The World Health Organization designated 2020 as the International Year of the Nurse and the Midwife, in honour of the 200th anniversary of Florence Nightingale's birth.
Nightingale, undoubtedly the instigator of modern nursing, was born in Italy on May 12, 1820, one year after Queen Victoria, and she died on 13 August 1910 at the age of 90, outliving the monarch by 9 years.
Nursing prior to the Nightingale era
Nursing is as old as humanity itself, with the word nurse originating from the Latin nutricia, meaning ‘to nourish’. Although all societies throughout history attended to the sick and injured, it was the Middle Ages that saw the arrival of nursing linked to religious orders, something that prevails to this day.
Baly (1995) gives a good description of nursing within the religious orders prior to the modern era. Not all nursing orders relied on nuns. For example, the Knights Hospitaller of the crusades (derived from the Latin hospitále, a word used to describe a residence for pilgrims and travellers), were members of a religious order devoted to the care of the sick or needy. The origins of the hospitallers came from an 11th century hospital founded in Jerusalem by Italian merchants from Amalfi specifically to care for sick and poor pilgrims. Later, the hospitallers founded similar institutions in French and Italian cities that were on the route to the Holy Land and where the celibate knights combined the tending and caring for the sick with defending the Crusader kingdom.
One of the hospitaller orders, the Knights of Malta, founded a large hospital in Valetta, today's capital of Malta. On a guided tour of the Sacra Infermeria (The Holy Infirmary), built in 1574, I was astonished to see that each bed space had its own recessed toilet facility and that the wards opened on to a courtyard garden where the knights grew medicinal herbs and patients were able to have fresh air and exercise. Florence Nightingale herself was to make fresh air a cornerstone of her hospital designs in the late 19th century. In addition, many monasteries throughout the British Isles in the pre-Reformation era established hospitals or infirmaries within their grounds. One of the largest in England was the Cistercian Abbey of Rievaulx in North Yorkshire near Helmsley, which cared for the large number of monks and lay persons who lived there (Furniss, 1968).
Later in the 15th century, a former Portuguese solider who was later canonised as Saint John of God was responsible for the foundation of the Hospitaller Order of St John of God, a Roman Catholic religious order of nursing brothers who worked with the sick in a variety of hospitals throughout Europe. Today, St John of God is the patron saint of hospitals and the sick.
In 1880, the nursing brothers of the French Province of the Hospitaller Order of Saint John of God, took possession of some buildings in Scorton, a small village in North Yorkshire, with the intention of creating a hospital for ‘unwanted people’, ‘cripples and incurables’ (Saint John of God Hospitaller Services, 2020). The hospital continued to expand and in 1951 the General Nursing Council approved the hospital to offer the monks training for State Registration in Nursing. It was not until 1968 that women become part of the nursing staff for the first time. In the early 1970s, some of the monk nurse trainees were seconded to the Friarage Hospital in nearby Northallerton (built on the site of an old Carmelite Friary), where I had the pleasure of working with some of them during my time as a student nurse. In 2019, the Saint John of God Hospitaller Services Group was formed across the UK and Ireland from 9 organisations founded by the Hospitaller Order of Saint John of God.
In countries such as Germany, the Protestant Church established deaconess institutes, such as the example at Kaiserwerth, founded in 1836 by Theodor and Friederike Fliedner, a Lutheran pastor and his wife, with an emphasis on caring for the sick. Nightingale spent several periods there in the years before the Crimean War.
Untrained and incompetent
Despite the many religious institutions that offered care to certain members of society, most nurses in the pre-Nightingale era were considered slovenly and incompetent. Descriptions of nurses, such as Charles Dickens's Sairey Gamp in the novel Martin Chuzzlewit, were to become representative of all that was bad with nursing. Similarly, within a mental health context ‘lunatic attendants’ (who, after several title changes reflecting changing attitudes, became mental health nurses) were referred to as the ‘unemployable of other professions’ (Norman and Ryrie, 2018).
In assessing the accuracy of Dickens's portrayal of Gamp, who is untrained, incompetent and a dissolute drunkard, Glasper and Charles-Edwards (2002) point out that Dickens was a strong supporter of the medical fraternity who were keen to have complete control over health and caring. Dickens was a close friend of paediatrician Charles West who founded the Hospital for Sick Children in London's Great Ormond Street. Furthermore, Rafferty (1995) suggested that, in developing the character of Gamp, Dickens provided the ammunition that may have undermined the embryonic female-led working class domiciliary nursing movement in favour of a medically dominated, subservient nursing workforce. That notwithstanding, no formal educational training for nurses existed in the 19th century, although some hospital doctors offered tuition on the basic elements of care to their nursing staff.
The Nightingale era
Throughout the 19th century and early 20th, anyone could call themselves a nurse, irrespective of level of training. Many people who claimed to be a nurse prior to the Nightingale era were uneducated and often had little or no formal training. Gail Thomas's (2016) ‘brief history of nursing’ reveals that nursing was not perceived as being worthy of respect, nor was it an activity thought to demand skill or training. In Florence Nightingale's words, nursing was left to ‘those who were too old, too weak, too drunken, too dirty, too stupid or too bad to do anything else’.
The Nightingale family were wealthy landowners with estates in Hampshire and Derbyshire. Like her sister, Florence was not formally educated, but she received tuition as befitted a young lady in the early part of the 19th century. She was clearly intelligent: she learnt a number of foreign languages and had an aptitude for mathematics. She was also an avid reader and a keen correspondent, who would later in life pen thousands of letters. Allegedly, she showed a vocational talent for caring and from a young age, when she tended to the sick and needy in the Derbyshire village where she spent her formative years.
By the time she was 17, she was convinced that nursing was her calling. She had a deep conviction that God had spoken to her and it was her Christian duty to better mankind. An admissions tutor in a contemporary university department of nursing interviewing Nightingale for a nursing degree would probably seek an occupational health report!
In context, it has been suggested, after a critique of the historical literature, that Nightingale heard voices and suffered a number of depressive episodes in her teens, coupled with periods of extraordinary scholarly output. At least 14 000 letters are known to survive, along with 147 printed publications, and hundreds of private notes and memoranda. These features are consistent with a diagnosis of a bipolar disorder (Washington Times, 2003). Florence Nightingale was also known to be an acerbic character and capable of making hurtful accusations in her correspondence—this is also compatible with a bipolar disorder. For example, she described fellow nurse Mary Seacole, who cared for soldiers during the Crimean War, as ‘a brothel-keeping quack and anyone who employs Mrs Seacole will introduce much kindness—also much drunkenness and improper conduct’ (Robinson, 2006).
When Florence informed her parents that she wanted to take up nursing as a vocation this set the cat among the pigeons, for it was not seemly for a woman of position at that time to engage in work of this type. Her family did everything they could to dissuade her. However, her family wealth made it possible for her to tour Europe, an opportunity she used to secretly spend some time visiting and observing nursing care at the Kaiserwerth hospital in 1849. Against her parents' wishes, Nightingale returned to Kaiserwerth in 1851, where she was able to further explore the concept of nursing.
She never undertook formal training as a nurse and always denied having been trained at Kaiserwerth where she believed the nursing was non-existent and hygiene conditions appalling. What she did admire was the devotion of the deaconesses, but she soon recognised that good nursing needed more than this (Baly, 1995). It was at this stage of her development that Nightingale recognised that formal education had to be a fundamental component of preparation to be a nurse. This was to be the cornerstone of her later reforms for the nursing profession.
Nursing champion
What Florence Nightingale wanted to do next was to spread her nursing wings on a bigger project. In early 1853, Sydney Herbert, a friend of the family and a member of parliament, arranged for her to take up the post of superintendent at a clinic in Harley Street—the Establishment for Gentlewomen During Illness.
Over the coming months, Nightingale made inspection visits to other hospitals and eventually became an authoritative figure on all aspects of nursing. She was soon lobbying her friend Sydney Herbert on the need to reform hospital nursing across the country. By spring 1854, Nightingale was a recognised champion of nursing within government circles and, as Britain and France were drawn into the conflict between Russia and the Ottoman Empire in the Crimea, she was well placed to become the hero so badly needed to alleviate the suffering of the common British soldier fighting in a strange land for a somewhat obscure cause.
Conclusion
The Crimean War was to become Florence Nightingale's baptism of fire. From the Harley street clinic she led a small party of nurses and nuns to the British Army hospital at Scutari. This former Ottoman barracks was situated in a district of Istanbul on the Asian shore of the Bosphorus where, on arrival, Florence Nightingale cited Dante's famous quotation from the Inferno: ‘Abandon hope all ye who enter here’. (Baly, 1995)