When Florence Nightingale sailed back to England at the end of the Crimean War in 1856 she was already a legend in the eyes of the British public, someone who had struggled to improve the standards of care delivery to sick and wounded British soldiers. Regretfully, 11 of Nightingale's nurses died of illnesses during the war. This article looks at the contribution Florence Nightingale made to the establishment of formal education for nurses in the years following her return.
Background
When she returned from the Crimea Nightingale was recuperating from Crimean fever, which was most likely to have been caused by brucellosis (Young, 2005), an illness that may be followed months—or even years—later by serious complications. It is in no doubt that after Nightingale returned she became a bedridden invalid plagued by periods of depression for many years, which only improved after she reached the age of 60.
Although Young (2005) considers that her symptoms were consistent with a diagnosis of brucellosis, Mackowiak and Batten (2008) are confident that they were consistent with criteria used today to define post-traumatic stress disorder (PTSD). This is perhaps unsurprising, given the sights and sounds she would have witnessed throughout the war.
Allegedly, Nightingale never spoke of her wartime experiences after returning to England and she never returned to nursing practice, possibly to avoid care scenarios that might have rekindled those traumatic memories. Similar to people who have PTSD today, Nightingale shielded herself from much social interaction preferring, despite her physical and mental health problems, to communicate through her writings and correspondence.
She was indeed a prolific writer, producing in excess of 200 reports, pamphlets and books on many aspects of health care such as nursing, in addition to penning thousands of letters. This prodigious outpouring has led some authors to suggest that she may have had bipolar disorder (Andreasen, 2008).
Although she never returned to nursing, Nightingale amassed what today would be referred to as a significant database of military and civilian nursing of the period.
She became an oracle for all interested in nursing as an emerging profession. Despite Nightingale having no knowledge of paediatrics, Dr Charles West, the founder of Great Ormond Street children's hospital, corresponded with her to seek advice on the optimum way to care for sick children. However, she was an opponent of his initiative, believing that children should not be in hospital wards (McDonald, 2004).
Despite her poor health, on her return from the Crimean War, Nightingale saw the reform of War Office measures for the care of the sick and wounded as her top priority, rather than civilian hospital nursing (Selanders and Crane, 2012). She was even consulted by members of the US military medical profession during the civil war for advice on nursing.
When she published Notes on Nursing: What it is and what it is not in 1859, this was to be the first nursing textbook of its kind to be published and written before the opening of the first school of nursing in July 1860. It became the core text for many future schools of nursing (Nightingale, 1970).
The opening of the Nightingale school of nursing
Although military health care was one of Nightingale's enduring interests, she also had a major input into public health and hospital design. But it was the establishment of the first UK school of nursing for which she will long be remembered, because this changed the face of nursing forever. In 1855, prior to her return to England, there had been a swell of public opinion that the nation should honour her contribution to the war effort. A fund was set up to enable members of the public and the armed forces to contribute. By 1859, the fund amounted to £45 000, equivalent to about £5.7 million today. The Nightingale Fund still exists and is used to help underwrite course fees for nurses and healthcare assistants.
Initially, Nightingale set up the fund as a distraction from her ongoing work to modernise military health care, but after a decision was made to rebuild St Thomas' Hospital in London she decided that a dedicated school of nursing within its grounds would be the best way to use the fund (Baly, 2002).
The matron of the new hospital was Sarah Wardroper, and she and Nightingale became friends. Although not a nurse, Mrs Wardroper was an esteemed nurse manager who had raised standards of nursing throughout the hospital. It was Nightingale's view that Wardroper would make an excellent first superintendent of the school, soon to become the first secular training school for nurses in the world.
Mrs Wardroper was willing to take charge of the training school and Nightingale recognised that she herself was both too ill and overcommitted elsewhere to personally lead the development of the new school. Initially, she had wanted Elizabeth Blackwell, the first woman to be put on the English Medical Register to head the school, but Blackwell turned down the post. Mrs Wardroper remained at the hospital until 1887 at the age of 74, and it was a tribute to her leadership that the school was such a success in the early years.
However, much of the medical establishment at St Thomas' Hospital, led by consultant surgeon John Flint South, were very much opposed to the notion of a nursing school. South was rooted in the past and thought that nurses needed little training other than the traditional duties of a housemaid in terms of cleaning and bedmaking..
The resentment of the medical staff was thwarted when it became clear that the Nightingale initiative had the ear and support of the royal family, in particular that of Albert, the Prince Consort, and prominent figures such as Baron Sidney Herbert. Both Nightingale and Mrs Wardroper realised that, if the initiative was not to be stifled at birth by the medical fraternity, then the first probationers for the school must be beyond reproach.
Mrs Wardroper was left to manage the recruitment, selection and training of the first 15 probationers; however, Nightingale still took a hand in organising a system for recording the progress of trainees. To this end, she designed a ‘Monthly Sheet of Personal Character and Acquirements’, configured in two parts. The first consisted of a moral record that included punctuality, quietness, trustworthiness, personal neatness and cleanliness, as well as ward management. The second component covered technical aspects, recording skills acquisition, which were graded as excellent, good, moderate, imperfect and nil. Mrs Wardroper was also able to add her own personal comments on the progress of each probationer.
Many readers who trained as nurses prior to the Project 2000 initiative will remember having to complete booklets recording prowess in individual skills that had to be signed off by the ward sister. Even today, student nurses are expected to complete an ongoing achievement record to ensure that they meet the requirements of the Nursing and Midwifery Council.
The first 15 probationers arrived on 9 July 1860 and the Nightingale Fund was able to give them a salary of £10 for the duration of the course, which in the early period lasted for one year. A nurses' home was created adjacent to the school on the upper floor of the hospital as accommodation for the probationers. The concept of the nursing home was devised by Nightingale herself and each probationer had their own bedroom, a set-up that later became ubiquitous across all hospitals in the UK.
Later, Nightingale employed the first home sister in 1872—also emulated widely—perhaps as another way of keeping her probationers beyond reproach. Many readers may reflect with some nostalgia on the shenanigans they got up to as student nurses to avoid being spotted by the home sister after breaking curfew. In some cases being found with a member of the opposite sex resulted in instant dismissal, something that lasted into the 1970s.
Discussion
The launch of the first nursing school in 1860 drew a line in the sand, catapulting nursing into a new era in which nursing would be respected as a professional career choice for women and to break with its former Dickensian stereotype of the drunken and inept Sairey Gamp. No longer would nurses be seen simply as handmaidens to medical practitioners, but recognised in their own right as complementary and parallel health professionals.
This did not happen overnight and it should be stressed that in the early years of the Nightingale school the cohorts of probationers were not actually trained to nurse, but rather trained to train others. These disciples were poised to promote the Nightingale training methodology across the entire country and further afield—to the USA and Australia. The graduates of the Nightingale school would go on to become matrons in hospitals around the country, firmly establishing nursing as a respectable profession and a vocation.
Initially, the probationer nurses undertook a one-year training course that included some theoretical input such as lectures. However, the course was mainly configured as an apprenticeship, with the probationers learning clinical skills and developing competencies under the supervision of the ward sister, with both Nightingale and Wardroper maintaining vigilance and scrutiny of their ward diaries and reports. To further create a professional image Nightingale empowered one of the first probationers, a Miss van Rensselaer, to design the uniform for the school of nursing.
After completing the course the probationers, if successful, were entered on the Register of Certified Nurses, and employment was found for them. This, however, was simply a local register and formal nurse registration was nearly 60 years away. Nightingale, however, was not a supporter of later campaigns to introduce statutory registration for nurses.
Eventually Nightingale reluctantly accepted that the school should offer two routes to nursing: the one-year route for more prosperous, well-educated ladies, who would pay to train, and a two-year course for the less well educated, who would receive a small salary. Nightingale foresaw that the top nursing positions would in future be awarded to the better educated probationers not due to their social status within the community, but simply because they were better educated.