Good Night, Florence

Good Night, Florence

By Roxanne Nelson

Special to The Washington Post

In an unprecedented and surprising move, one of the world's great icons has been summarily knocked from her pedestal.

Florence Nightingale, long considered the founder of modern nursing, was ditched by a group of British nurses. In 1999, delegates at the annual conference of Unison, Britain's largest trade union representing nurses and other public service workers, unanimously declared that nursing was long overdue for a more contemporary role model.

The United Kingdom, like the United States, has been chafing under the strain of an acute shortage of nurses. While there are multiple reasons for the shortage, the Unison nurses believe that the legacy of Florence Nightingale is one of them. They feel that she "has held the nursing profession back too long" and represents the "negative and the backward elements of nursing." Unison nurses even requested that International Nurses' Day, celebrated on Nightingale's birthday (May 12), be moved to a different date. A recent BBC documentary and a new biography take a fresh and more nuanced look at the life and impact of a woman who has often been treated simply, as a kind of saint or a symbol of selfless service.

This year marks the 150th anniversary of the beginning of Nightingale's nursing career, when she went to work as superintendent of the Institution for Gentlewomen in London. Given the span of time, it is undoubtedly true that some of Nightingale's agenda has become outdated. So can she be held accountable for the problems that today's nurses are grappling with? How realistic is it to blame a woman who's been dead for nearly 100 years for a nursing crisis that is occurring here and now?

Not very, says Patricia D'Antonio, editor of the Nursing History Review and an associate professor of nursing at the University of Pennsylvania. "The first thing to recognize about Nightingale is that she was, and still is, a towering 19th century figure involved in every major British reform initiative [of her time], not just nursing. The result is that she has emerged as both a symbol of the power of nursing to make a difference in patients' lives and a lighting rod for all the profession's discontents -- and there certainly are many of those. But there is no credible way to draw a direct link between Nightingale and the problems of contemporary nursing."

Myth Information

A revival of interest in Nightingale has attempted to separate the myth from the real woman, and to perhaps pin the blame elsewhere for the woes of today's nurses. According to the BBC documentary ("Reputations: Florence Nightingale, Iron Maiden," which first aired in July 2001) Nightingale, long revered as a ministering angel and the romanticized "lady with the lamp," was in fact a manipulative, neurotic and sexually repressed woman. It also suggested she was driven by ambition rather than compassion, a point that was reinforced in a letter from Nightingale's sister to a mutual friend.

"She has little or none of what is called charity or philanthropy, she is ambitious -- very, and would like . . . to regenerate the world. . . . I wish she could be brought to see that it is the intellectual part that interests her, not the manual," wrote Parthenope Nightingale to Mary Mohl, also calling her sister a "shocking nurse."

For those interested in the hidden history of proper Victorian ladies, Nightingale's sexuality has long been the subject of speculation. The rumor that she died of syphilis has been a running theme that challenges her chaste and proper image. The BBC documentary's notion that she may have been a repressed lesbian is also not entirely new, as it has been rumored that she was in love with her cousin Marianne Nicholson and had more than a passing interest in other women as well. While Nightingale's name appears on lists of famous lesbians, this is really the first time that the possibility has been presented in the mainstream media.

Regarding Nightingale's reputation as a demanding, even overbearing leader: Australian nurse and educator Mary Chiarella, in her book "The Legal and Professional Status of Nursing" (Churchill Livingstone, 2002), says that Nightingale referred to nursing as a "calling" and rejected the idea that it could be a profession. She also imposed a regime upon her nurses similar to one followed by Catholic nuns, in that they had to be devout, chaste and good women. The book says that Nightingale also expected nurses to practice poverty and obedience, and, according to Chiarella, Nightingale's legacy lives on in the form of economic disadvantage and poor working conditions for nurses throughout the world.

The accepted idea that she was responsible for dramatically lowering the mortality rate of British soldiers in Scutari, at the Barrack Hospital during the Crimean War, has also been put to rest. With a group of 38 handpicked women, Nightingale volunteered to go nurse wounded soldiers. She hoped to show the value of female nurses in a military setting, despite a less than welcoming response from the army command. Her nurses scrubbed the wards, laundered bloody uniforms, changed bedding and prepared meals. According to the widely accepted story, two years after her arrival, the death rate at the hospital had plummeted from 40 percent to 2 percent.

In reality, it appeared that the opposite occurred. The death toll continued to rise after Nightingale's arrival, and the mortality rate at her hospital was higher than at any other in the region.

"There is no doubt that mortality dropped sharply after March 1855, but it was as a result of the sanitary commission from England, which arrived in Scutari and cleaned out the sewer on which the Barrack Hospital rested," says Mark Bostridge, author of "Florence Nightingale: The Making of an Icon," a biography to be published by Penguin in September. "This commission was authorized by the British prime minister, Lord Palmerston, and there is no evidence that Florence Nightingale played any part in the work it carried out. In fact, it seems that she only became aware of the decisive role played by poor sanitation in the deaths of soldiers under her care after the war, when she analyzed the statistics."

The Reign of Florence

What remains undisputed about Nightingale are the basic facts of her life. She was born on May 12, 1820, in Florence, to the wealthy English couple William and Frances Nightingale, during their extended honeymoon through Europe. Her family returned to England in 1821, dividing their time between Embley Park, their mansion in Hampshire, and a summer home at Lea Hurst. Her world was one of extreme wealth and luxury, and she was expected to live out her life in frivolous pursuits and domestic routines.

But Nightingale, who excelled academically and had received what was considered a "man's" education, felt herself to be called by God to some unnamed great cause. At the age of 25, Nightingale decided she wanted to be a nurse.

Hospitals of the Victorian era were squalid places where patients were tended by uneducated women who were more apt to be nursing a bottle of whiskey than a patient. It was not a place for a well-bred woman to be, but Nightingale was remarkably persistent in her goal. Finally, at age 31, she was given permission by her father to study nursing, and began her career as the superintendent of a hospital for invalid women.

A year later, with England's entry into the Crimean War in 1854, Nightingale embarked on her famous journey to the Barrack Hospital in Scutari, Turkey (now known as Uskudar, a district of the city of Istanbul). Nightingale returned home to England in 1856 to a hero's welcome, and then went on to establish the first modern school of nursing at St. Thomas' Hospital in London in 1860.

Generation after generation has been fixated on the sentimentalized story of Nightingale in the Crimean War, making her hospital rounds by candlelight. The myth of her as a docile, obedient, saccharine nurse has largely obscured who this highly complex woman really was and the enormous contributions she made to public health, statistics and nursing.

Although nursing is considered to be her first and foremost vocation, Nightingale spent less than three of her 90 years working as a nurse. After her work in the Crimean War, she spent the next half-century in almost complete seclusion, which added to her mystique. Her primary interest was not the reform of civilian nursing in Britain, says Bostridge, but rather a thorough overhaul of the health of the army in peacetime.

"The Crimean War diverted her interests into military nursing and the health of the army," explains Bostridge. "Although the school in her name was founded in 1860 -- because it was necessary to do something with the fund of public money collected during the war -- Nightingale didn't really put her stamp on it until after 1871, when she had the time to oversee it regularly."

For nearly 50 years, Nightingale crusaded behind the scenes, where she introduced sanitary science to nursing and the British Army, transformed nursing into a respectable occupation, revolutionized the public health system of India (without leaving England), campaigned for the rights of prostitutes and the property rights of married women, and became a pioneer in statistical analysis. And during her stay in Turkey during the Crimean War, she succeeded in cutting through the bureaucratic mess and completely overhauled the running of the hospital.

Modern Nurses

It is the myth that modern nurses are rebelling against, not the real woman, says Lois Monteiro, professor emeritus in the Department of Community Health at Brown University and a member of an international group of researchers working on the collected letters of Nightingale.

"I do think the broader woman is the important role model, not the one walking around with the lamp and ministering to soldiers," she says. "If nursing looked at the real model -- that of a reformer, a politician, a statistician and a sanitarian -- they might get somewhere."

Nightingale has been accused of keeping nursing in a lowly position because she bitterly opposed the movement by British nurses for professional registration (a system of accreditation, similar to those of many trades at the time, seeking to legitimize the vocation). But, as D'Antonio explains, Nightingale resisted this change because she felt that registration, with its attendant exams, would never be able to capture the qualities of a good nurse.

Nightingale also never expected nurses to be impoverished, adds Monteiro. "She believed first in education, and then as an educated, respected group, they would be paid accordingly."

D'Antonio agrees that Nightingale can't be blamed for low wages or the ever-increasing workloads that most nurses are now facing. "I would lay contemporary problems not at Nightingale's feet," she says, "but on the doorstep of the training school model."

The training programs of the late 19th and early 20th centuries frequently had students working shifts of 12 hours or longer, and care of the patient was combined with housekeeping chores. Nurses today still sometimes find themselves responsible for cleaning equipment or doing other tasks that should be handled by support staff.

Hospitals never had to pay for nursing care since they got free student labor, D'Antonio points out. "Nurses' training schools were funded and operated by hospitals to meet their staffing needs, and not the educational needs of nursing students. They used a barter system -- three years' work for a diploma -- and when nurses graduated, they left the hospital."

Thus far, Unison is the only organization to give Nightingale her walking papers. But Monteiro believes it may be time for nurses to have a more contemporary role model, such as the nurse practitioner, as an example of a goal they can strive for.

Florence Nightingale was right for her time, contends Monteiro. Who is right for our time remains an open question. *

Roxanne Nelson last wrote for Health about the illness of Tiny Tim in Dickens's "A Christmas Carol."

Special to The Washington Post

Tuesday, April 29, 2003; Page HE01