“It will take 150 years for the world to see the kind of nursing I envision”

Painting of Nightingale In the Florence Nightingale Museum

The year 2020 marks the bicentennial of Nightingale’s birth and approximately, at least, the 150th anniversary of her prediction that “It will take 150 years for the world to see the kind of nursing I envision.”  What was that vision, in what ways is it relevant today, and to what extent has it been realized? Although volumes could be written to answer these questions, for the purposes of this blog, it is possible only to highlight a few: her founding of and contribution to documented nursing disciplinary knowledge, i.e., nursology, her contribution to nursing education, and her championing of evidence-based practice and policy.

• In 1860, Nightingale published the first recorded conceptual framework for nursing, in  “Notes on Nursing.”  in it, she clearly differentiated nursing from medicine; she saw medicine as removing obstructions to nature’s ability to heal  but nursing as creating the best conditions e.g., nutrition, cleanliness, ventilation, etc. for that healing to occur. I think she would be pleased to see the Nursology.net site, dedicated to furthering nursing knowledge.  The site currently hosts 53 nursing theories, from conceptual frameworks to mid-range and situational theories, but each focused on health, as opposed to disease, and on the nurse’s role in promoting healing. And, I think Nightingale would be pleased to see the large numbers of nurses who practice, teach, and.or conduct research guided by nursing
  

  Turkish lamp from the Florence Nightingale museum

  disciplinary knowledge.  But, I think she would be dismayed at the powerful influence the medical model still has on health care generally and on many nurses, whose practice consciously or unconsciously is strongly influenced by it (Bradley & Falk-Rafael, 2011). It is not possible to practice nursing without an idea of what the scope and nature of that practice is (i.e., a conceptual framework) and if that framework is not solidly rooted in nursing’s disciplinary knowledge, it is vulnerable to dominant influences from other disciplines (Rafael, 1999, 1998).

• It is no coincidence that also in 1860, Nightingale founded her training school for nursing. Before the introduction of a trained nursing workforce, people who provided patient care (if there were any) might be called nurses  but who, according to McDonald, “were mainly low-paid, disreputable hospital cleaners, notorious for demanding bribes from patients and stealing their gin” (McDonald, 2013, p.36). Some of the important features of the Nightingale program were the requirement that all nurses be trained in a hospital setting, regardless of where they intended to work (e.g., the military, district nursing, midwifery, administrative roles), some of which required additional training. It became a model for many other schools of nursing in Europe, North America, and Australia.  Undoubtedly, some readers of my vintage who initially trained in general hospitals as late as the 1960s, would recognize familiar aspects of her model. (I recall reciting the “Florence Nightingale pledge” on the occasion of my completing the first 6 month’s probationary period of my training)!  Nightingale’s approach  was basically an apprenticeship model in which nursing students provided hands-on nursing care under the supervision of more senior nurses (e.g, clinical co-ordinators/headnurses/ward sisters). The learning that took place on the wards was augmented by classes given by physicians.  McDonald further notes that while Nightingale did not envision university schools of nursing, she advocated for “a professorship of hospital administration, hospital construction, and hospital nursing.”  While admission to universities remained off-limits for women in Nightingale’s time, I believe she would be most pleased to see the  progress that has been made in university education for nurses, both at an entry-to-practice level and in graduate education. In her time,  without regulatory bodies and examinations, graduation from a training school was the only guarantee that a nurse was indeed qualified to practice. My guess is that she would have welcomed regulatory bodies to allow a more diversely qualified nursing workforce.  I would guess that she might even support the use of personal support workers if they were under the supervision of adequately prepared nursing staff.  I fear she would not be in favour of the extensive use of personal support workers seen in some settings, without that supervision.
• Nightingale’s use of statistics to demonstrate the effects of nursing care in the Crimean War are legend.  What is less known is what McDonald describes as her reputation as the  “the ultimate statistician. Nightingale was deeply influenced by the work of Quetelet, a renowned Belgian mathematician and statistician and author of “Social Physics.” McDonald noted that Nightingale advocated for pilot projects to evaluate the effects of changes to policy and practice. Similarly she stressed evaluation, including cost-benefit analyses, of existing programs and/or policies,  frequently developing the appropriate questionnaires for data collection herself if none were available.  Nightingale used empirical evidence to support approaches to making childbirth safer. Although initially intending to open a lying-in hospital, she decided against it after finding that the mortality data among women giving birth  where they were in contact with medical personnel (e.g. lying-in hospitals) were higher than when they gave birth at home or even in workhouses. Likewise, although her initial rejection of germ theory is well known, her acceptance of it when presented with the evidence by Joseph Lister is less well known. Nightingale’s reputation as a statistician resulted in her  nomination by William Farr, a renowned British statistician, to be the first woman to become a fellow of the Royal Statistical Society in Britain. Her reputation was international; in 1874, she  was elected an honorary member of the American Statistical Association.  I think Nightingale would be pleased to see the growth in the number of nurse researchers, the number of nursing journals that report that research, the existence of hospital libraries and librarians to facilitate access to that research, and the emphasis on evidence-informed practice. Is it enough? I suspect that Nightingale would still see room for improvement!   

Would Nightingale have envisioned a pandemic in which, at the time of writing this blog, more that 3 million people in the world had contracted COVID-19, with approximately 1/3 of those cases being in one of its wealthiest, powerful, and most advanced countries, the United States?  I’m guessing that were she alive today, she might have seen it coming.  Nightingale was a systems thinker; just as she reflected on the cholera outbreaks by noting facetiously “I sometimes wondered why we prayed to be ‘delivered from plague, pestilence and famine’ when all the common sewers of London ran into the Thames”, she might made a similar remark about prevailing economic trends.  Nightingale was a keen advocate for a comprehensive public health system and for government involvement in providing a social safety net, including income security and pensions.

Last evening, I read an article  in the Toronto Star  which spoke to the increased vulnerability to COVID-19 of people with low incomes, who, for a variety of reasons that include the need often  to  work in jobs in which they are more likely to be exposed to the virus. In addition, they tend to be able only to afford housing far from where they work, requiring the use of public transportation, creating further risk. Among the author’s suggestions was one that seemed very familiar:  “It would be far cheaper for society . . .to take a significant portion of . . . public funds and put them into . . . housing that’s affordable for all income cohorts within a reasonable[distance]  . . . of where they have to work, so that there would be more choices throughout any metropolitan region for people than they are given now.”  I was reminded of Nightingale’s famous quote made in 1868: “And if all the money that is spent on hospitals were spent on improving the habitations of those who go to hospitals, and (on prisons) of those who go to prison,  we should want neither prisons nor hospitals.”

Do I believe she would have seen a pandemic coming? Yes, because it seems, unfortunately, society has not learned important lessons from history.

Sources

Bradley, P. & Falk-Rafael, A. (2011). Instrumental care and human-centred caring: Rhetoric and lived reality. Advances in Nursing Science 34(4), 297-314.

McDonald, L. (2013). The timeless wisdom of Florence Nightingale. Canadian Nurse, 109(2), 36.

Rafael, A.R.F. (1999). From rhetoric to reality: The changing face of public health nursing in Southern Ontario. Public Health Nursing, 16(1), 50-59.

Rafael, A.R.F. (1998). Nurses who run with the wolves: The power/caring dialectic revisited. Advances in Nursing Science. 21(1), 29-42.