Many books have been written about Florence Nightingale, the founder of modern nursing. Three excellent and engaging ones are:

• Mark Bostridge (2008) Florence Nightingale: The Making of an Icon. New York: Farrar, Straus and Giroux.
• Barbara Montgomery Dossey (2009) Florence Nightingale: Mystic, Visionary, Healer. Philadelphia: F. A. Davis.
• Gillian Gill (2004) Nightingales: The Extraordinary Upbringing and Curious Life of Miss Florence Nightingale. New York: Ballantine Books.

Family Background and Youth

Florence Nightingale was born in Florence, Italy, May 12, 1820. Her parents were William Edward Nightingale (known by his initials as W.E.N.) and Frances (Fanny) Smith. She had a sister Parthenope (known as Parthe or Pop) who was a year older than Florence, also born in Italy. Their parents were, however, from England and among the most wealthy and influential families there. W.E.N.’s father, William Shore, had acquired his wealth as a banker in the developing industrial area of Sheffield, and W.E.N. had been named William Shore after his father. He became known as W.E.N. after he changed his surname to Nightingale in 1815, a change that inheritance laws then required for him to inherit his Great-uncle Peter Nightingale’s estate at Lea Hurst, Derbyshire. (Dossey 2009, 5)

Known for her beauty, Frances Smith Nightingale (Nightingale’s mother), also came from a wealthy and influential family. Her father, William Smith, was a member of England’s Parliament for over 40 years and Fanny’s grandfather had built considerable wealth in the grocery business. (Dossey 2009, 6)

English culture in the early 19^th century was typically patriarchal and roles for women were very limited. Certainly, the role expectations for women in wealthy families were as wives and mothers. Their activities centered around entertaining, managing the household staff, and supervising the raising of children. Strong expectations were at work for Florence to follow in her mother’s footsteps. Florence’s sister, Parthenope, did follow the script, and she would eventually marry Sir Harry Verney, a member of Parliament and wealthy, well-known philanthropist. (Dossey 2009, 214)

The Nightingale home in Lea Hurst, where Florence lived her early years, was cold and her mother Fanny wanted to live in a warmer environment and nearer to the social life of London. Florence was often sick and confined to her bed in her young childhood. She and her sister were each other’s playmates, though they often joined in play with their cousins who lived nearby.

In 1825, the family moved to Embley Park, a 4,000-acre estate in warmer Hampshire, England, closer to members of the Smith family. Many family visits ensued, but even more important for Florence were the many visits by prominent thinkers and politicians of the day to the Nightingale home. These articulate and influential leaders were instrumental in educating Florence about progressive issues of the day, and later as she crafted her own reform efforts, they were her allies and supporters in improving health care.

All her biographers report that Florence’s interest in health began early in her life. She cared for her thirteen “sick dolls . . . all ill in rows in bed” (Bostridge 2008, 45), doctored injured animals, and later in her youth was deeply touched by the needs of those who lived on or near the estate. She often expressed concern for those who were ill or lived in poverty. Florence cared for her Aunt Jane and Aunt Julie during major illnesses as well as her Grandmother Shore during her illnesses and final days.

Florence was especially fond of her Aunt Mai (W.E.N.’s sister who married Fanny’s brother) and cared for her during an illness. Aunt Mai was often her niece’s champion throughout Florence’s decidedly unconventional life. Typical of girls of the 1800s, Florence had her governesses from whom she learned to read and write. As she grew into her late teens she told her father she wanted to study mathematics, but her parents thought that women did not need to know this subject. With Aunt Mai’s intervention, they relented and let her be tutored in mathematics.

Upper-class women were limited to charitable and philanthropic activities, generally conducted at a decorous distance. This role would not satisfy Florence’s passion for helping others, a determination that frequently drew strong criticism from her parents and sister. Dossey (2009), Gill (2004), and Bostridge (2008) all describe Florence as a sensitive and spiritual person. Florence’s early diaries record her prayers and seeking for direction. She felt she had three specific calls from God “to be a savior,” one in 1837 when she was 16, another in March 1850 a few months shy of 30, and a third two years later in 1852. She understood “a savior” to be a person “who saves from error” by taking action to right the wrongs of the world. (Dossey 2009, 33, 65-66, 80-82; see also Bostridge 2008, 54-55.)

Even so, she loved her parents and tried to comply with their expectations for her. She was presented into society before Queen Victoria in 1839 at the customary age of 18. She had several suitors with whom she had long relationships, but she finally rejected offers of marriage.

Kaiserswerth and the Pursuit of a “Meaningful Vocation”

In 1850, while traveling in Egypt, Greece, and Europe with family friends, the Bracebridges, Florence tarried two weeks in July at the Institution of Deaconesses at Kaiserswerth, a well-known facility in Germany for training nurses and deaconesses (Protestant nurses) in helping the sick and poor. With her parents’ reluctant permission, a year later Florence spent three months training at Kaiserswerth. Later that year, she visited hospitals in Paris and met with physicians and collected reports and information about the workings of the hospitals there. She wrote copious notes on every venture.

One woman who undoubtedly expanded Florence’s view of her own potential was Elizabeth Blackwell, M.D., the first woman doctor in the United States, a graduate of the Geneva Medical School in New York. She was another formidable woman social reformer. Her family moved from England to the United States after her father’s profitable sugar factory burned down. He was an Abolitionist, and Elizabeth’s sister, Emily, graduated from Case Western Reserve University as a physician.  In 1849 Blackwell went to study obstetrics in Paris. While there, she acquired a devastating eye infection from a patient and her eye was eventually removed. After recovering, she moved to London in 1850 to resume her studies at St. Bartholomew’s Hospital. In London she met Florence, and they developed a life-long friendship and corresponded frequently. (https://en.wikipedia.org/wiki/Elizabeth_Blackwell; Dossey 2009, 72-75.)

Florence, however, was not drawn to the medical profession. In her experience nurses were more likely to benefit a patient than doctors. As Gill (2004) explains, “With its reliance on bloodletting, purges, emetics, blisters, opiates, and medications based on heavy metals and alcohol, . . . [m]any patients were treated but few were cured, and some died from the treatment” (191).

Florence was a prolific writer and many of her letters and papers have been preserved. Often bored with her passive life, she longed to be active in her community. She wanted a purposeful life and is well known for her “Cassandra” treatise, which was part of a larger work, Suggestions for Thought to the Searchers After Truth Among the Artizans of England (1854). In “Cassandra,” “Florence argued for the liberation of upper-class Victorian daughters from the prison of the drawing room. She condemned society’s insistence that privileged young women must spend their days in endless trivial occupations instead of being allowed to pursue meaningful vocations” (Dossey 2009, 81).

W.E.N., Florence’s father, eventually acquiesced to his daughter’s desire to escape the stifling confines of polite society and gave her money to live an independent life. In August 1853, Florence Nightingale became the Superintendent of the Institution for the Care of Sick Gentlewomen in Distressed Circumstances at No. 1 Harley Street. She introduced her views of how hospitals should be organized and how plans should be implemented. This 27-bed hospital was her initiation into managing “sickness, health and healing” (Dossey 2009, p. 88). Again, her quarterly reports, notes, lists, and letters written at this time were evidence of her grasp of both medicine and understanding of hospital administration.

After a year in this position, Florence ended her work with this group; she had plans to become the superintendent of nurses at King’s College Hospital and start a program to prepare nurses to assist in surgeries. Chloroform had just been introduced into medical practice after extensive studies by James Y. Simpson, Professor of Midwifery in Edinburgh. This advancement allowed longer procedures to be undertaken, often with far better outcomes, and Nightingale recognized the need for additional training for nurses to assist in surgery. (Dossey 2009, 96-97)

These plans were short circuited in 1854 by a severe cholera outbreak in London. Dr. John Snow’s statistical mapping of this deadly disease was a major breakthrough in understanding its causes. He linked the outbreak to contaminated water at the Broad Street pump (Johnson 2006, 154). (Snow is also known for his practice of medical hygiene and early use of anesthesia.) During this time of crisis, Nightingale left her work at Harley Street and worked at the Middlesex Hospital where the cholera patients were admitted. She helped admit and care for many of the victims of this often-fatal disease. (For more on this subject, see Stephen Johnson 2006, The Ghost Map: The Story of London’s Most Terrifying Epidemic and How It Changed Science, Cities, and the Modern World.)

The Crimean War and “The Lady with the Lamp”

Further afield, events were unfolding that would lead Florence to volunteer her help elsewhere. After a number of skirmishes, Turkey declared war on Russia in October 1853. Subsequently, Russia attacked and destroyed Turkish naval forces in Sinope harbor and “massacred the sailors in the water” (Dossey 2009, 103). England joined with France in 1854 to quell Turkey’s conflict against Russia. Both countries sent troops to Turkey. There were many bloody battles and heavy losses all around. War correspondents gave graphic descriptions of the battles and the pathetic conditions of the Barrack Hospital treating the British soldiers in Turkey.

Touched by these news articles about the war, Florence launched plans to lead “a small private expedition of nurses” to go to Scutari, and she began contacting nurses and soliciting donations. Therefore, when Sidney Herbert, Secretary of War, wrote to request she take a group of nurses to Scutari on behalf of the government, she was happy and prepared to accept (Dossey 2009, 110-114). (He no doubt knew of her work at the Harley Street Institution and Middlesex Hospital from his wife Elizabeth, one of Florence’s close friends.) Even before receiving his letter, Florence had submitted letters to several influential government officials requesting permission to go to Scutari, including her neighbor at Embley, Lord Palmerston, who was Home Secretary. In addition, she had written to Dr. Andrew Smith, Director-General of the army’s Medical Department. She wanted to be known as a knowledgeable, experienced nurse, not simply “a lady.”

Florence is justly famous for her heroic efforts at Barrack Hospital in Scutari. In October 1854 she arrived with her band of 38 female nurses. She quickly assessed the situation and began implementing measures she had learned at Harley Street as Superintendent of the Institute for the Care of Sick Gentlewomen in Distress. Initially the group was not well accepted but that soon changed as the hospital was overwhelmed with injured and ill soldiers after the Battle of Balaclava.

Florence wrote to Dr. William Bowman, her friend and colleague from Harley Street, “I have no doubt that Providence is quite right and that the Kingdom of Hell is the best beginning for the Kingdom of Heaven, but that this is the Kingdom of Hell no one can doubt” (Dossey 2009, 125). Florence told Bowman, “We have now four miles of beds—and not eighteen inches apart. . . . These poor fellows have not had a clean shirt nor been washed for two months before they came here” (Dossey 2009, 125).

Of conditions in the hospital, Dossey (2009) observes, “The vermin-infested wards were as bad as the worst slums of London” (126). Set over a network of cesspools and blocked sewer lines, the bathrooms overflowed, and the windows were closed. The stench was described as “appalling.” Her first tasks were to establish a new level of cleanliness. The boiler for laundry services was not working when Florence arrived. Her request for a new boiler was denied. However, she was able to negotiate a boiler in the town and set up a laundry facility in a house nearby. She paid for this out of the funds she brought with her from the donations she had been given.

Food and other supplies were often stolen enroute to the hospital and what did reach them was of low quality. Food preparation was described as primitive. The same thirteen pots were used for both cooking meat and preparing tea. Meat was often undercooked and often mostly bone. Florence used donated money as well as her own to purchase vegetables at a market near the Barrack.

After winning the support of her physician colleagues, she was given more freedom to implement new health measures, though she had many detractors who often stonewalled her efforts. New anesthetics were introduced into surgery. At her insistence, sanitation principles became accepted routines. Even so, the death rate was staggering, especially in that winter of 1855. Nightingale calculated the mortality rate of hospital patients in January of that year as “1,000 per 1,174” and it was no understatement to say, as she did in a letter to Sidney Gilbert, that their situation was “a calamity, unparalleled in the history of calamity” (Dossey 2009, 143).

Florence Nightingale became known as “The Lady with the Lamp” for her strenuous work ethic, which included 20-hour workdays. Also, her kindness in writing letters and comforting the wounded soldiers set a pattern for other nurses. During her work in Scutari, Florence wrote reports back to London of her work, describing in detail her efforts, drawing diagrams of conditions, and recording significant events.

As well as being known as the “mother of modern nursing,” Florence Nightingale is also known as the “mother of statistics.” While overseeing the nurses at the Barrack Hospital, she designed a method for visually representing the causes of mortality. The causes of deaths were noted by month, in a wedge design, and by size and color. One graph was from April 1854 to March 1855 and the other April 1855 to March 1856. Florence’s attention to detail was recognized and validated by Dr. William Farr, “the great British pioneer in medical statistics” (Gill 2004, 420). After the war, he became her friend and ally in efforts to reform the British health system. His admiration for her work included naming a daughter after her, Florence Farr (Bostridge 2008, 262n).

The Crimean War ended in March of 1856 with the signing of a treaty. Florence stayed on at the Hospital to care for the recovering soldiers. She kept up her writing, cleaning, caring for the soldiers, administering medications, and other tasks. War correspondents writing reports of the war portrayed the soldiers and the nurses as heroes. Not wanting any fanfare and physically and emotionally drained, Florence returned to England incognito with her Aunt Mai and a queen’s messenger to assist with obtaining passports (Dossey 2009, 183, 179-80).

Many demands awaited her upon her return home to London; Florence, however, first needed to recover from the exhausting venture. As she was recuperating, a new mission grew in importance to her. Approximately 97,800 soldiers fought in the war. While 4,500 died of battle-related injuries, many thousands more, in fact over 17,600, died of disease and exposure. The lack of policy and preparation, of organization and job descriptions led to premature and preventable deaths. Florence felt it was her responsibility to those who had died to advocate for major reforms in the Army’s Medical Department. Working closely with her allies, many significant changes were instituted within the Military.

Training Schools for Nurses and Publication of Notes on Nursing

After the War, the need for nurses to be educated and equipped with skills to care for those who were ill or injured was undisputed. With Florence’s name recognition and influence resulting from the laudatory press coverage of her work, people were willing to financially support educational programs for nurses. With funding dedicated to the project, Florence organized “the world’s first secular training school for nurses” at St. Thomas’s Hospital in London (Dossey 2009, 231). Florence emphasized the need for studying a patient’s condition and for using statistics to develop administrative plans. She also encouraged knowledge of anatomy and physiology to understand disease and injury. After its opening, requests to help develop other nursing schools and provide staff for other hospitals soon followed.

By 1860, Florence had written and published the first edition of Notes on Nursing. Within a month of its publication, Notes on Nursing sold 15,000 copies. While it was targeted more for the care of a sick person at home, it covered a broad range of topics, such as ventilation, rules for visitors, sick room management, diet, activities, bedding, and many other healthcare suggestions (Dossey 2009, 238-39). Notes on Nursing was quickly translated into many languages. A revised edition printed shortly after (published as Notes on Nursing for the Labouring Classes) simplified the text and took out technical language. It included a section on “Minding Baby” for new mothers (Bostridge 2008, 360-61).

Influence Abroad

Dorothea Lynde Dix.

In April 1861, the Civil War began in the United States of America. President Abraham Lincoln appointed Dorothea Dix, “the New England reformer best known for her work on behalf of the mentally ill,” to be Superintendent of Female Nurses for the Union Army (Bostridge 2008, 361). The Army officers and Dix faced the same chaos that Nightingale had experienced in the Crimean War six years earlier. Dix had read Nightingale’s Notes on Nursing and it strongly influenced her work in the Civil War. According to Bostridge, Dix greatly admired Florence Nightingale’s work and twice had made plans to meet with her, first in Scutari and then in England, but other obligations intervened, and these meetings never took place (362).

Harriet Martineau.

Harriet Martineau, a famous English author and journalist (also thought of as the first female sociologist), had written several articles on Nightingale’s work in the military hospital in Scutari. Concerned about the Civil War because of her close ties to America and her New York publisher, Martineau wrote to Florence asking for input on how to advise the Union Army on caring for their wounded and ill soldiers. Florence quickly responded by suggesting several of her written reports and publications (Dossey 2009, 248-49). Following the pattern of the “Sanitation Commission” that Florence had encouraged in Great Britain, President Lincoln established the United States Sanitary Commission. This agency eventually evolved into the American Red Cross.

Although Nightingale remained involved with nursing, nursing education, sanitation, and the British Army the rest of her life, she was less involved the last decades of her life due to ill health. Florence’s writings decrying the subjugation of women sparked interest by many women in the suffragette movement in England and the United States. They saw Florence’s recognition and contributions to society as goals that they too could achieve.