launched in 1948) is unthinkable without the fundamental reform of those bed-sharing, rat-infested places with drunken “pauper nurses.” Nightingale’s vision of care, as early as 1864, was that it should be as good as that in the “best nursed hospital.”¹⁸ This is called “one-tier” health care in Canada.

No other workhouse reformer had remotely as bold a vision as Nightingale. William Rathbone and Louisa Twining who advocated workhouse visiting, were radicalized by Nightingale.¹⁹ It is my hope that nursing instructors will see the merit of incorporating some Nightingale material in their courses, for example:

Nightingale’s advice on health promotion and disease prevention (still salient)
Methodological principles, how to do research (for evidence-based health care)
Ethical principles (primacy of patient care, recognition of patient’s dignity and rights, not so-termed)
Insistence on good salaries, holidays, pensions and safe working conditions. (Hospital design and scheduling had to be attentive to the risk of sexual assault.)
Multi-disciplinary approach (including use of architects and engineers as well as doctors and nurses)
Pioneering study of maternal mortality post-childbirth (good on the methodological approach and reasoning through the data, before the cause of the disease was identified)
Autonomy of the nursing profession (doctors give medical orders, but must not hire, dismiss, promote or discipline nurses)

Moreover, doctors were not good administrators:

As for doctors, civil and military, there must be something in the smell of the medicines which induces absolute administrative incapacity.

Students might benefit by some understanding of the sorry state of nurses’ working conditions when Nightingale began her school, such as the “wooden cages” on the landing at St Bartholomew’s Hospital, which served as nurses’ sleeping quarters.

Given the high rate of hospital-induced diseases, Nightingale’s views on cleanliness and ventilation, and the need for ongoing monitoring, are all well worth revisiting.

Nightingale’s old-fashioned common sense and wit, with which I conclude, make her still a good read:

A good nurse must be a good woman….The bad woman, the clever nurse, must be an idiot if she cannot hoodwink the doctor.”²⁰

Notes

¹ Both edited by Lynn McDonald and published by Wilfrid Laurier University Press 2009. Chapters 4 and 5 in a short book also give relevant material: Lynn McDonald, Florence Nightingale at First Hand (London: Continuum 2010).

² On the increased requirements see especially Nightingale’s articles in Richard Quain’s Dictionary of Medicine, in volume 12, The Nightingale School; for an abbreviated treatment see McDonald, “Mythologizing and Demythologizing” 100-05.

³ Nightingale letter to the president of the Sydney Infirmary 26 May 1867, Add Mss 47757 f191.

⁴ Letter to William Ogle 2 January 1865, Royal College of Physicians of London 2415/1.

⁵ Undated notes on Netley Hospital, Add Mss 45826 f148.

⁶ See The Nightingale School (12:903-10), and (abbreviated) in McDonald, “Mythologizing and Demythologizing,” in Notes on Nightingale: The Influence of a Nursing Icon, ed., Sioban Nelson and Anne Marie Rafferty (Ithaca NY: Cornell University Press 2010) 100-05.

⁷ Isabel Hampton Robb’s textbook on nursing, Nursing: Its Principles and Practice for Hospital and Private Use, 1893, was widely used and much reprinted, but was not influenced in any direct way by Nightingale.

⁸ Related in Extending Nursing (13:474-91).

⁹ Nursing and nurse training in India are too complicated to deal with in this short paper. On Australia, see Judith Godden, Lucy Osburn: A Lady Displaced: Florence Nightingale’s Envoy to Australia (Sydney University Press 2006).

¹⁰ Hampson letter 28 May 1895, Add Mss 45813 ff64-65.

¹¹ Letter of Charlotte Smith to Nightingale 19 March 1895, Add Mss 45813 ff39-45; Nightingale’s advice to De’Ath, Add Mss 45813 f29, Public Health Care (6:575).

¹² C. Herbert letter 28 October 1895, Add Mss 45813 f124.

¹³ Moriarty letter 28 November 1895, Add Mss 45813 f144.

¹⁴ Letter to Nightingale 16 November 1896, Add Mss 45814 f17.

¹⁵ Burt letter 5 March 1894, Add Mss 47741 f119.

¹⁶ F.B. Smith, Florence Nightingale: Reputation and Power (London: Croom Helm 1982) 178.

¹⁷ Brian Abel-Smith, A History of the Nursing Profession (London: Heinemann 1960) 41.

¹⁸ Letter 1864, in Public Health Care (6:238).

¹⁹ John Stuart Mill and leading public health officers were also moved to stronger positions as a result. The reform of workhouse infirmary nursing is related in Public Health Care (6:223-506).

²⁰ Letter 1879, in Extending Nursing (13:475-76).