ARTICLE

A COMPREHENSIVE BIOGRAPHY OF FLORENCE NIGHTINGALE

“ THE LADY WITH THE LAMP ”

Nursing has never been simple. Early care stressors included exposure to

the elements and a lack of knowledge as to how to treat serious injuries or

diseases. Through ensuing generations, environmental conditions have

improved and science has provided effective treatment pathways. However,

other complexities, including societal acceptance of the profession, gender

discrimination, and educational and regulatory disarray, have created a

multifaceted and complicated backdrop against which nurses continue to

provide the most basic of human interventions: caring.

In the nineteenth century, one woman, because of her religious

convictions and profound vision of the potential of nursing, altered the status of

nursing from that of domestic service to that of a profession and the strength of

her own person to create a permanent professional transformation One of the

most effective tools that she employed was advocacy, both for individuals and

for the nursing collective. The purpose of this article is to explore Nightingale’s

use of advocacy as a tool and to identify the continuing value of her conceptual

and practical advocacy strategies for the nursing profession in the 21stcentury. 

WHO WAS FLORENCE NIGHTINGALE?

On May 12, 1820, Florence Nightingale was born as the second of two

daughters to English parents. As a young woman, she displayed exceptional

intellect, learning multiple languages and being particularly capable in

mathematics. Nightingale seemed to be most comfortable in the solitary

activities of reading, writing in her journals, and attempting to discern purpose

in her life. She deeply believed that she had a God-given purpose to better

mankind, but the route to achieving this goal was unclear

As a young woman, Nightingale wished for meaningful work and began to

imagine herself caring for others, defying her parents’ desire that she marry into

a socially prominent family. On at least three occasions she declined proposals,

indicating that she could not pursue her own goals as a married woman .By the

age of 17 she had discerned that she had a Christian duty to serve humankind.

By the age of 25 she had identified nursing as the means to fulfil this mandate .

When she was 30 years old, she was permitted two brief periods of instruction

in nursing at Kasiserswerth, a Protestant institution in Germany . This

experience helped her to understand the essential components of basic nursing,

hospital design, and personnel administration. Of even greater consequence was

Nightingale’s perception that formalized education was a necessary component

of nurse preparation .

In 1852 Nightingale was offered the superintendency of a small hospital on

Harley Street in central London . During her twelve months in this position, she

developed effective administrative skills, identified appropriate qualifications

for those employed as nurses, and affirmed her belief that egalitarian and

competent care were basic human rights for all people .As Nightingale was

preparing to leave the Harley Street position, she was appointed by the

Victorian government to lead a group of thirty-eight women to Ottoman,

Turkey, to provide nursing care for British soldiers fighting the Crimean

War .Nightingale’s singular motivation was to improve the light of the

wounded. She stated, “...I did not think of going to give myself a position, but

for the sake of common humanity” .Her administrative skills allowed her to

negotiate the male worlds of both the military and medicine. She successfully

solved the issues of supply purveyance, resolved interpersonal squabbles

between nursing factions, and designed care modalities in the face of massive

overcrowding, incompetence, uncaring physicians, and a military structure that

was outdated and inept. In a letter to her uncle, Nightingale stated that the

Purveyor had intentionally withheld supplies for his own gain, noting, “This

little Fitzgerald [Purveyor] has starved every hospital when his store was full- &

not, as it appears from ignorance, like some of the honourable men who have

been our murderers, but from malice presence.”

On her return from the Crimea, Nightingale worked tirelessly to develop

nursing as an essential and educated component of healthcare. Her

establishment of the Nightingale School in London in 1860, and the distribution

of trained nurses abroad established the basis for nursing education worldwide.

Through the support of Queen Victoria and Prince Albert she was able to design

improvements for the British military and establish public health standards in

India. Additionally, her lifetime of work and her passion for improving

healthcare provided nursing with a foundational philosophy .

Nightingale remained actively concerned with the development and

behaviour of the Nightingale nurses educated at the Nightingale School until her

death in 1910 at age 90. Between 1872 and 1900, she wrote a series of thirteen

letters to the Nightingale nurses that both documented the progress nursing

made in the late nineteenth century and warned nurses that they must remain

current, competent, and caring. In 1897, she wrote of the danger of relying on

words over actions:

“There is no doubt that this is a critical time for nursing... ...There is a curious

old legend that the nineteenth century is to be the age for women and has it not

been so? Shall the twentieth century be the age for words? God forbid.” .

ADVOCACY IN NURSING

Advocacy has been defined as an active process of supporting a cause or position However, advocacy has not always been a clear expectation in nursing. Seminal documents in the development of the American nursing curriculum, such as Nursing and Nursing Education in the United States and A Curriculum Guide for Schools of Nursing do not explicitly mention advocacy. Early nursing education emphasized conformity and a position subservient to the physician. Isabel Hampton Robb, an early leader in the development of American nursing education, encouraged obedience as the primary activity of the nurse. In 1900 Robb stated:

Above all, let [the nurse] remember to do what she is told to do, and no more;

the sooner she learns this lesson, the easier her work will be for her, and the less

likely she will be to fall under severe criticism. Implicit, unquestioning

obedience is one of the first lessons a probationer must learn, for this is a quality

that will be expected from her in her professional capacity for all future time.

While Nightingale expected obedience in following the rules and medical

direction, her intent was to allow nurses the autonomy of purpose to advocate

for patients and the profession .It is probable that she would have disapproved

of Robb’s emphasis on obedience.

NIGHTINGALE AND ADVOCACY

The term ‘advocacy’ was first utilized in the nursing literature by the

International Council of Nurses in 1973. Today the American Nurses

Association (ANA) states that high quality practice includes advocacy as an

integral component of patient safety. Advocacy is now identified both as a

component of ethical nursing practice and as a philosophical principle

underpinning the nursing profession and helping to assure the rights and safety

of the patient. Nurses are seen as advocates both when working to achieve

desired patient outcomes and when patients are unable or unwilling to advocate

for themselves.

Since 1973 advocacy has been considered a major component of nursing

practice - politically, socially, professionally, and academically. Despite the

seeming lack of a professional focus on advocacy before the early 1970s, it is

argued that Nightingale implicitly laid the foundation for nurse advocacy and

established the expectation that nurses would advocate for their patients.

The scope of Nightingale’s effect on nursing and her utilization of advocacy

as a functional principle, like the profession itself, is complex. Nightingale did

not directly address the concept of advocacy. She did, however, demonstrate

advocacy in exceptional ways throughout her lifetime. We know of

Nightingale’s actions, thoughts, and motivations through her correspondence.

At least 13,000 letters remain in public archives and private collections. She

was the shadow author for a number of official government documents relating

to healthcare in the military and the subcontinent of India. Some of her most

insightful writings, such as those found in Suggestions for Thought, were

published privately, thus controlling the distribution to friends and colleagues.

The volumes Nightingale published for public consumption, including Notes on

Hospitals  and Notes on Nursing: What it is and what it is not, specifically

outline the role of the nurse and the environment in which care should occur..

Nightingale was a singular force in advocating for as opposed

to with individuals, groups, and the nursing profession. Her expressions of

advocacy grew with age, experience, and public acceptance of her as both nurse

and expert. Her significant contributions include her advocacy for egalitarian

human rights and for advocacy in her leadership roles. Nursing is now

recognizing how her ideas and techniques can be useful in the 21stcentury.

ADVOCACY THROUGH PROMOTION OF EGALITARIAN HUMAN RIGHTS

As a young woman, Nightingale became acutely aware of the unequal

status and opportunity provided to men as compared to women in English

society. Stark described the social structure:Victorian England was a country in

the grip of an ideology that worshipped the woman in the home. Women were

viewed as wives and mothers, as potential wives and mothers, or as failed wives

and mothers. The woman who was neither wife nor mother was called the “odd

woman” or the “redundant woman” .

In Nightingale’s frustration, she wrote the lengthy essay Cassandra, named

after the tragic Greek mythological figure who, although able to predict the

future, was not believed, and therefore, was powerless. As a part of this diatribe,

she compares the perceived value of a woman’s activity to that of a man:Now,

why is it more ridiculous for a man than a woman to do worsted work and drive

out everyday in a carriage?... Is man’s time more valuable than woman’s? or is

it the difference between man and woman this, that woman has confessedly

nothing to do?

Nightingale’s first significant demonstration of advocacy for individuals came

as she was superintendent of the Hospital for Gentlewomen in Distressed

Circumstances. On one hand, assuming the superintendency of this institution

had to have been extremely daunting for a woman of 32 entering her first

employment. The hospital was a newly acquired facility in poor condition with

inadequate furnishings and a poorly trained staff. She reported that in the first

month of occupancy she had experienced a gas leak with small explosions, a

fight between workmen in the drawing room, a drunken foreman, and the death

of 5 patients . On the other hand, it was the opportunity to participate in a

healthcare situation under her control that allowed her to create and utilize

environmental and patient care standards that were to become foundational to

the development of modern nursing .

Nightingale did have the general support of the Ladies’ Committee, the

body to whom she reported. Her first major concern, however, was a policy held

by the Committee stating that only individuals who were members of the

Church of England would be admitted to the institution. Nightingale could not

accept this position, perhaps because of her liberal Unitarian upbringing and her

deeply rooted beliefs in the value of individuals without respect to religious

preference. In a private note to her close friend and ally, Mary Clarke Mohl, she

airs her frustration, indicating she would leave the post if this disagreement

could not be resolved:

Eventually, she won the battle with the Committee so that patients of all

faiths – or no faith – were equally admitted to the hospital . The importance of

this event cannot be overlooked in Nightingale’s development as a social

reformer and healthcare advocate. She won this encounter partially through

logical persuasion, but also because of her status as a ‘lady’ – a person of the

upper class. This allowed her to meet the committee members on equal social

footing. Use of personal position and social acquaintances, logic and debating

skills, and the development of statistical evidence were tools she would refine

and employ over the next fifty years. This immediate victory helped her to

retain her moral convictions and to move forward as an advocate for women

and nursing.

Nightingale next turned her attention to the development of care

standards for patients, including the right to a peaceful death. The chronically

and the mentally ill were often ignored by staff. Those determined to be

‘malingerers’ and the dying did not meet the criteria for admission .

Nightingale, however, accepted these patients and allowed them to remain as

long as she believed that they were benefiting from care despite staff objections.

For a staff member to refuse to work to Nightingale’s standard resulted in

dismissal, signalling the application of administrative standards of care. This is

explicitly demonstrated in her May 15, 1854, report to the Governors when she

wrote, “I have changed one housemaid on account of her love of dirt and

inexperience, & one nurse, on account of her love of Opium & intimidation” .

Nightingale advocated for patients on a larger stage during her 20 months

in Scutari and the Crimea. These nurses were individually selected for their

ability to nurse, the likelihood that they would accept authority, and the

expectation that they would remain for the duration of the conflict. Ultimately,

many of those selected did not fulfil these criteria. However, Nightingale never

wavered from the idea that a basic human right was high-quality patient care

provided by a dedicated nursing staff.

ADVOCACY THROUGH LEADERSHIP

Leadership was one of Nightingale’s innate qualities. During her fifty

productive years, she continually benefited from the cumulative experiences of

Harley Street, Scutari, the Crimea, and her interactions with government

officials in determining the potential of nursing. Her education, social stature,

extensive range of acquaintances, and international travel provided essential

context, opportunity, and a public voice. Her major contributions to the

profession had evolved from leadership of a few at Harley Street and in the

Crimea to the professional collective. She was able to explore the potential of a

refocused nursing, as opposed to remodelling the status quo.

A second major outcome/theme of Nightingale’s leadership was the

establishment of the Nightingale School at St. Thomas’ Hospital in London. She

advocated for educated nurses who had a knowledge base and a specific role in

healthcare. Further, she envisioned the extension of nursing as the essential

force which would meet the growing healthcare needs in sectors outside of the

hospital. This resulted in the development of nursing in the military, midwifery,

poor law nursing (care of paupers), and nurse visiting . This role expansion

created a full range of services in and out of the hospital and across the life

span, thus further expanding the role and autonomy of the nurse.

Nightingale’s continuing complaint from adolescence and into

adulthood concerned the strict social mores relative to women and work outside

of the home. Nursing actually served to begin to change the location of

women’s work from the home into a formal workplace. Two factors contributed

to the success of this change. The first was that nursing education under the

Nightingale model took place in a tightly controlled environment that included a

nurses’ home with a matron who functioned as parent and guardian . This

allowed families to agree to send their daughters to nursing school, as nursing

education was deemed to be in safe surroundings. The second factor was that

nursing was initially viewed as domestic work that had been transplanted into

the hospital, thus extending the typical woman’s sphere

THE VOICE OF FLORENCE NIGHTINGALE ON RESEARCH

The historical context of nursing research Florence Nightingale is often seen

as the very first nurse researcher. Her research in the 1850s focussed on

soldiers’ morbidity and mortality during the Crimean War. Nightingale

identified ‘research’ questions in practice and undertook a systematic collection

of data to try to find answers to the problems. Her‘research’ eventually led to

changes in the environment for sick people including cleanliness, ventilation,

clean water and adequate diet. However, Nightingale’s contribution is seen as

atypical with Kirby pointing out that the development of nursing research in the

United Kingdom really only started with the inception of the National Health

Service (NHS) – now the world’s largest publicly funded health service – in the

late 1940s. Prior to this, the development of nursing research had relied on a

few highly determined individuals and was bound up with the

professionalization of nursing, the demands for suitable nurses, and the raising

of educational standards for nurses . Furthermore, in the 1950s, sociologists and

psychologists were more likely to be undertaking research into nursing and

nurses; only a small number of pioneering nurses were researching nursing and

nurses themselves, one being Marjorie Simpson, who started the first self-help

group for nurse researchers in 1959 called the Research Discussion Group .This

went on to become The Research Society of the Royal College of Nursing,

which continues today. The Royal College of Nursing is the body in the UK that

represents nurses and nursing, promotes excellence in practice and shapes

health policies

A PASSIONATE STATISTICIAN Let's begin by looking at Nightingale as a systemic thinker and a “passionate

statistician.” Her work in nursing and social reform was informed by a religious

faith or philosophy that favoured a systemic approach: God made the world and

runs it by laws, which we can discover by research in both the biophysical and

social spheres. For Nightingale, this entailed the best possible research, access

to the best available government statistics and expertise, and the collection of

new material where the existing stock was inadequate. Nightingale's leadership

style was very much knowledge based.

She herself was a pioneer developer of survey instruments, always vetted

by other experts and pretested on appropriate cases. She was also a pioneer in

the graphical presentation of data. At a time when research reports were only

beginning to include tables, Nightingale was using bar and pie charts, which

were colour coded to highlight key points (eg, high mortality rates under certain

conditions). Nightingale was keen not only to get the science right but also to

make it comprehensible to lay people, especially the politicians and senior civil

servants who made and administered the laws.

EVIDENCE-BASED PRACTICE Several examples clearly reflect an evidence-based framework,

ranging from Nightingale's first work after her return as a heroine from

the Crimean War in 1856, to a late attempt to influence social policy with

a proposal for a chair in “social physics” at Oxford University in 1891.

SYSTEMATIC DATA COLLECTION Nightingale returned from the Crimean War with a conviction that the

desperate loss of life she witnessed should never occur again. She pressed for

the creation of a royal commission to investigate the causes of the high

mortality (eg, for every 1 soldier that died from his wounds, 7 died from

disease). She worked with a team of “sanitary experts,” including William Farr,

who was Britain's leading social statistician at the time. The royal commission

report that was eventually produced showed Nightingale's work from its

conception, terms of reference, choice of members, and analysis of data to its

recommendations for change. One recommendation was for the creation of a

statistical department to track rates of disease and mortality and to identify

problems so that they could be dealt with promptly.

Nightingale revolutionized hospital data collection and invented a

statistical wedge diagram equivalent to today’s circular histograms or circular

statistical representation, and in 1858 she became the first woman admitted to

the Royal Statistical Society. She developed and wrote protocols and papers on

workhouses and midwifery that lead to successful legislation reform. She was a

recognized expert on the health of the British Army and soldiers in India for

over 40 years; she never went to India but collected data directly from Army

stations, analyzed the data, and wrote and published documents, articles, and

books on the topic. Besides her numerous other recognitions, she received the

Order of Merit in 1902, the first woman to receive this honor. She wrote over

100 combined books and official Army reports; her 10,000 letters now make up

the largest private collection of letters at the British Library with 4,000 family

letters at the Wellcome Trust in London.

Nightingale found another opportunity to achieve reforms during the 1860

International Statistical Congress, which was held in London and presided over

by the eminent Belgian statistician, Adolphe Quetelet. She sent a letter

advocating the uniform collection of hospital statistics, so that outcomes could

be compared by hospital, region, and country. The delegates took up her

proposal, adopted a resolution to that effect, and forms were duly drawn up.

Jocelyn Keith described the proposal as “the first model for the systematic

collection of hospital data using a uniform classification of diseases and

operations that was to form the basis of the ICD code used today.” Nightingale

sent a proposal for improved statistics of surgical operations to the International

Statistical Congress held at Berlin in 1863, which took the analysis a step

further.

Nightingale attempted unsuccessfully to have the census modified to

make it a more effective source of data for public policy. As the 1861 census

was being prepared, she tried to have questions on health status and housing

added, conscious that health outcomes were influenced by housing. A question

on health would provide information that mere mortality data did not: “We

should have a return of the whole sick and diseases in the United Kingdom for

one spring day, which would give a good average idea of the sanitary state of

all classes of the population.”

RECOGNITION AND ROLE IN NURSING EDUCATION

Nightingale was a nurse, an educator, administrator, communicator,

statistician, and an environmental activist. Her specific accomplishments

include establishing the model for nursing schools throughout the world and

creating a prototype model of care for the sick and wounded soldiers during the

Crimean War (1854–1856). She was an innovator for British Army medical

reform that included reorganizing the British Army Medical Department,

creating an Army Statistical Department, and collaborating on the first British

Army medical school, including developing the curriculum and choosing the

professors.

After the war she returned home to a hero’s welcome and was awarded

the “Nightingale Jewel,” a brooch with an engraved dedication from Queen

Victoria, for her service in the Crimea. She was also granted a prize of $250,000

from the British government and used the money to establish St. Thomas’

Hospital and the Nightingale Training School for Nurses. Her work lifted the

reputation of nursing from lowly and menial to a respectable profession to

which many upper-class women aspired.

Nightingale established nursing education by writing the first textbook

on the subject in 1960, entitled Notes of Nursing. This book outlined the

principles of the nursing profession, provided advice on how regular women

could care for their families, and how illness could be properly managed. In her

writing, Nightingale emphasized the importance of patient observation to figure

out their symptoms and needs, as to be able to provide the right care. The

importance of sanitary conditions was also stressed, as well as warmth, clean

air, light in rooms, and a nutritious diet.

Florence Nightingale opened the first nursing school in 1960, which was

the beginning of professional education and training in the field. Her school, the

Nightingale School for Nurses, was a part of St. Thomas’ Hospital in London,

and offered the first official training program for nurses so that they could work

in hospitals, help the poor, and teach others. The training emphasized the

important of patient home care and taught students how to care for the sick at

home and the practice of midwifery. Many of the students at the school

continued on to be matrons at major hospitals in England, as well as went on to

establish their own training programs throughout the world.

Florence Nightingale (1820–1910), the philosophical founder of modern

secular nursing and the first recognized nurse theorist, was an integralist. An

integralist is a person who focuses on the individual and the collective, the inner

and outer, and human and nonhuman concerns. Nightingale was concerned with

the most basic needs of human beings and all aspects of the environment (clean

air, water, food, houses, etc.)—local to global. She also experienced and

recorded her personal understanding of the connection and an awareness of the

Divine, which she knew to be something much greater than she was. This was a

major connecting link woven into the entirety of her life, work, insights and

vision. She clearly articulated and demonstrated the science and art of an

integral worldview for nursing, healthcare and humankind.

NIGHTINGALE, ADVOCACY, AND 21STCENTURY LEADERSHIP

Nightingale’s lasting legacy is a composite of her accomplishments and her

vision of what can and should be undertaken by the profession. She wrote

prolifically and demonstrated methods that were effective. Her lessons have

become the roadmap for future generations.Perhaps the most significant and

enduring of Nightingale’s contribution to nursing is learned not by reading one

document, but rather by synthesizing the entire body of literature that she wrote

regarding nursing. From this body of literature can be extracted nursing’s

foundational philosophical base . The Table summarizes the major referents

defined by Nightingale as essential to nursing practice, education, and

research.nightingale understood the value of and the methods for achieving

visionary leadership. She repetitively utilized techniques which have been

developed as the stair step leadership development model. This paradigm

blends the ideas of Nightingale with the current leadership terminology of Burn,

who identified the relative merit of leadership outcomes, with the ‘novice-to-

expert' concept which focuses on the necessity of building leadership skills.

The goal of this stair step leadership development model is to identify a

progression of stages through which individuals achieve positive leadership

behaviours over time. This model does not assume that an individual holds a

formal leadership position in order to demonstrate leadership; rather, it assumes

that all nurses are leaders by virtue of assuming the role of nurse. The ultimate

goal of this model is that leaders and followers achieve a mutually defined goal

with collective purpose and long-term effectiveness.

The first three steps of the model identify the progression from novice nurse to

someone who is experienced in a specific realm of nursing. This is consistent

with Benner’s model. This progression may be repeated multiple times as the

nurse moves from position to position. Additionally, it supports the idea that

leaders are developed rather than the belief that some have innate leadership

capabilities while others do not .

Expected outcomes of the model are that an individual ultimately will

assume the characteristics of either a transvisionary or transformational leader.

Burns has defined these levels. Transactional leaders tend to exchange valued

commodities, such as exchanging work for pay. This is often coercive in nature,

and while perhaps effective for the short term, does not achieve long-term

results. Conversely, transformational leaders seek to create long-term or

permanent change through the mutual identification of goals between

individuals and the organization. This is effective in achieving change that has

lasting value.

CONCLUSION

Today we recognize Nightingale’s work as global nursing where she

envisioned what a healthy world might be with her integral philosophy and

expanded visionary capacities. Her work included aspects of the nursing process

as well. Her work was social action that demonstrated and clearly articulated the

science and art of an integral worldview for nursing, health care, and

humankind.

In the 1880s Nightingale began to write that it would take 100–150 years

before educated and experienced nurses would arrive to change the healthcare

system. We are that generation of 21st-century Nightingales and health

diplomats. We must tell nurses’ stories beyond nursing and see ourselves as

health journalists and social media communicators to transform health care with

others and carry forth her vision of social action to create a healthy world.

Nightingale was ahead of her time. Her dedicated and focused 50 years of work

and service — still informing and impacting our nursing work and our global

mission of health and healing for humanity.

REFERENCES

BOOKS

1. Barbara Montgomery Dossey (2010). Florence Nightingale: Mystic, Visionary, Healer.  Philadelphia, PA: F. A. Davis.

2. Benner, P. (2000). From novice to expert: Excellence and power in nursing practice. Upper Saddle River, NJ: Prentice-Hall.

3. Bostridge, M. (2008). Florence Nightingale: The woman and the legend. London: Penguin.

4. Dossey, B.M. (2000). Florence Nightingale: Mystic, visionary, healer. Springhouse, PA: Springhouse.

5. Glicken, M. (2005) Improving the Effectiveness of the Helping Professions: An Evidencebased Approach to Practice.Thousand Oaks, CA: Sage.

6. National League of Nursing League of Nursing Education. (1937). A curriculum guide for schools of nursing. New York: National League of Nursing Education.

7. Nightingale, F. Letter to the International Statistical Congress, 19 July 1860. In McDonald L, editor. Women theorists on society and politics. Waterloo: Wilfrid Laurier University Press.

JOURNELS

1. Stark, M. (1979). Cassandra: An essay by Florence Nightingale. New York: The Feminist Press.

2. Vaario, H. & Leino-Kilpi, H. (2004). Nursing advocacy – A review of the empirical research 1990-2003. International Journal of Nursing Studies

3. Notes on Nursing. Wikipedia. http://en.wikipedia.org/wiki/Notes_on_Nursing. Viewed 2/6/2015.

WEBSITE

1. Nightingale Declaration: http://www.nightingaledeclaration.net/the-declaration2. Nightingale Overview: http://www.nightingaledeclaration.net/why-florence-

nightingale3. Nightingale Moment: http://www.nightingaledeclaration.net/nightingale-moment