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9. Nightingale paper: Groniek issue on women

Florence Nightingale

Lynn McDonald, “Florence Nightingale.” Groniek special issue: Vrouwen/Women: Struggle against Prevailing Standards 46,198 (2014):49-59

Abstract. This paper presents important aspects of the life and work of Florence Nightingale, founder of the modern profession of nursing, advocate for women, and visionary of public health care. In the course she had to reach past the narrow limits of the life permitted ‘ladies’ in Victorian society. The paper gives background on the writing of her famous feminist essay, ‘Cassandra’. It relates her research methodology. It shows how her faith-based vision led to fundamental reforms in the ‘workhouse’ system, and in time to the creation of a full public health care system in Britain.

Florence Nightingale (1820-1910) is well known as the heroine of the Crimean War (1854-56), when she led the first team of British women to nurse in war, for which she was honoured with a fund. She used it to establish the first secular nurse training school in the world. It opened in 1860, and soon began to send out trained teams to introduce the new standards in other hospitals, and to which nursing leaders came from other countries for training. Women were not then allowed in the medical profession, and Nightingale correctly understood that getting admission to it would do little for women – few would be eligible – and would not help to reform it. Nursing was to be a new, patient-centred, profession for women.

Nightingale was a privileged member of her society, given a good education by her father at home – when neither university nor even secondary school were options for women. At age sixteen she experienced a ‘call to service,’ which she understood to be from God, but her family did not allow her to realize it by becoming a nurse, as she wished. Nursing was then a disreputable and ill-paid occupation. She was allowed to travel, however (the Nile, and much of Europe) and she used those opportunities to observe social conditions and visit the great European hospitals. She was thirty three before she was allowed to take on a position, as lady superintendent of the genteel ‘Establishment for Gentlewomen during Illness,’ in Harley St., London, from which she left for the Crimean War in October 1854.

Nightingale chafed at the restrictions of her class, ‘ladies’ who were not allowed to work, while aware of how poor women were overworked, paid badly and kept to menial jobs. She wrote privately about this while in her twenties, a three-volume work, Suggestions for Thought, which she had printed, but not published, for circulation to a select number of people for comment. Women’s advocate John Stuart Mill was one who sent her detailed comments. He was himself influenced by it in writing his On the Subjection of Women, 1869.

With the status Nightingale acquired in the Crimean War she was able to set her own post war agenda. Promptly on her return to London in 1856 she gathered a team: doctors, architects, engineers and statisticians. They provided her with their professional expertise, but it is clear from their letters to her that they deferred to her for her vision of social and public health care reform. The second half of this article shows how much she accomplished of those aims. The Collected Works of Florence Nightingale, sixteen volumes, reports this diverse work.

Part 1 relates her gender-related work. She, like women theorists of every age, attended both to issues of her sex – the need for the vote, property rights, access to education, the professions and income security – along with her reform agenda for the whole of society. Sadly, in my view, the great writing by women thinkers on social justice, peace, revolution, war, and the environment is ignored. They have been paid some attention as critics of male theorists on gender, but their work went far beyond that. I treat Nightingale with such women as Mary Astell, Catharine Macaulay, Mary Wollstonecraft, Germaine de Stakl, Beatrice Webb and Jane Addams as great thinkers, who pioneered ideas of importance for their society, and indeed were recognized in their day for doing so. Unfortunately, the (male) academic world failed to incorporate their work into the ‘canon,’ and their brilliant publications languished. Their books were well known work at the time and some of them were widely disseminated through translation.

The emancipation of Women and critique of gender roles

Nightingale worked on too many women’s issues to be discussed here: suffrage; midwifery and maternal mortality post-childbirth, access of women to the profession of medicine, and discriminatory provisions in the treatment of prostitutes; female medical services for Indian women (who would not see a male doctor) and child marriage. Along the way she mentored not only leading nursing matrons around the world. but promoted university education for women – she mentored the mistress of Girton College, Cambridge and the first woman to be accepted into the civil service in Britain (McDonald, 2005).

Nightingale’s forty years plus work in establishing nursing as a profession was only secondarily a women’s concern – nursing became the best-paid occupation for women in Britain, with career paths and rising salaries. Its prime purpose for Nightingale was to improve patient care, and hence it is treated along with other public health reforms in Part 2.

Nightingale’s Suggestions for Thought is the main source for her views on the limited roles permitted women in her society. It includes an anguished cry, ‘Cassandra,’ an essay named after the prophetess of Troy, who was not believed. Suggestions for Thought is a much more complicated work than meets the eye. When Nightingale revised it, hastily, for printing in 1860, she gave it, apart from ‘Cassandra,’ conventional philosophical garb: reasoned argument in the third person. The critical edition, which takes up a whole volume of the Collected Works, includes the fascinating earlier drafts.

The original purpose of the writing was outreach to the unchurched working class, as is evident in the title of the first volume, Suggestions for Thought to the Searchers After Truth among the Artizans of England. J.S. Mill advised a change in title, given that the writing was directed not only to workers. The title of the second volume, accordingly, is more descriptive: Suggestions for Thought for Searchers After Religious Truth.

The key sections on gender roles were rewritten from two distinct draft novels; some sections on religious views originated as fictional dialogues among real people, but who never met: the Protestant reformer John Calvin, Jesuit founder Ignatius of Loyola, the agnostic Harriet Martineau, evangelical American author Jacob Abbott, and an unnamed ‘M.S.,’ who debated all of them. One section was rewritten from an exchange between Nightingale and her closest medical collaborator, Dr John Sutherland, who had headed the Sanitary Commission that saved so many lives during the Crimean War. The two worked together closely on reforms in health care in the army, hospitals (civil and military), nursing and better access for the poor to hospitals and health care, but they differed on religion.

The anguished ‘Cassandra,’ which appears at the end of the second volume (McDonald 2008, 547-92), was originally written as a novel of ideas, albeit with phantoms, maidens and enchantresses. The crossed out drafts show dialogue between an anguished woman with no significance to her life, Nofriani, and her conventional brother, Fariseo, who fails to understand her. The setting is a Palladian palace – the two have no practical challenges such as earning a living. The name ‘Cassandra’ does not appear in the original draft, but was jotted in before the text went to the printers. ‘Cassandra’ was first published in 1928 as an appendix to Ray Strachey’s book on the women’s movement in Britain. Novelist Virginia Woolf quoted it the following year in her feminist plea, A Room of One’s Own.

Some examples of Nofriani/Cassandra’s passionate outcry are:

Why have women passion, intellect, moral activity…and a place in society where no one of the three can be exercised?…Oh miserable suffering, sad female humanity!…Give us back our suffering, we cry to heaven in our hearts – suffering rather than indifferentism, for out of nothing comes nothing. But out of suffering may come the cure. Better have pain than paralysis! (McDonald 2008, 548, 549, 553).

Passion, intellect, moral activity – these three have never been satisfied in woman. In this cold and oppressive conventional atmosphere, they cannot be satisfied….Women often try one branch of intellect after another in their youth, e.g., mathematics….It is impossible to follow up anything systematically. Women often long to enter some man’s profession, where they would find direction, competition (or rather opportunity of measuring their intellect with others) (McDonald 2008, 553, 556).

Women are never supposed to have any occupation of sufficient importance not to be interrupted….See how society fritters away the intellects of those committed to its charge!…Society triumphs over many. They wish to regenerate the world with their institutions, with their moral philosophy, with their love….Women dream till they have no longer the strength to dream (McDonald 2008, 558, 559, 565).

The next Christ will perhaps be a female Christ. But do we see one woman who looks like a female Christ? or even like ‘the messenger before’ her…to prepare the hearts and minds for her? (McDonald 2008, 589).

Nightingale’s methodology as a social and public health care reformer

When Nightingale finally had the opportunity to work she took it and continued to produce papers, books, mentor women, and lobby politicians and other leaders until well into her old age. After the Crimean War, she began her research to ascertain the causes of the high death rates of the war hospitals. She produced a massive report herself, worked to get a royal commission established, with good terms of reference and excellent members, and to which she herself gave written evidence. In the course she developed her team of doctors, a major statistician and two engineers, one army and one civil, and learned the research skills she would use for the rest of her working life. Nightingale was also significantly influenced by the great Belgian statistician, L.A.J. Quetelet. The medical statistician, Dr William Farr, was so impressed with her ability that he nominated her to become a Fellow of the Royal Statistical Society, the first woman to be so named. She was also made an honorary member of the American Statistical Association.

Nightingale’s methodology reflects both her deep Christian faith, and her firm reliance on the best social science methodology available. God made the world and runs it by laws, she said. However, there is disease, desperate poverty and ignorance. We can ascertain the causes of these failures in society by conducting research – preferably hard-nosed quantitative research – to understand the ‘laws of God,’ also known as the laws of nature. When we do, we can intervene to repair the damage. God indeed wants all people to take part in this work – Nightingale was nothing if not democratic in this principle – the building of a better society was to be the work of the whole of society, not an elite.

She never set out a list of instructions on how to do research, but one can be discerned from her usual practice, and it still makes good sense today.

  1. Get the best information available, especially from official reports and statistics.
  2. Interview experts, where possible, to get greater context.
  3. If the available information is inadequate, collect your own.
  4. Draw up a questionnaire, consulting those who will use the information collected.
  5. Test the questionnaire on a limited basis.
  6. After revision, send it out to all in the study.
  7. Use tables to relate major findings.
  8. Use charts to convey key points vividly.
  9. Use examples as illustrations, especially personal stories,
  10. After writing up the results, send them out to experts for review, and revise further.

For research intended for application, clear recommendations must be spelled out, and an information campaign planned to gain support for them. Here, it must always be remembered that, whatever care went into the recommendations, the results may not be beneficial, and indeed may result in harm, lessons learned from Quetelet’s Physique sociale. Ongoing monitoring is required for any new program, in whatever subject, be it health care, education, or hospitals.

Reforming public health care

Nightingale held to an environmental understanding of health and disease. ‘Health is not only to be well, but to be able to use well every power we have,’ she said in a late essay. She sought health promotion and disease prevention over treatment for disease after the fact. When she started to work, hospitals had enormously high death rates, a staggering ten percent of admissions for London’s top teaching hospitals. Hospital care accordingly should only be a last resort. Her priorities were:

  • Promote health through clean air, water, decent housing and nutrition, safe childbirth, schools for children;
  • When illness occurs, intervene in the least obtrusive way, through home visits by the doctor and nurse;
  • Leave hospitals as a last resort, especially for children;
  • Move hospital patients out at the earliest possible, to a convalescent branch, preferably at the seaside.

As Nightingale stated succinctly in her Notes on Hospitals, 1863, ‘It is a rule without exception that no patient ought ever to stay a day longer in hospital than is absolutely essential for medical or surgical treatment.’ She stressed the dangers of hospitals in the preface she added to this edition: ‘It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm’.

Responding to a request for advice on constructing a new hospital she wrote:

  1. Whenever it is proposed to construct a new hospital, the first and most important question…is whether the hospital is necessary.
  2. Hospitals are a hard necessity of an inferior, imperfect, civilization.

She acknowledged in an 1869 letter their usefulness for ‘a certain class of poor persons,’ but generally held that people recovered better when provided for at home (McDonald 2012, 764). Hospitals in cities and towns desirably would be confined to accident and emergency cases.

Nightingale continued to work on safer hospital design and administration along with her work on broader health care reforms and nursing. Hospitals were unsafe places for nurses and doctors as well as patients. She held that nurses’ death rates in hospital jobs were an important indicator to be tracked.

Nightingale, in short, wanted fewer hospitals, but we will see shortly that she wanted better patient care at them, and of course better patient care at home, too. Hospitals would always be essential for training nurses and midwives, as they were for training doctors, for only in hospitals would a sufficient number and diversity of difficult cases be available.

It is not well known that nursing is a very recent profession. Medicine is ancient in origin, in the West dating back to the fifth century B.C.E. with the Hippocratic School in Greece. However, in the mid nineteenth century in Great Britain and western developed countries, there was no secular profession of nursing. In places with Roman Catholic nursing orders, respectable care was given, although, Nightingale thought, with poor standards of hygiene. In secular hospitals the ‘nurses’ so-called were seldom more than hospital cleaners. Occasionally doctors gave a woman nurse some informal instruction, and she then looked after his patients. But there was no system of training or supervision, and the wages and working conditions were abysmal. ‘Nurses’ were known for loose sexual morals, and what would be called sexual harassment now was common. (Nightingale insisted on ‘no holes and corners’ in hospitals as a key means of avoiding such opportunities.)

For Nightingale, nursing was the missing link. Doctors visited patients, at home or in hospital, left instructions for the administration of drugs, foods, drink, etc., to whomever took them, typically a wife, mother or sister. Indeed her Notes on Nursing of 1860 was directed to improving care of family members at home, not for professional nurses (her school had not yet opened when she wrote the book). As medicine and surgery improved, and the variety of drug treatments increased enormously, the need for a skilled person to provide ongoing patient care would become even greater. When Nightingale started the scope was much more limited.

Reform of the workhouse infirmaries and the Poor Law system

One of Nightingale’s greatest achievements – and one not well recognized – was her introduction of trained nursing into the worst hospitals of her country, the dreaded workhouse infirmaries. In her time, hospitals in the U.K. were largely run by voluntary boards, for fee-paying patients, although the very well off would always prefer and get treatment at home. Charity wards took in some of the poor, but the great majority of Britons who required hospitalization had to go into the workhouse infirmaries. These provided (occasional) medical attendance, but had no trained nurses. Instead, ‘pauper nurses’ were paid a small fee, typically spent on alcohol, to women inmates who were not themselves sick. Bed sharing was common, hospital equipment limited. Nursing at the regular civil hospitals was gradually being improved, but not in the workhouse infirmaries.

Nightingale’s faith gave her sympathy with the destitute, and God, but wanted the best for all. As a young woman, when she was not permitted to work, she was allowed to visit such institutions. But she gave it up:

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.

She resolved to act when she could, and correspondence with a doctor during the Crimean War shows them considering what she might do on her return. However it was years of work getting better nursing in the regular hospitals, so that it was only with the offer of financial support that the workhouse project could get underway, in 1865. This occurred thanks to William Rathbone, a Liverpool philanthropist who had already helped to establish trained nursing and home visiting.

Rathbone’s offer enabled nurses to be trained at the Nightingale School in London for the Liverpool Workhouse Infirmary. Paid nurses of course cost the system more than ‘pauper nurses,’ or, taxes would have to have been raised without his offer. The three-year experiment was a success, as Nightingale and Rathbone expected. Patients who got better could leave the workhouse, meaning that breadwinners could work and their families leave the workhouse if they had had to go into one; mothers of families could get back and look after their children, again, resulting in inmates leaving the workhouse.

This reform was next followed up in metropolitan London, which required legislation in Parliament. J.S. Mill, then a radical Member of Parliament, supported it. It can be seen as the first step to the establishment of a full public hospital system, achieved in Britain only in 1948 with the launching of the National Health Service. Given that there were five patients in the workhouse infirmaries for every one in a regular hospital, the establishment of a full, high-quality hospital system could not have been achieved without this step.

Nightingale, however, had a bolder vision still, the virtual abolition of the workhouse system. At the time the welfare system in the U.K. required nearly all people who were destitute to enter the workhouse – a measure intended to be deter the poor from seeking financial relief. The result was that workhouses contained an enormous diversity of inmates – the sick, aged, infirm mentally or physically, disabled, unemployed and the children of any of these. Most of them, according to Nightingale, should not be there, but be looked after according to their need. Age, sickness, industrial accident, etc., were not matters for which deterrence made sense. Only the ‘willfully unemployed’ should be subjected to the harsh treatment of the workhouse.

Nightingale summarized this great system reform in a letter to Edwin Chadwick in 1866, as the A.B.C.s of workhouse reform:

  1. To insist on the great principle of separating the sick, insane, infirm and aged, incurable, imbecile and above all the children from the usual pauper population of the metropolis.
  2. To advocate a single central administration.
  3. To place all those classes (especially those suffering from any disease, bodily or mental) under the distinct and responsible administration, amenable directly to Parliament (McDonald 2010a, 145 and 2004 347).

Her A. classification became a key organizing principle in the evolution of the welfare state. Her B., on central administration, was directed both to achieving economies of scale and ensuring cross-subsidies between the more prosperous areas of London (which could raise taxes more easily, but needed workhouse infirmaries less), and the poorer (which could not raise taxes readily, yet needed the workhouse infirmaries more). Her C. again stressed central administration (the old workhouses were funded and administered locally).

Nightingale, then, can be seen not only as a reformer of health care, hospitals, and nursing, but a visionary calling for, and arguing the feasibility of, major structural change. She saw the first steps taken in the direction she advocated, but these were only piecemeal. It took World War II and the rebuilding of Europe after it for these greater changes to be legislated. She had first to find a place for herself as a woman, to overcome the restrictions that limited even the most privileged of women in her society. This she did, working systematically through the prescribed limits and exposing them, especially in Suggestions for Thought. That settled, she struck out to follow her own calling to serve and save lives. She found allies among leading men to do this, and inspired and mentored many women to take on greater challenges as well.

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