Florence Nightingale and Irish Nursing
Journal of Clinical Nursing, 2014
Aims and objectives. To challenge statements made about ‘Careful Nursing’ as a ‘distinctive system’ of nursing established by the Irish Sisters of Mercy, prior to Florence Nightingale, and which is said to have influenced her.
Background. Numerous publications have appeared claiming the emergence of a ‘distinctive system’ of nursing as ‘Ireland’s legacy to nursing’, which, it is claimed, influenced Nightingale’s system. One paper argues that the Irish system has its philosophical roots in Thomist philosophy. Several papers argue the ongoing relevance of the Irish system, not Nightingale’s, for contemporary nursing theory and practice. Nightingale’s influence on and legacy to Irish nursing are not acknowledged.
Design. A Discursive paper.
Methods. Archival and published sources were used to compare the nursing systems of Florence Nightingale and the Irish Sisters of Mercy, with particular attention to nursing during the Crimean War.
Results. Claims were challenged of a ‘distinctive system’ of nursing established by the Irish Sisters of Mercy in the early nineteenth century, and of its stated influence on the nursing system of Florence Nightingale. The contention of great medical satisfaction with the ‘distinctive’ system is refuted with data showing that the death rate at the Koulali Hospital, where the Irish sisters nursed, was the highest of all the British war hospitals during the Crimean War. Profound differences between the two systems are outlined.
Conclusions. Claims for a ‘distinctive’ Irish system of nursing fail for lack of evidence. Nightingale’s principles and methods, as they evolved over the first decade of her school’s work, remain central to nursing theory and practice.
Relevance to clinical practice. Nightingale’s insistence on respect for patients and high ethical standards remains relevant to practice no less so as specific practices change with advances in medical knowledge and practice.
What does this paper contribute to the wider global clinical community?
Nightingale influenced clinical practice throughout the world in her lifetime, including Irish nursing.
Her influence continued through the writing she left behind and the leadership given by nurses she herself mentored, including Irish nurses.
Nightingale’s basic principles remain relevant around the globe, especially as crises and scandals of poor care appear.
While Florence Nightingale (1820-1910) is still recognised as the major founder of the modern, secular profession of nursing, her vision, principles and methods are largely ignored in nursing in the West, although they are still respected and taught in many other parts of the world, notably in Japan, China and India. Statisticians, architects and healthcare experts continue to see the relevance of her work to today’s practice. In recent years, however, the very originality of her principles and methods of nursing has come under attack, as derived from an earlier nursing model formulated by the Irish Sisters of Mercy. This system, termed ‘Careful Nursing’ in an unpublished conference paper (Doona 2000), was said to be no less than ‘Ireland’s legacy to nursing’. Another paper from the same conference took up the theme (Meehan 2000). Its author subsequently published three articles on the ‘Careful Nursing’ thesis (Meehan 2003, 2005, 2012), two newspaper articles (Meehan 2002, 2004) and a book chapter (Meehan 2007).
In the last of these sources, Meehan held that ‘Careful Nursing’ constituted a good model for contemporary nursing practice. It provided ‘meaningful direction for practice’, could ‘help decrease incidents of incompetent and insensitive practice and sustain already exemplary directions’, constitute a ‘basis for theory development’ and ‘help close the relevance gap between nursing practice and nursing science’ (Meehan 2012, p. 2005).
These claims will be examined with contrary evidence from relevant primary sources. The ‘Careful Nursing’ model will be specifically compared to the nursing model established by Nightingale, beginning in 1860 with the opening of her school, the first secular training school for nurses in the world. What the Irish Sisters of Mercy actually did in their nursing during the Crimean War will be related. Brief comments will be made on Meehan’s argument that ‘Careful Nursing’ was grounded on Thomist philosophy. Finally, the appropriateness of ‘Careful Nursing’ as a model for contemporary nursing theory and practice will be challenged, and the ongoing usefulness of Nightingale’s core principles and methods proposed.
Of the many publications arguing for ‘Careful Nursing’ as ‘Ireland’s legacy to nursing’ and the source of Nightingale’s nursing, the prime source used here is the third journal publication by Meehan (2012). Here, she added to the original ‘distinctive system’ claim, based on the ‘visitation of the sick’ practised by the Irish Sisters of Mercy, the contention that it reflects Thomist philosophy, using citations from Aquinas’s thirteenth-century Summa Theologica. This article looks forward, as well, with the bold claim that ‘Careful Nursing’ forms a good basis for contemporary nursing practice. Points from the other papers are referred to only when they add some further information or contention.
The newspaper articles are even more emphatic in arguing that the Irish Sisters were the ‘real pioneers of tending the war wounded’, not Florence Nightingale (Meehan 2002, p. 50). The headline of that story proclaimed, ‘For 150 years, Florence Nightingale has been known as the mother of modern nursing. But was an Irish nun really the Lady of the Lamp?’ (Meehan 2002, p. 50). The story pointedly mentioned Nightingale’s English status, implying that the credit given to her reflected the unhappy fact of England’s oppression of Ireland. It asserted that ‘it was, in fact, an Irishwoman, Mary Catherine McAuley, the founder of the Sisters of Mercy, who first developed the basic principles of modern nursing’. These principles were then taken by her sisters (McAuley died in 1841) in 1854 ‘to the blood-sodden Crimean peninsula, laying down the basic ground rules and concepts of modern nursing’ (Meehan 2002, p. 50).
Quite apart from the Irish Sisters of Mercy founding ‘modern nursing’, to be debated shortly, the assertion that they did so on the ‘blood-sodden Crimean peninsula’ is false. The sisters, as Nightingale, were initially sent to Turkey, not the Crimea. They later nursed at the Balaclava Hospital, beginning more than a month after the fall of Sebastopol and the last battle of the war. They never saw ‘blood-sodden’ soil, although they saw the misery the soldiers suffered, especially from frostbite, malnutrition and cholera.
In the second newspaper article, Meehan made the claim that the superior of the Bermondsey Sisters of Mercy, Mary Clare Moore, who served at the same hospital as Nightingale in Turkey, tried ‘to guide’ her. Meehan described Nightingale as ‘inexperienced’, while ‘the Irish nursing nuns had developed a comprehensive and effective system of nursing called careful nursing’ (Meehan 2004, p. 15), points to be disputed shortly with primary source data.
This is a discursive paper.
All the published journals and correspondence by the Irish Sisters of Mercy pertaining to the Crimean War, biographies of the founder of the order and of the superior/founder of the convent at Bermondsey were consulted. For Nightingale material, archival sources were fully read, of her entire oeuvre; for the reader’s convenience, available published sources are also given in citations. Key elements of Meehan’s ‘distinctive system’ are identified, and alternative explanations and data cited from primary sources in refutation or qualification.
A ‘distinctive system’?
Several stages are identifiable in Meehan’s development of ‘Careful Nursing’.
1. That Catherine McAuley (1778-1841), the founder of the Irish Sisters of Mercy, established a ‘distinctive nursing system’, beginning with their sick visiting in 1828, augmented by their nursing in a Dublin cholera depot in 1832. Sisters took the method with them to the Crimean War (Meehan 2012, p. 2006). Meehan also briefly recognised the earlier work of Mary Aikenhead, founder of the Irish Sisters of Charity (Meehan 2012, p. 2006). Nightingale, in fact, sought to get hospital experience with that order in 1852 at the Dublin hospital they nursed, St Vincent’s, but it was then closed for renovations (McDonald 2004b, pp. 708-716). She was disappointed to learn that the sisters did not do night duty nor attend operations (McDonald 2002, pp. 259-260). However, as this order did not send nurses to the Crimean War, their work forms no part of the discussion at hand.
That McAuley was a devout leader of her community and tireless visitor and counsellor of the sick poor is not in the slightest disputed. However, it must be realised that the main purpose of visiting was religious – saving souls – as can be seen in the chapter on it in the Rule and Constitution in Table 1. Meehan cited nothing from McAuley’s own words, and quite a different impression is gained when they are read. The rule was first submitted to Archbishop Murray, who amended it; here, McAuley’s initial drafting is used, except in one place where Murray’s significant addition is noted.
2. Meehan cited Dock that the Irish sisters ‘were recognized as skilled nurses and had attained “brilliant prestige in nursing”’ (Meehan 2012, p. 2006). However, Dock’s reference was to McAuley only, and that but a brief remark in a four-volume work (Dock 1912), nearly a volume of which is given to Nightingale’s nursing and substantial sections to that of religious orders, Roman Catholic and Protestant.
3. Mary Clare Moore, who had worked with McAuley during the 1832 Dublin cholera epidemic, is said to have taken the Irish sisters’ method to Nightingale at Scutari. According to Meehan, Nightingale ‘acknowledged privately her reliance on their nursing knowledge and skill, particularly that of Moore’ (Meehan 2012, p. 2006). She gave no specific source and there is no such acknowledgement in Nightingale’s substantial surviving writing. Moore was a solid supporter of Nightingale in difficult circumstances, but her work was largely administrative, in the linen stores and on ‘extra diets’. Her poor health precluded her from more active nursing duties. There is no discussion of methods of nursing in their correspondence (Sullivan 1999).
4. Meehan asserted that ‘Moore has been recognised as one of the greatest influences on Nightingale in nursing matters’, citing Baly’s As Miss Nightingale Said, a book of brief quotations, for which she gave no page number (Meehan 2012, p. 2006). The book, however, contains no mention either of Moore, any Sister of Mercy or Irish nursing. Moore was a spiritual influence on Nightingale, notably after the Crimean War when she introduced her to the mystical writers (in McDonald 2002 276-280, 283, 287-290). Nightingale recognised Moore’s superior fitness for superintendence, from having administered her convent and founding others. Moore was Nightingale’s senior in age by six years and many more in general experience – she made her vows at age nineteen.
5. Meehan stated that Moore attempted ‘to guide’ Nightingale, whom she called an ‘inexperienced nursing superintendent’ (Meehan 2004, p. 15). But Nightingale was more experienced in both nursing practice and superintendence, having nursed in a German hospital with deaconesses in 1851 (McDonald 2004b, pp. 513-543), Paris hospitals with the Sisters of Charity and other orders in 1853 (McDonald 2004b, pp. 719-747), at the Middlesex Hospital in the London cholera epidemic of 1854 (McDonald 2009a, pp. 112-113) and both nursing in and managing her own small hospital on Harley St., London, in 1853-1854 (McDonald 2009a, pp. 60-112). She assisted at operations and did night nursing, neither of which the Sisters of Mercy then did. As a Sister of Mercy, Moore visited the sick at home and in hospital, but never did regular hospital nursing. As Table 1 makes clear, counselling the sick, urging repentance in preparation for death, was the prime focus of those visits. Moore’s cholera depot experience consisted of shifts of two to three hours each, over a period of seven months, in 1832 (Sullivan 2012, p. 117).
6. Meehan claimed that the ‘distinctive’ Irish model emerged from a ‘content analysis of historical documents’ (Meehan 2012, p. 2006), not an example of which she gave. She did not employ any objective, computer-based, content analysis programme. Moreover, she did no content analysis of, or even, apparently, read, Nightingale’s writing on nursing. The only Nightingale sources Meehan cited were her correspondence with Moore, which was not on nursing, and Notes on Nursing, a book she wrote before her training school opened, for mothers and girls with healthcare responsibilities at home (for critical editions, see McDonald 2009a, pp. 577-705 and 2004a, pp. 17-161). Bolster went further than Meehan in stating that Nightingale actually used Bridgeman’s system in writing the book, having made a ‘complete revision’ of her own ideas on nursing, but failed to acknowledge her debt (Bolster 1964, p. 252). She gave no evidence in support of this inference, and none is evident.
In any event, Notes on Nursing was never intended for use by hospital nurses, although the medical instructor at the Nightingale School subsequently assigned sections of it to pupils. Nightingale’s system can be seen clearly from what was taught in her school from its inception (in McDonald 2009a, Croft 1873), and in her later papers (Nightingale 1882 in McDonald 2009a, pp. 713-752; Nightingale 1893 in McDonald 2004a, pp. 203-219), none of which Meehan cited in her many publications on the subject.
Meehan’s ‘distinctive system’ claim was taken up by members of the large healthcare union, Unison, who seek to have Nightingale replaced as the acknowledged founder of nursing: ‘It was Joanna Bridgeman who developed the system of nursing and management that Florence Nightingale adopted’ (Walker & Wheeler 2010).
7. Meehan asserted (without a citation) that ‘the Koulali General Hospital became known among the doctors as the model hospital of the East’ (Meehan 2005, p. 33). This claim originally occurs in the journal of an Irish sister, M.A. Doyle (Luddy 2004, p. 25), and it was repeated by another sister (Croke, in Luddy 2004, p. 75). No citation of any doctor actually saying this, however, is given, and none is known of. Bolster credited the ‘model hospital’ statement to ‘ladies and nurses’, not doctors, citing a memoir of a then Anglican sister who later converted to Catholicism (Bolster 1964, p. 147).
That the ‘purveyor-in-chief placed all hospital supplies at their disposal and told Bridgeman to act as if the hospital were her own’ (Meehan 2005, p. 33) does not constitute such evidence, as purveyors were not doctors.
Dr Sutherland, head of the Sanitary Commission, had a strongly contrary view of the hospital: it had the worst sanitary conditions and, consequently, the highest death rates of all the war hospitals (Sutherland 1857, pp. 23-26). This was not the fault of the sisters or the doctors, but the defective privies, sewers and drains. If blame is to be laid, it must go to the War Office for accepting defective buildings in the first place, and the inspector general of hospitals who approved their use. This was Dr John Hall, to whom the sisters deferred without question (Nightingale obeyed his instructions, but was highly critical of his direction in many respects).
Sutherland and his team deserve much of the credit for the great decline in the Koulali death rates, by their extensive sanitary reforms. In his evidence to the Royal Commission on the Crimean War, he stated ‘At Koulali the mortality fell to an 18th part of what it was when the sanitary works were commenced’, repeating the key point that ‘at that hospital the defects were the most serious, and the loss of life from them had been the greatest’ (UK 1858 2:334). Most astonishing in all the writing by the Irish Sisters of Mercy is the absence of any comment on either the high death rates or their decline, although they noted the rats, vermin and general dirt and the terrible suffering of the soldiers.
The fact of the high death rate at Koulali was known at the time, without the exact numbers. Nightingale presumably heard it initially from Sutherland and told chef Alexis Soyer, who reformed the kitchens and improved army food, when they travelled on the same ship to Balaclava. In his journal, he noted that although the hospitals were ‘so well situated, it was reported by medical men that they were very unhealthy, more especially the lower one’ (Soyer 1857, p. 150). In her reports after the war, Nightingale discussed the high Koulali rates (McDonald 2010, pp. 903 and 961).
8. Meehan gave Thomist philosophy as the ‘philosophical assumptions’ of ‘Careful Nursing’, asserting that they ‘markedly matched the thinking of Thomas Aquinas’, which ‘built on and extended the thinking of Aristotle’. They provided no less than
the foundations for how nurses think about themselves as nurses, the patients they care for, the nurse-patient relationship and the attitudes and actions they engage in to protect patients and foster their healing and health. (Meehan 2012, p. 2907)
A table and text give highly idealised paraphrases from Aquinas (Meehan 2012, pp. 2908-2909), in language that the ‘angelic doctor’ would scarcely recognise, notably referring to God as ‘an infinite transcendent reality’ (2909). Aquinas’s Summa Theologica in English translation is a two-volume work of some 2500 pages, all using the method of disputation, with initial statements, objections and replies. There is no reference in it to health, disease, healing, nursing or medicine. It is difficult to believe that it influenced McAuley or any of her sisters, for nuns then did not study Thomism – priests did. Similarity in fundamental principles, such as the unity of God, the dual spiritual/physical dimension of human existence, etc., could come from many sources other than Thomism.
The Irish Sisters of Mercy and the Crimean War
The Irish Sisters of Mercy during the Crimean War worked assiduously in dangerous conditions, giving service highly appreciated and recognised. Two of their number died of disease while nursing at the Balaclava Hospital. While they did not influence Nightingale’s nursing, they, as she and her nurses, carried out doctors’ instructions on food and stimulants and assisted in cleaning the soldiers brought into the wards. Faced with dirt and disorder at Koulali on their arrival, as Nightingale was at Scutari, they set to work with a rigorous cleaning.
The three who left journals, Bridgeman, Doyle and Croke, show a high level of education and culture – although Croke was given to humorous versifying and so is not excerpted here. Their observations en route, such as on the Turkish political system and continued existence of slavery, are interesting. They made many converts, including Anglican sisters.
Meehan and Bridgeman both stated that Nightingale treated them badly, by refusing to admit them on arrival to her hospital at Scutari (Meehan 2004, p. 15 and Bridgeman in Luddy 2004 pp 126-141 and 223). Both ignore the fact that Nightingale was herself under constraint, given that the doctors stipulated a maximum of fifty women between the two hospitals at Scutari (letter to Sidney Herbert in McDonald 2012, p. 99), while, as Nightingale explained to Bridgeman, their group would have added 46 for a total of 86 (in McDonald 2012, pp. 86-87), fifteen of them Irish nuns. Another letter to Herbert explained that the proportion of Roman Catholics had already caused ‘an outcry’, which would increase with new additions (in McDonald 2012, p. 84). A more nuanced account is Luddy (2004, pp. xiii-xiv). Bolster acknowledged Herbert’s apologies to both Nightingale and Bridgeman (Bolster 1964, p. 113). None of these sources pointed out that Herbert’s letter that no further nurses would be sent until and unless Nightingale explicitly asked for them was a public document, published in the Times (Herbert 1854).
Meehan stated incorrectly as well that ‘the nurses found employment in three hospitals outside the jurisdiction of Nightingale’, noting Koulali (Meehan 2007). However, it was Nightingale who ‘found employment’ for them, although she could not keep all 46 together in any one hospital (Nightingale letter to Bridgeman in McDonald 2012, p. 92 and her letters to Sidney Herbert pp. 95-96 and 98-99).
Doyle’s journal, beginning at the General Hospital, Scutari, shows the most sympathy with the stricken soldiers. She was perspicacious also in noting that the remedies the doctors tried, which were standard for the time, did not work. The effective treatment is oral rehydration period, which was not known for another century. The frequent use of substances to increase sweating, vomiting and purging through the bowels was counter-productive. Interestingly, the death rate from cholera in the Dublin 1832 epidemic, at the hospital where the Irish sisters nursed, was about 30% of patients admitted (Sullivan 2012, p. 118), or lower than the Crimean rates. The ‘stuping’ described as Bridgeman’s speciality relieved cramps, but did not arrest the disease. Depending on the dose and time of administration, it could have contributed to the patient’s collapse (Table 2).
Remarkably, Bridgeman saw both their assignment to Koulali and its closing for British use as signs of God’s intervention on their behalf. None of the three who kept journals remarked on the exceptionally high death rates and the concerted, effective cleaning and renovation conducted by the Sanitary Commission which brought them down.
By contrast, after the war, Nightingale immediately set to work researching the causes of the high deaths, to make comprehensive recommendations for changes to ensure that they did not recur. When that work was completed, she turned to the establishment of her training school, from which trained matrons and nurses took the new ideas and practices to hospitals in many places, including Ireland.
Nightingale’s system of nursing evolved substantially from its start in 1860, so that her later writings must be relied on to see its full development and influence (Table 3).
None of these points, mainly derived from Nightingale’s writing, augmented in point 2 with the medical instructor’s lectures, formed any part of McAuley’s visitation practice and were only minimally part of the nursing of the Crimean War nurses. None of these sisters had had regular hospital experience, and very few afterwards did any hospital work – Gonzaga Barrie, of the Bermondsey group, exceptionally headed the nursing at a London chronic-care hospital, the ‘St Elizabeth Hospital for Incurables’ in the language of the time.
The Crimean War Irish sisters and Nightingale’s approach overlap on following doctors’ orders on administering food, drink and medication, feeding helpless sick and keeping the wards clean. The Irish sisters’ ranking of spiritual guidance over healing the body differs from Nightingale’s system, where spiritual guidance was strictly limited. Threats of ‘the dreadful judgments of God towards impenitent sinners’ and the prospect of being ‘miserable for all eternity’ are good Catholic teaching, but would not be allowed in any Nightingale school.
Most of the above elements of Nightingale’s nursing were developed after the Crimean War, but were heavily influenced by the experience she gained there. They in turn influenced Irish nursing, a point never acknowledged by Meehan nor her initial source (Doona 2000). Other authors have acknowledged this considerable influence (Scanlan 1991, Fealy 2006). Substantial correspondence reporting Nightingale’s work for Irish nursing in detail is available (McDonald 2009b, pp. 384-404 and 2004a, pp. 490-506).
‘Careful Nursing’ as a model for contemporary nursing theory and practice
Meehan set out ten ‘key concepts’ of ‘Careful Nursing’ for practice: disinterested love, contagious calmness, a restorative environment, ‘perfect’ skill in fostering safety and comfort, nursing interventions, health education, participatory authoritative management, trustworthy collaboration, power derived from service and nurses’ care for themselves (Meehan 2003, p. 102). The components of each are described, although without any concrete source given for any of them. Some have odd names – contagious calmness – although the meaning is clear. The content seems appropriate for disinterested love, contagious calmness and nurses’ care for themselves, which self-care in the cholera epidemic meant short shifts and even in the war hospitals time off for regular religious exercises and retreats. Two concepts have no known origin in the early practice of the Irish Sisters of Mercy: nursing interventions, meaning ‘specific healing procedures’, and health education, on which there is simply not a word. Some of Meehan’s key concepts entail considerable exaggeration: ‘perfect’ skill in fostering safety and comfort (even if ‘perfect’ is put in quotation marks) and power derived from service, when obedience to superiors and priests was unquestioned.
Table 1. ‘Visitation of the Sick’, 1841 Rule and Constitutions of the Religious Sisters of Mercy (Sullivan 1995, pp. 297-299)
The first three paragraphs relate the principle of mercy, the miraculous cures performed by the Saviour and the call to imitate his labours. McAuley’s text on the actual visiting begins with Article 4:
4th The sisters appointed by the mother superior to visit the sick shall prepare quickly and, when ready, shall visit the Blessed Sacrament to offer to their Divine Master the action they are about to perform, to ask from him the graces necessary to procure his glory and the salvation of souls
5th Before the sisters leave the convent, they shall endeavour to understand perfectly the way they are to go, and if some places cannot be found without making enquiry, it will be most prudent to go into a dairy, huxter [fruit and vegetable shop] or baker’s shop where the poor are generally known, always speaking with such reserve as ensures respect, but not to continue looking about since charity is not only kind and patient, but doth not behave unseemly
6th Two sisters shall always go out together. The greatest caution and gravity must be observed passing through the streets, walking neither in slow or hurried pace, keeping close, without leaning, preserving recollection of mind and going forward as if they expected to meet their Divine Redeemer in each poor habitation, since he has said, ‘Where two etc. are in my name I will be’
7th One of the sisters should be capable of reading very distinctly and have sufficient judgment to select what is most suitable to each case. She should speak in an easy, soothing, impressive manner, so as not to embarrass or fatigue the poor patient. The other sister can be very conducive to the good which is accomplished by uniting in fervent prayer
8th Great tenderness must be employed and, when death is not immediately expected, it will be well to relieve the distress first [added by Archbishop Murray: ‘and to endeavour by every practicable means to promote the cleanliness, ease and comfort of the patient’], since we are ever most disposed to receive advice and instruction from those who evince compassion for us
9th The sisters shall always have spiritual good most in view; hence, when they find habits have been careless, religious duties long neglected and coldness and indifference seem to prevail, it is most necessary they should endeavour to create alarm by speaking of the dreadful judgments of God towards impenitent sinners and admonishing the patient that, if we do not seek his pardon and mercy in the way he has appointed, we must be miserable for all Eternity. They should add the strongest entreaties with evident deep concern, for, if our hearts are not affected, in vain should we hope to affect theirs; above all, they should pray in an audible voice and most earnest emphatic manner that God may look with pity on his poor creatures and bring them to repentance. This will be most likely to dispose them for a confession, upon which all depends, and for the accomplishment of which every prayer and instruction shall be offered. The sisters shall question them on the principal mysteries of our Holy Faith and, if necessary, instruct them
10th When recovery is hopeless, it must be made known with great caution and, if time permit, done by degrees, assuring them of the peace and joy they will feel when entirely resigned to the will of God, inducing them to pray that he may take all that concerns them into his divine care and dispose of them as He pleases. Let the sisters, if possible, promise attention to whatever object engages their painful, anxious solicitude, that the mind may be kept composed to think of God alone
11th When the sisters return to the convent, they shall again visit the Blessed Sacrament, thank Jesus Christ for his protection, humble themselves before him for any imperfections they may have fallen into, and most earnestly pray that, whatever assistance has been afforded through his grace and mercy, may conduce to his own glory, the salvation of their souls and of those whom they have instructed
Table 2. Journal notes by the Irish Sisters of Mercy at the war hospitals (Luddy 2004, pp. 19-22 and 24-25)
Mary Aloysius Doyle, at the General Hospital, Scutari:
My first day in the wards of the General Hospital, Scutari. Where shall I begin, or how can I ever describe my first view? Vessels were after arriving and the orderlies carrying the poor fellows, who had, with wounds and frostbite, been tossing about on the Black Sea for two or three days, and sometimes more. Where are they to go? Not an available bed. They are laid on the floor one after another, till the beds are emptied of those who are dying of cholera and every other disease. Many died immediately after being brought in; their moans would pierce the heart….
The look of agony in those poor dying faces will never leave my heart….We went round with hot wine and relieved them in every way as far as it was possible for us to do so. We went to the Catholic solders, took the names of those in immediate danger, that the chaplain might go to them at once….
I will try to describe the cholera first and then the frostbite, these latter the worst of all. The cholera was of the very worst type, and when once attacked the patients only lasted four or five hours. Oh, those dreadful cramps….The usual remedies ordered by the doctors were stuping, poultices and mustard, etc….Rev Mother was a splendid nurse and had the most perfect way of doing everything. For instance, the stuping seems such a small thing, and, if not properly done, it does more harm than good….A large tub of boiling water, blankets torn in squares, a piece of canvas with a running at each end to hold a stick. The blankets put into the boiling water, lifted out with a tongs and put onto the canvas, an orderly at each end; they wring the flannel out so that not a drop of water remains. A preparation of chloroform sprinkled on and applied to the stomach, a spoonful of brandy and immediately after a small piece of ice to try to settle the stomach, but very seldom it succeeded; rubbing with mustard and even with turpentine, but cholera is proof against all. Rarely, very rarely, anyone got over it….
When the poor wounded men are brought in out of the vessels they are in a dreadful state of dirt, and they are so weak that, whatever cleaning they get, must be done so cautiously….so worn out with fatigue, so full of vermin, from the soiled clothing and poverty of blood….Most, or I may say all, of them required spoon feeding
[At Koulali, where the account also begins on the sad condition of the soldiers, ‘such desolate, worn-out looking patients’] In the beginning there was great rubbing and scrubbing to bring it into anything like an English hospital, but they succeeded so well that the ladies, the doctors and nurses were all delighted and, as for the orderlies, they used to look round in great delight and exclaim, ‘There is nothing like it anywhere.’…
Some thousands passed through the hospital during the sisters’ time there. They had a very pretty chapel (adorned by the liberality of the soldiers), where there was daily Mass, two Masses on Sundays and Benediction in the evening. Convalescent patients thronged to hear daily Mass, men off duty came when it was possible and the sisters had the satisfaction of knowing that no Catholic ever left Koulali without receiving the sacraments, nor did a simple Catholic die without the consolation which Mother Church reserved for her dying children.
Mary Francis Bridgeman (Luddy 2004, pp. 141-43, 154, 215)
We arrived in Koulali late in the afternoon of the 27th [January 1855] where we found all in a state of utmost confusion and dirt. The food (meat, bread, etc.) so bad that it brought serious illness on two sisters and laid the foundation of delicacy in others. All had much to suffer in many ways, but then the work we came to do was there in abundance….On the feast of St F[francis] de Sales [28 January] we began our work in the British military hospital at Koulali….
The wards in Koulali were filthy. No kitchen there or place to cook for the patients….The diseases were like those in Scutari, the number much less so….On the feast of the Purification [2 February] a second hospital was opened….Miss Stanley gave Revd Mother the charge of it, and it was arranged that we should all live there and sisters be appointed to go daily to the barracks from it
The first day the General Hospital opened 200 patients were admitted who had come from the Crimea. Most of these were so prostrate as to be unable to aid themselves. It was necessary to cut and comb their overgrown hair and beard, wash their faces and even feed them like babies. Many a time the poor fellows burst into tears on being spoken to and exclaimed, ‘Oh, it is long since I heard a kind word before.’.. .
Koulali began to grow in general esteem. Lady Stratford [wife of the British ambassador, patroness at Koulali] was flattered and was vain of the good name and nice state of her hospitals. She knew and acknowledged (in secret) that their continuance depended on the nuns and she valued them for this, but she was a weak-minded silly bigot, who was at the mercy of every knave….
The name Koulali was acquiring, and the totally different system of nursing adopted there, with the full approval of the doctors, seemed to have keenly excited Miss Nightingale’s jealousy. The medical officers in Scutari generally disliked her; her assumption of authority, surgical skill, etc., her attending unsuitable operations, etc., disgusted them. Then the want of system, and the misconduct of the paid nurses made her and their presence be regarded as worse than useless
It seemed as if the persecution in all quarters did but increase the spiritual good, and God daily made some fruit visible to console us. We had from thirty to eighty communicants each Sunday at Koulali, many of them first communions. Few, if any of the Catholic soldiers left hospital without making their peace with God, and, notwithstanding our strict adherence in our engagement [not to proselytize], many were quietly received into the church and admitted to sacraments, both in Scutari and Koulali, and many apostates reconciled. In Koulali there were at least fifty added to the Church
Koulali was quite broken up soon after Miss Hutton and the unpaid ladies left it. God opened it to receive us in our time of need and to enable us to make friends. When this had been accomplished, the work seemed done and it was given up as a British hospital to become the depot of the German Legion.
Table 3. Nightingale’s system of nursing
1. Nursing is both an art and a science. As an art it must be acquired by apprenticeship-type training, at the bedside, with supervision by a more experienced nurse. The science of nursing is taught by qualified medical doctors
2. Nursing is a ‘progressive calling’ which must be updated with advances in medicine, surgery and public health (Nightingale in McDonald 1894 in McDonald 2009a, p. 749). Scientific knowledge is gained by research, but remains elusive. A healthy respect for unintended consequences is necessary
Lectures at the Nightingale School in its early years included fevers and respiratory diseases; the use of disinfectants (with a rudimentary explanation of germ theory), antisepsis; poultices, dressings, bandaging, enemata; bedsore prevention and treatment; artificial respiration and the management of convalescence (Croft 1873)
3. Neither medicine nor chemicals cure, but Nature, so that the nurse’s task is to put the patient into the best condition for Nature to heal (Nightingale 1860 in McDonald 2009a, p. 683)
4. It is the nurse’s duty, whether in hospital or home, to ensure adequate fresh air, ventilation, warmth, light, cleanliness, nutrition and quiet to the sick, chapters on each of which are in all the editions of Notes on Nursing. A requirement added for district/home nursing, the nurse must clean the sick room thoroughly on a first visit and teach the caregiver how to do so in the future (Nightingale in McDonald 2009b, pp. 750-756)
5. Both hospital and homes nurses must be trained in a hospital, as it would be impossible otherwise for them to become acquainted with the full range of diseases. Those doing home visiting or ‘district nursing’, require additional supervised training after that
6. All nurses work under the orders of a qualified physician or surgeon, who diagnoses the case and directs the treatment. Nurses report their observations to the physician or surgeon. Ability to report accurately in appropriate detail is a skill that must be learned
7. All nurses must be supervised by more experienced nurses appointed to that task. With experience, nurses can rise to higher posts with greater challenges and higher salaries
8. Hospitals are dangerous places which should be used only for essential medical and surgical interventions. Patients should be moved out to convalescent care at the earliest possible
9. In addition to ‘sick nursing’, or healing the sick, nurses can play a preventive role as ‘health nurses’ or ‘health missioners’ (Nightingale 1893 and 1894 in McDonald 2004a, pp. 600-601 and 607-621)
10. Nursing as a ‘calling’ was a ‘high calling’, from God (Nightingale 1872 in McDonald 2009a, p. 763). However, since the primary tasks of nursing are healing the sick and promoting health, patients desiring spiritual counselling should normally be referred to a chaplain. Nurses of faith may give an account of their beliefs, with discretion. Nursing as a profession must be open to persons of any faith and no faith at all
11. Nurses require good and rising incomes, benefits (pensions and health care), adequate holidays (a month at least) and decent residential accommodation (with privacy and comfort). The death rates of nurses at hospitals should be monitored (Nightingale 1863 in McDonald 2012, pp. 97-99)
12. The nurse’s prime responsibility is to the patient. When care is inadequate or abuses occur, the nurse should be the patient’s defender, informing the appropriate authorities and the public if the authorities will not act.
(in McDonald 2009b, pp. 475-476)
Creating a restorative environment would be a formidable challenge both in the slums and in the war hospitals where the Irish sisters served. Yet the term fits Nightingale’s ‘environmental’ approach ideally (Hegge 2013). Some of the ‘key concepts’ would seem to contradict the Irish sisters’ practice: participatory authoritative management, which is entirely downward, where nurses ‘gently but firmly’ inform nursing assistants what they must do, and trustworthy collaboration, her term for old-fashioned ‘obedience’ to medical direction. However, during the Crimean War, the Irish sisters clearly worked under doctors’ orders, and indeed, Bridgeman’s letters to and about the principal medical officer show extreme deference (in Luddy 2004, pp. 225, 227-228). Meehan, however, insisted that the Irish sisters were ‘certainly not subservient’, but to the contrary, were ‘self-assured, took the initiative and were quick to question’ (2003, p. 103).
Meehan expanded the ‘Careful Nursing’ scheme to fourteen concepts in a later paper, but again without giving concrete examples. The role of doctors is acknowledged only peripherally, as nurses diagnose and treat with unclear limits (Meehan 2012, pp. 2910-2911). As is typical of the recent nursing literature, doctors exist only as ‘other health professionals’ (Meehan 2012, pp. 2911-2912).
Space does not permit detailed discussion of these various points, but the first item, ‘therapeutic milieu’, can serve as an example:
The nursing-created surrounding and atmosphere that provides the culture within which clinical practice and management take place…[is] more than an environment… [but] a context rich in healing interpersonal relationships, cooperative attentiveness to patients and physical features which sooth[e] patients and provide for optimum safety. (Meehan 2012, p. 2910)
Under ‘clinical reasoning and decision-making’ come ‘cognitive processes and strategies…to understand patient data, choose between alternatives and make nursing diagnoses’, with ‘particular emphasis’ on ‘nursing diagnostic accuracy’. These processes are used ‘to identify needs for assessment and intervention by other health professionals’ (Meehan 2012, p. 2911). How this relates to either McAuley’s visitation of the sick or the Irish sisters in the Crimean War hospitals is not clear.
The lessons Bridgeman learned from the Crimean War pertained to religious governance:
The evil and misery of this whole mission was that it had no head. The unity of the Church was most grievously misrepresented; indeed the Protestants had some semblance of unity as they had a chief chaplain with authority to act, etc., command, appoint and remove chaplains, etc….What might have been the happy results had it been well arranged, and under one judicious ecclesiastical superior? Only God could calculate. (Luddy 2004, pp. 245-246)
Bridgeman further specified, as lessons for the future, that no sisters should be placed ‘under any secular lady, especially a Protestant’ and that nuns from different communities (in the same religious order!) should not be placed together (Luddy 2004, p. 246). At no time did she or any of the Irish Sisters of Mercy bring the gross defects of their hospital to the attention of any of the authorities.
The timing simply does not work for Meehan and Bolster’s case of the Irish Sisters influencing Nightingale. They opened their first hospital in Ireland in 1861, the Mater Misericordiae in Dublin, their first Irish training school not until 1891. By then, the influence of Nightingale and her school, mediated by progressive Protestant reformers, had long been made (Fealy 2006, p. 58).
The numerous claims made by Meehan of the existence of a ‘distinctive system’ of nursing, its influence on Nightingale and its viability as a model for contemporary use have been shown to lack firm evidence. The differences between the principles and practices developed by Nightingale and those of the Irish Sisters of Mercy are considerable, when primary sources are consulted. One might also note Meehan’s failure to acknowledge Nightingale’s influence on and legacy to Irish nursing. Space does not permit this to be explored here, but much material is available (McDonald 2009b, pp. 384-404). Nor did Meehan ever mention Nightingale’s great fondness for Ireland, from her own travels there in 1852 (McDonald 2004b, pp. 490-506).
Nightingale’s nursing was greatly influenced by the Crimean War – although not by the Irish Sisters of Mercy at it. Rather the terrible lessons she learned there of the consequences of unsanitary conditions, bad nutrition, etc., became the environmental factors of her postwar writing. She saw the massive decline in death rates brought about by sanitary reforms, while the Sisters of Mercy noted neither the appalling death rates nor their diminution.
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