Part III: Nightingale’s Neglected “Upstream” Advocacy

This is the third in a series focusing on Seacole and Nightingale
Part I:
Debunking A “Bitter Rivalry”: The Notable Works of
Mary Seacole and Florence Nightingale

Part II:
The Nursing/Healing Work of Mary Seacole:
Skillful Nurse and Doctress

It is clearly beyond the scope of a blog to highlight Nightingale’s many achievements and it is unnecessary, since many are already widely known.  Unlike Seacole, whose contributions were at an individual level of direct care provision, Nightingale was a visionary who worked, to a great extent, further “upstream”, addressing systems issues in health care, and advocating for healthy public policies, supporting each aspect of her work with extensive research and often statistical analysis.

In the Crimea, Nightingale’s role was largely administrative, supervising the nursing services and procuring from British government services, often with great difficulty,3 the necessary supplies to support patient care for the Scutari hospital. The hospital building had previously been an army barracks and proved woefully inadequate as a hospital. But her experience there, including the discovery in 1854 that the Scutari hospital was built over a cesspool,3 led to her postwar efforts at reforms brought about by her Notes on Matters Affecting the Health, Efficiency, and Hospital Administration of the British Army (1858). Her recommendations were supported by statistical analyses, pictorially presented as a “coxcomb,” similar to today’s pie charts.3 Consultants on the report included William Farr, the noted statistician (who interestingly resisted the novel idea of a pictorial representation of the data)3 and John Sutherland, a physician and sanitation expert with whom Nightingale was to work with frequently in the future. 

From Cohen, I. B. (1984). Florence Nightingale. Scientific American, 250, 128–137.

No doubt Nightingale’s Crimean experience also informed her Notes on Hospitals in 1859, related to hospital design, and iintroduced the separation of groups of patients in pavilions. The book was deemed essential reading for architects3 and based on the principle that “hospitals should do no harm.” However, criticisms of Notes on Hospitals were strongest in relation to the “anticontagionism” demonstrated in Nightingale’s resistance to creating isolation wards as well as to separating surgical and medical patients.”( It should be noted that, Notes on Hospitals and Notes on Nursing were written at a time when miasma theory still dominated medical thinking as the cause of disease and before Pasteur first inroduced Germ Theory in the 1860s. It would take another decade for it to be widely accepted as the supporting evidence mounted through the work of Lister and Koch. By 1870,  Nightingale had been convinced of germ theory and urged nurses to use antiseptic precautions.3

In 1859 (published in 1860), Nightingale wrote the first edition of her famous Notes on Nursing, articulating the first conceptual framework for nursing, which she envisioned as a “distinct branch of knowledge from medicine,”3(p.365) In 1860, she established the School for Nursing at St. Thomas Hospital and, in addition, funded a school for midwifery3 at King’s College, using the remaining money in the Nightingale Fund both for its establishment and for supporting the training of midwives.  She saw the latter as a way of restoring to women the field of midwifery, after a century of doctors increasingly encroaching upon it and claiming it as their domain.3

What is less well known, is that several editions of Notes on Nursing were published, including “Notes on Nursing for the Labouring Classes” in 1868.6 Its intent is made clear in her preface,  that is was not meant to be thought of as a means by which women could teach themselves to be nurses; it was intended to provide information to women upon whom the duty fell to keep their families healthy and to care for sick family members. In other words, the book was intended to provide the means by which women could teach themselves to care for their families.

District nursing was another concept that Nightingale had long promoted. First, she believed the home to be a better place to care for sick people than a hospital and secondly, her vision of district nursing included “health missionaries” who would be focused on disease prevention and health promotion in the spirit of Edwin Chadwick’s vision of a centralized public health system.3 The concept of district nursing became a reality in 1887 when Queen Victoria donated substantial funds towards its establishment.3      

One area of Nightingale’s activities that is perhaps less well known, is her advocacy for and efforts to empower women and men of the working classes, which she believed was the intended path for her to take in answering God’s call to her.3 Evidence of that is demonstrated in her rationale for supporting a midwifery school and in her preface to Notes on Nursing for the Labouring classes.

Nightingale’s consciousness regarding the plight of the working classes had been evident much earlier in her life, when her concerns had been raised regarding the inequities deepened by Britain’s Corn Laws, which basically kept prices high to the advantage of landowners, and wages low.3 Those laws were just one example of the consequences of the economic downturn of the 1840s, resulting in what Nightingale described as a “dreadful want of work.3(p.73) Similarly the Ten Hours Bill, of 1844, designed to shorten the working hours of factory women and finally  passed by the British Parliament in 18 47, was another bill she followed closely, becoming ever more aware of the growing gap between the working class and what she described as the “glassy surface of our civilized life.”3(p.74) Her interest in such matters were again deeply influenced by Chadwick.3

Additional examples of advocacy for women are worth noting. In the 1860s, the British Parliament passed a series of 3 Acts which together comprised the Contagious Diseases Act, intended to control the spread of sexually transmitted diseases in its armed forces. The means to achieve that purpose was to require the “forcible registration and internal examination of women”  who were “suspected of being prostitutes”3(p.404) in specific towns and ports frequented by the army and navy. Nightingale was deeply opposed to the Acts, although she was aware that up to half of the illness in the Army was caused by sexually transmitted disease. Against the advice of one of her closest friends and advisors, Benjamin Jowett, Nightingale signed a petition to repeal the Act, published in the Daily News, and further published 2 letters sharply critical of the Act, and particularly the faulty statistics underpinning it, under the pseudonym ”Justina” in the Pall Mall Gazette.3 The Act was finally repealed in 1886.

Another act of advocacy for working class women relates to an 1887 proposal for the creation of a register of nurses to identify professional nurses from those with less training, led by Ethel Bedford Fenwick, future founder of the British Nurses Association.3  Bostridge3 asserts thatNightingale was not opposed to nursing registration itself,3 but she strongly opposed Mrs. Fenwick’s intention to restrict professional nursing to societal ladies, thereby excluding working class women. One way of achieving this end was the proposal’s requirement that eligibility for registration be determined solely by written examination. Nightingale’s opposition was based partly on her belief that a written exam alone was inadequate to asses both application of knowledge and character, which she believed to be very important. Secondly, it would automatically disadvantage working class nurses, who she believed would not score sufficiently high. (Compulsory free and universal education in Britain was still decades away). Furthermore, Nightingale strongly objected to the proposal’s plan to assign responsibility for nursing education to medicine,3 fearing that would destroy her efforts to differentiate nursing as a profession different and independent from medicine.3 The matter ended in 1892 with a Royal Charter being granted to the association but the right to create a register withheld.  Registration was finally achieved in 1919, 9 years after Nightingale’s death. 3

Although working class women were the focus of these acts of advocacy, Nightingale, as a “lady” also experienced and rebelled against the societal restrictions’ imposed on ladies’ of her class, asking the famous question in her essay “Cassandra,”  “Why have women passion, intellect, moral activity – these three – and a place in society where no one of the three can be exercised?” 5(p1)  Thankfully, Nightingale did find a way to use all three; her efforts at achieving workhouse reforms were based on her belief that poor people should have the same quality of health care as wealthy people.  Her extensive work on the health of the British Army in India3, broadened to a concern with the health of Indian people themselves.3 Both problems, her statistical analysis had shown, stemmed from poor sanitation and contaminated water. Whereas the British Armed Forces could make needed changes to protect its army, Nightingale advocated for broader solutions to improve the health of Indian villages, including teaching Indian farmers safe and sanitary methods of farming3.  For Nightingale, health promotion involved equipping individuals, families, groups, and governments with the information and skills they needed to prevent disease and foster good health, as well as creating public policies that would enable and support those efforts. In doing so, she showed herself to be an extraordinary visionary. In 1868, decades before the Frankfurt School would formulate the tenets of critical social theory, she espoused many of its principles.  More than a century before world health leaders would meet at Alma Ata, USSR to identify social determinants of health, such as housing, she wrote, “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.” Nightingale understood in the deepest sense that the “personal is political”; that political policy decisions can either limit or enhance the health potential of populations, particularly those in the working class. ”

Nightingale was recognized during her lifetime, e.g., the New York Herald considered her an exemplar “to inspire American women”3(p.362) during the American Civil War. The founder of the International Red Cross, Henry Dunant, declared she was his inspiration in founding the International Red Cross.

In concluding this blog series, it is important to celebrate the accomplishments and contribution each woman made. Mary Seacole was an independent, resourceful, committed woman healer who deserves to be recognized for her contributions to nursing and health care. Nightingale was a visionary who formalized nursing and promoted both health and healing through advocacy of healthy public policies.

The combined nursing work of Seacole and Nightingale demonstrates the spectrum of Critical Caring Theory from downstream healing work at the individual level to upstream nursing work in promoting health at a systems level.

Critical Caring is rooted both in Watson’s Caring Theory and Nightingale’s political advocacy and efforts to influence policies with the potential to improve the lives of many people. In a study of public health nurses,7  one participant characterized her practice, which included downstream nursing of individuals and families caring for individuals and families while also advocating for policies that would promote health equity, e.g., affordable housing, adequate minimum wage levels, etc. as the “ trombone slide” that she believed is nursing’s imperative.  

This is the last in a series of 3 posts, exploring the lives and nursing work of Mary Seacole and Florence Nightingale. Part 1 examined the very disparate circumstances that would lead each to serve in the Crimean War of 1854-1856. Part 2 focused on the nursing/healing work of Seacole at the individual, downstream level, both before and during the war. Part 3 has examined Nightingale’s visionary upstream thinking and advocacy for public policies with the potential to improve the health and lives of entire populations. Together, their nursing work exemplifies the full spectrum of Critical Caring Theory


  1. Ehrenreich, B. and English, D. 2010. 2nd ed. Witches, Midwives, and Nurses… A history of Women Healers, Feminist Press.
  2. Seacole, M.  2020. Memoirs of Mrs. Seacole: The Autobiography  of Britain’s Greatest Black Heroine, Business Woman, and Crimean Nurse. Books, Kindle edition.
  3. Bostridge, M. 2017, Florence Nightingale: The woman and her legend. Penguin Books, Kindle edition
  4. McDonald, L. 2017, Florence Nightingale, Nursing, and Healthcare Today. Springer Publishing; Kindle edition)
  5. Nightingale, F. 2017.eCassandra and Suggestion for Thought, Routledge, (1868 edition) Kindle edition.
  6. Nightingale, F. 1958. Notes on Nursing for the Labouring Classes,  Kindle edition.
  7. Falk-Rafael, A., Betker, C. 2012. Witnessing Social Injustice Downstream and Advocating for Health Equity Upstream: The “Trombone Slide” of Nursing. Advances in Nursing Science. 35(2), pp. 98-112.

10 thoughts on “Part III: Nightingale’s Neglected “Upstream” Advocacy

  1. While I found your series informative, as a Black nurse scholar and historian, I wanted more. Maybe what I am looking for goes beyond the scope of this blog. I wanted to hear more about Mary Seacole’s contributions to nursing and the challenges she experienced as a Black woman who wanted to practice nursing. She overcame racist barriers to care for those from marginalized communities. I wanted to learn about how she was able to practice when nursing was seen as a white woman’s profession. The fact that she died in bankruptcy is very telling to me. If she was compensated for her travel, her knowledge, and the care she provided, that would have never happened. The historical aspects of racism in nursing, need to be discussed and a series on the relationship between Florence Nightingale and Mary Seacole was the perfect opportunity to do so. 
    I felt disappointed when I read, “Unlike Seacole, whose contributions were at an individual level of direct care provision, Nightingale was a visionary…”  This is troublesome to me because we cannot say that Mary Seacole was not a visionary. Is there enough “published” information to do so? The stories of Black nurses are essentially absent from nursing history. Our stories are often told through the lens of White supremacy and often left up to interpretation from someone who does not know the history of slavery and how racism has made contributions to our absence in published literature. From what I have learned about Mary Seacole, I view her as a visionary in providing what is now known as preventative care and advanced practice nursing. I wonder how much Florence Nightingale learned from her observations of the care that Mary Seacole provided. 
    I have difficulty honoring the legacy of Florence Nightingale.  I cannot do so until I am able to honor the legacies of nurses of African diaspora.  I want their contributions to nursing recognized and celebrated as visionaries, theorist, and researchers. 

  2. NIghtingale’s Neglected “Upstream” Advocacy blog post gives another insight to the deep respect for Florence Nightingale’s brilliance that is relevant today in 2022. The “Polar-Area Diagram” depicts the needless death of solders over time that resonates with today’s war atrocities and horrific deaths in the Crimea and the Ukraine conflict. Sad comment on society in 2022 that Ukraine is suffering the consequences of social injustice due to geography.

    • Thank you so much, Rosemary. I was deeply aware of the irony of the timing of this blog and just a few days ago became aware of actually having distant relatives still living there.

  3. Thank you, Adeline, for uncovering the works of Mary Seacole and Florence Nightingale, two Giants in Nursing History. Your blog series is scholarly. Quite a lot of literature search is behind the series. I feel proud of the works of both of them. Thank you once again for your work. Dorothea Fox Jakob

    • Thank you, Dorothea. My hope was that nurses would know more about both nurses and value them both!

  4. Thank you so much Adeline for these great blog series and the contributions each nurse made in advancing nursing practice and knowlegde!!! Indeed food for thought. As I reflected on the blogs, I wondered what the citation history of Seacole’s work was/is both past and present? What were the facilitators and barriers if any? What can we learn from these two histories to advance our discipline? Any thoughts?

    • Great questions! One of the limitations of writing about Seacole is the fact that there is so little known about her. I learned her name for the first time close to 10 years ago when teaching Internationally educated nurses in a leadership course. I had asked students to pick a nurse leader and present her to the class, identifying the attributes of leadership she/he demonstrated. But I had not read her book, until ~2 years ago when encouraged to write a letter protesting her picture being hung in a local hospital. I could not do that based on the disparaging description of her given with the request so wanted to read the book first and was amazed and disturbed that I had not known about her before and that! There is also a website you may be interested in

      • Thank you for sharing Adeline! This is an excellent contribution to nursing and nurses worldwide !

  5. Adeline, Thank you very much for very informative the three-part blog series about Mary Seacold and Florence Nightingale. All of us have so much to learn about the history of nursology and all those nursologists who brought us to where we are now, as imperfect as we are for not dong more to provide context for the many vauluable contributions by our colleagues of color. Onward to every more learning about us over the years from pre-recorded/written history to now and beyond.

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