Why the founder of modern
nursing is still important
It is 200 years since the birth of the founder of modern nursing, Florence Nightingale. She is an iconic figure of history who transformed the face of healthcare and established the first professional training school for nurses.
To mark the bicentenary, the Florence Nightingale Museum is staging an exhibition celebrating her life through 200 objects, places and people.
Here, Nursing Standard looks at some of the highlights of that exhibition and their modern equivalents, and explores why Florence Nightingale's legacy is vitally important to all nurses.
Florence Nightingale is known as the ‘Lady with the lamp’, but many popular images depicting her making her rounds do not show the style of lamp she would have actually used. This was because most artists did not visit the hospital at Scutari in Turkey where she nursed in 1854 at the height of the Crimean War (1853-56).
Miss Nightingale carried a traditional fanoos, made of waxed linen, when doing her rounds in the four miles of dark wards at the vast military hospital. You can see from our animation here how the lamp should have looked.
Florence Nightingale Museum collections officer Chloe Wong says that Miss Nightingale and her colleagues would have used whatever equipment was to hand, and the most readily available would have been this style of lamp using a candle.
‘ Florence would find those who were in their final hours, keep them company and write letters home on their behalf’
‘Florence walked around the hospital at night, and often had the help of a young recovered patient who would carry the lamp for her. She didn’t want men to die alone in the night,’ Ms Wong says. ‘She would find those who were in their final hours, keep them company and write letters home on their behalf.’
This image of the nurse tending men on their sick beds fired up the public imagination back home in Britain, fuelling Miss Nightingale’s fame and focusing on the work of nurses. Pictures were generally drawn by artists who had never been to Scutari and often tended to use an incorrect style of lamp.
Today – a watchful eye
Anne Marie Rafferty, president of the RCN and professor of nursing policy at the Florence Nightingale Faculty of Nursing and Midwifery, King’s College London, says the iconic image of a nurse with a lamp resonates with the work carried out by every member of the profession today.
‘The lady with the lamp image has become the universal symbol for nursing. It is iconic and instantly recognisable,’ Professor Rafferty says. ‘I see the image as surveillance, the very raison d’etre of the nurse. The word “ward” derives from the Anglo-Saxon “wearden” meaning to watch. “Watching” the sick was the original function of the nurse long before Miss Nightingale came on the scene.’
‘We need to shine a light on the expertise that nurses bring in managing competing priorities and organisational complexity on a day-to-day basis’
However, this image does need updating to reflect the complexity of care that nurses provide. ‘We need to shine a light on the expertise that nurses bring in decision-making, managing competing priorities and organisational complexity on a day-to-day basis,’ Professor Rafferty says.
Short-staffing is compromising such surveillance at the heart of nursing care, Professor Rafferty says. ‘Evidence shows there can be high levels of missed care in many systems and the most missed item is comfort talk with patients. With the current levels of nurse vacancies, it is unlikely that many have the luxury of spending enough time with patients. Staffing safely sounds easy, but is difficult to do. We need to empower nurses to design their solutions into systems,’ she says.
This small wooden chest housed the personal medicine set Miss Nightingale used to treat the injured of the Crimean War. It contains 13 large bottles and two pill boxes, one marked Tonic pills and the other Cough pills.
Among other medicines, there are bottles of powdered rhubarb, quinine, carbonate of soda and essence of ginger.
Miss Nightingale took the chest with her when she travelled from London to Scutari hospital in 1854 with 38 nurses.
Her journey followed a government appeal for nurses and came after newspaper reports highlighted the dreadful conditions and lack of medical supplies experienced by soldiers fighting the Crimean War. The filthy hospital lacked even basic equipment and food. ‘All were swarming with vermin, huge lice crawling all about their persons and clothes. Many were grimed with mud, dirt, blood and gunpowder stains. Several were completely prostrated by fever and dysentery,’ wrote assistant surgeon Henry Bellew describing the patients at Scutari hospital, in a letter in January 1855.
Miss Nightingale and her team of nurses set about reorganising the hospital to ensure adequate supplies of food, blankets and beds, as well as improving general conditions and cleanliness.
Today – community nurses’ kit
Community nurses need to take essential supplies with them on their rounds.
Parveen Akhtar, palliative care and end of life community matron and Queen’s Nurse in Lambeth and Southwark, London, says nurses need a significant amount of kit in their backpack, and, if they have one, a car.
Patients should have supplies of everything they need such as continence pads and any dressings, but often this is not the case, Ms Akhtar says.
‘The more specialised your role becomes, and the more skilled you become, the more kit you need to carry’
Community nurses carry the fundamentals for infection control prevention, such as gloves, aprons, alcohol rub, soap and shoe covers. Diabetes management is a major part of community work, so nurses also carry glucose monitoring equipment and insulin, along with a range of dressings and bandages, continence supplies, a spare catheter, syringes and needles and ampoules of sterile water.
Spare batteries are essential for patients with syringe drivers and sometimes larger items, such as bladder scanners, are needed.
Nurses also have to carry identification and a personal safety alarm, as they are often lone workers. They carry paperwork, a tablet, a prescription pad and a mobile phone.
Ms Akhtar says she has seen the amount of equipment needed grow throughout her career: ‘We try to take everything that could be needed to prevent any delay, we have to anticipate whatever we may need. The more specialised your role becomes, and the more skilled you become, the more kit you need to carry.’
‘ Miss Nightingale wrote every hour she could, she would write all night ’
This beautifully painted writing chest was presented to the now famous Miss Nightingale in 1856 when she returned, with newly acquired fame, from Scutari. It was a gift from the people of Lea, Holloway and Crich in Derbyshire, where the Nightingale family had a home.
To describe Miss Nightingale as a prolific writer is an understatement. After the Crimean War, she campaigned for public health reform, writing letters to anyone she thought might have influence.
She was often confined to bed by poor health, believed to be caused by the bacterial infection brucellosis contracted while caring for patients in the war. Despite this, she wrote 14,000 letters and more than 200 books and pamphlets throughout her life.
‘Miss Nightingale wrote every hour she could, she would write all night,’ says Florence Nightingale Museum collections officer Chloe Wong. ‘When we think about campaigning in the modern day we might think about placards and protests, but she did everything from behind the scenes.’
Today – social media
Social media has revolutionised how nurses communicate, campaign, learn and work with each other.
The speed of communication through forums such as Twitter and Facebook has allowed nurses to spearhead and support influential campaigns on staffing, pay and professional issues. Examples include the high profile #hellomynameis campaign to help patients identify who is caring for them, and @wenurses, a Twitter thread with more than 87,000 followers where nurses share knowledge and offer support.
Twitter can also be the perfect place for a grass-roots campaign demonstrated when Royal London Hospital nurse Jessica Anderson was denied a world record for the fastest time in a marathon dressed as a nurse because she was wearing scrubs, the uniform she wore for work every day. Guinness World Records said she should be wearing an old-fashioned dress, a pinafore apron and a nurse’s cap.
In the Twitter backlash using the #whatnurseswear hashtag, nurses posted pictures of themselves in their scrubs until Guinness World Records relented and awarded Ms Anderson the record.
A Swedish midwife prompted international debate when she posted a candid photo of menstrual blood on her scrubs trousers after saying she was too busy to take even a toilet break on her shift due to staff shortages.
Jimmy the tortoise
This gleaming tortoise shell is what remains of Jimmy, a ward pet in the hospital at Scutari in 1855 and 1856.
Miss Nightingale was devoted to animals, and in her influential book Notes on Nursing she explains the value of pets to support recovery: ‘A small pet animal is often an excellent companion for the sick, for long chronic cases especially. A pet bird in a cage is sometimes the only pleasure of an invalid confined for years to the same room. If he can feed and clean the animal himself he should be encouraged to do so.’
Florence Nightingale Museum collections officer Chloe Wong says: ‘Jimmy was effectively a therapy animal and we know she thought animals could help people when they were unwell.’
Jimmy was one of a number of animals in Miss Nightingale’s life. Best known is Athena, the little owl she rescued when she saw her being tormented by a group of boys at the Acropolis in Greece while on holiday.
Ms Wong says: ‘Athena was a type of burrowing owl, and she was happy being carried around by Miss Nightingale in her pocket. Her rescue of Athena shows that she would always act if she saw something happening that she thought was wrong.’
Miss Nightingale had the owl for about six years, but Athena died just as she was preparing to leave for Scutari. According to a book about Athena written by Miss Nightingale’s sister, the death delayed Miss Nightingale leaving for Turkey for two days while she had the pet embalmed.
‘A small pet animal is often an excellent companion for the sick, for long chronic cases especially’
Today – pet therapy
Miss Nightingale was ahead of the trend when it comes to the benefits of animals in caring environments, as a wide range of pets are now regularly welcomed on to wards and into hospices and care homes.
Dogs, cats, donkeys and chipmunks are among the animals brought to visit patients and residents.
An RCN survey in 2016 found that 90% of nurses believe animals can improve the health of patients with depression and other mental health problems. Nearly half of the more than 750 nurses surveyed had worked with animals in their career and, of those, 98% said it benefitted the patient.
Animal therapy is now carried out so often that the RCN has written guidance on bringing dogs into clinical settings. It helps deal with concerns such as infection prevention control and allergies so that patients can benefit from animal visits.
A study at Southampton Children’s Hospital with six therapy dogs showed overwhelming support from staff and patients for the animal visits. A survey of 200 staff and parents over 12 months found the presence of dogs reduced anxiety in young patients who were waiting for tests, investigations and examinations.
‘Patients, staff and visitors enjoy the benefit of the human-animal bond when they see one of our dogs on the wards’
Lyndsey Uglow, lead therapy dog handler at Southampton Children's Hospital, said: ‘The positive effects of animal assisted intervention have been clear to me for such a long time. We understand a therapy dog visit would not be appropriate for every type of patient however, where it is possible, the results of this study show that patients, staff and visitors enjoy the benefit of the human-animal bond when they see one of our dogs on the wards.’
Robotic animals have also been developed to mimic the therapeutic benefits animals can give patients. One is Paro, a white, fluffy baby seal robot, which the Japanese makers say offers animal therapy in clinical settings where it can be hard to have live animals. Research suggests it can improve patient relaxation, motivation and socialisation.
This precise, elegant diagram is an early example of a pie chart, and was a revolutionary way to make complex statistics easy to understand.
When Miss Nightingale arrived in Scutari she found wounded and dying men in horrific conditions. There were patients lying on the floor, rats were rife, and not even basic medical records were kept.
She realised that the conditions were killing more soldiers than the battle. Always a keen mathematician, she started collecting data, and used a team of people to help her gather it.
When she got home two years later, Miss Nightingale drew up this diagram to provide a visual demonstration of the causes of death in the Crimean War.
Each wedge demonstrated a month’s worth of deaths, with the red showing deaths from battlefield wounds, widely believed to be the leading cause of soldier deaths. The much larger blue areas were deaths from preventable disease, including frostbite, dysentery, cholera and typhus, caused by the unsanitary conditions in the battlefield hospitals.
Miss Nightingale was one of a small group of mathematicians who seized on the power of graphics and was the first woman to join the Statistical Society (later the Royal Statistical Society), according to the Science Museum in London.
When the diagram was published in a book in 1859, it was deemed unsuitable for distribution to the libraries at army barracks due to concerns about the nature of the causes of death affecting morale.
Today – data
Collecting data on every aspect of health is now the norm, thanks to the pioneering work of statisticians such as Miss Nightingale.
From patient observations, time and dose of medication, to falls and antimicrobial resistance data, nurses collect data all the time.
Independent consultant nurse Caroline Shuldham sees statistics as fundamental to every aspect of nursing.
‘Data help us answer clinical questions about the best care for patients, the quality of care and patient outcomes,’ she says.
‘Data are part of modern life and nursing has some catching up to do to ensure we can use it effectively’
‘Data are key when identifying areas for improvement and monitoring the impact of changes. This means understanding data is particularly relevant to nursing. For example, nurse managers use data for budgeting and staffing; nurse researchers collect and analyse data; nurse educators teach others and inform the practice of clinical nurses.’
There are a range of skills needed to work with data, but not all nurses will need them all, Dr Shuldham says. Some can be collected relatively simply and will be familiar to much of the workforce, such as measuring harm-free care with NHS Improvement’s Safety Thermometer.
All nurses need a basic understanding of data and statistics, Dr Shuldham says. ‘Data are part of modern life and nursing has some catching up to do to ensure we can use it effectively.’
Notes on Nursing
Florence Nightingale published more than 200 books, reports and pamphlets on various topics, including nursing, sanitation, hospital planning and organisation. Her most famous work, Notes on Nursing: What It Is and What It Is Not, was published in 1860 and has never been out of print.
It was intended not for nurses, but, according to Miss Nightingale’s preface, contained ‘hints’ for all women who cared for the health of others. According to her, this was probably every woman in England.
Nevertheless it swiftly became a textbook for nurses, Florence Nightingale Museum collections officer Chloe Wong says.
The book includes sections on food and making a house suitable for recovery through warmth, clean air, light and sanitation, quiet and personal cleanliness.
Ms Wong says: ‘This is a hugely important text. It was one of the first books to provide people with sensible advice on looking after sick people, and it was affordable. A lot of it remains relevant today, she talks about the importance of handwashing, for example. One way in which it is different from a modern textbook is that parts are in the first person, so we can hear her voice coming through.’
Today – journals
Journals, including Nursing Standard and its sister specialist RCNi titles, have been at the forefront of improving communication among nurses and establishing evidence-based practice. Journals uphold Florence Nightingale’s belief in the importance of research and data to further the nursing profession.
The American Journal of Nursing, which has been published since 1900, credits itself as the oldest nursing journal in the world. Meanwhile Nursing Research, founded in 1952 and still running, was the first nursing journal with an express mission to publish research.
The increasing digitisation of journals and books means that nurses all around the UK and beyond can increasingly access this vital information remotely. Members of the RCN library can access 1,100 journals and 30,000 books online.
Subscribers to Nursing Standard, the UK's most widely read nursing journal, can access the online archive of clinical and continuing professional development articles, as well as a history of nursing best practice stretching back to the journal’s first edition in 1987.
‘Florence believed a strong sense of community among nurses was crucial to encourage good patient care’
Florence Nightingale (seated in center) with Nightingale School trainees
Florence Nightingale (seated in center) with Nightingale School trainees
Nurse leader – Sarah Wardroper
The Nightingale Training School, established at the new St Thomas’ Hospital, in London in 1860, is one of the most important aspects of Florence Nightingale’s legacy.
The first 15 trainee nurses, known as ‘probationers’ arrived on 9 July 1860. Training was a year long, and they were paid an annual salary of £10. Trainees were also provided with free accommodation and meals at the ‘Nightingale Home’. Ms Wong says: ‘Florence thought it was important that the trainees lived together. She believed a strong sense of community among nurses was crucial to encourage positive habits and good patient care.’
Miss Nightingale chose St Thomas’ Hospital for her nursing school partly because of the high regard she had for the hospital’s matron Sarah Wardroper.
While she had received little training herself, Mrs Wardroper, a doctor’s widow, was considered to be a well-organised, efficient and respectable woman by Miss Nightingale. At this point, nursing was still not widely considered to be a respectable job for women.
Ms Wardroper was made superintendent of the new school and described by Miss Nightingale as a ‘hospital genius’.
‘As well as running both the training school and the hospital nursing, Mrs Wardroper did most of the reconnaissance work for teams of matron and nurses sent to other hospitals,’ according to the book Florence Nightingale: The Florence Nightingale School.
Today – Eileen Sills
Chief nurse at Guy’s and St Thomas’ NHS Foundation Trust since 2005 and director of patient experience since 2012, Eileen Sills can be seen as a direct professional descendent of Sarah Wardroper.
Dame Eileen has a national reputation for strong, visible clinical leadership including her introduction of Clinical Fridays, which increase the amount of time senior nurses spend on the front line, and the Safe in Our Hands forum where nurses share successes and challenges to improve patient care.
She was the driving force behind the development of an award-winning training film to raise staff awareness of dementia. In 2013 she was made Dame Commander (DBE), Order of the British Empire, in the Queen’s New Year honours.
‘You have to be able to see it through the eyes of your patients and your staff’
In 2017, St Thomas’ Hospital staff helped care for those caught up in the Westminster terror attack that took place nearby.
Dame Eileen says that the important attributes for nursing leadership are to be ‘approachable, honest, to have integrity and to never be ashamed to say when you have made a mistake’.
‘You need to love your job and your staff need to know you are there for them and will support them,’ Dame Eileen says. ‘However, they also need to know what your standards are, and although you will be supportive, you also need to know when to be a little bit tougher. I see my role as a conductor of an orchestra, not a soloist, or one of the players. But when needed I will roll up my sleeves and work alongside them to get the best out of them. You have to be able to see it through the eyes of your patients and your staff.’
Scutari hospital sash
This sash with a red trim was worn by Miss Nightingale’s team of 38 nurses. The Florence Nightingale Museum says the sash, which was worn over one shoulder, was one of the earliest examples of a professional nursing uniform.
It helped patients identify who was part of Miss Nightingale’s team, as opposed to the so-called camp followers. Camp followers were women who held various unofficial roles in the army and travelled with a regiment as wives, cooks, nurses, midwives, seamstresses, laundresses and even prostitutes, according to the National Army Museum.
‘The sash was a way of saying I am an official nurse. It helped establish dignity and respectability for the nurse and could have had an impact on the way the patients might treat and talk to them’
Miss Nightingale and her nursing colleagues had travelled at the request of secretary of state for war Sidney Herbert.
The Florence Nightingale Museum collections officer Chloe Wong explains: ‘It was a way of saying I am an official nurse, I am part of a commission from the government and I am not a camp follower. It helped establish dignity and respectability for the nurse and could have had an impact on the way the patients might treat and talk to them. Miss Nightingale wasn’t necessarily taking nurses with the most experience, they were chosen more for their attitude and capabilities. But the sash marked out that they were part of her team.’
Today – #hellomynameis
Helping patients identify who is caring for them remains an issue today.
A badge with a name and title is now a standard part of any nursing uniform. But the proliferation of different healthcare roles, and the different titles used by different employers for the same role has added to confusion.
A hospital ward can have a nursing team that includes healthcare assistants, nursing assistants, nursing associates, assistant practitioners, nursing students and registered nurses.
While being treated for terminal cancer, Kate Granger became concerned that she often did not know who was treating her. Her response was to start the social media campaign #hellomynameis to encourage and remind healthcare staff of the importance of introducing themselves. Many staff started wearing name badges and lanyards carrying the #hellomynameis campaign name.
‘I firmly believe it is not just about common courtesy, it runs much deeper,’ said Dr Granger, who died in 2016. ‘Introductions are about making a human connection between one human being who is suffering and vulnerable, and another human being who wishes to help. They begin therapeutic relationships and can instantly build trust in difficult circumstances.’
Since it was launched in 2013, #hellomynameis has made over 2 billion impressions on Twitter.
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