Known as “The Lady with the Lamp,” and considered a founder of modern nursing and environmental nursing theory, Florence Nightingale was a passionate, innovative, and caring nurse practitioner and prolific writer. In addition to writing over 150 books, pamphlets, and reports on health-related issues, she is also credited with creating one of the first versions of the pie chart. However, she is mostly known for making hospitals more hygienic and compassionate.

Florence Nightingale was born on May 12, 1820, in Florence, Italy, the city which inspired her name. Although her parents were from England, she was born in Italy while they were traveling. 

The younger of two daughters, Florence was part of an affluent British family that belonged to elite social circles. Her mother, Frances Nightingale, came from a family of merchants and took pride in socializing with people of prominent standing. Frances was beautiful, gracious, and well prepared for the life of an upper class, successful Victorian wife and mother. Her goal was to provide an elegant country home that met the highest standards for entertaining her large family and the upper classes in society, and to prepare her two daughters for marriages that would provide a life equal to that of which they were accustomed: a life in which they did little, and much was done for them. Despite her mother's interests, Florence herself was reportedly awkward in social situations and preferred to avoid being the center of attention whenever possible. Strong-willed, she often butted heads with her mother, whom she viewed as overly controlling.

Florence's father was William Edward Nightingale (W.E.N.) having changed his original surname, "Shore", a wealthy landowner who would be associated with two estates, one at Lea Hurst, Derbyshire, and the other at Embly, Hampshire.

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Italian Flag

It may seem a strange principle to enunciate as the very first requirement of a

hospital that it do the sick no harm.

~Florence Nightingale
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Florence Nightingale's Home at Lea Hurst, Derbyshire

Early Life

 

Unable to find a teacher who met the standards of the Nightingale’s, especially those of her father, resulted in Florence and her sister Parthenope being home-schooled by their father. The girls received instruction in modern and classic languages (German, French and Italian), history, geography, mathematics, literature, grammar, writing, and music. Florence was the better student of the two sisters, while Parthenope, often called Parthe, was more drawn to the arts and to those activities which were more suitable to little girls in upper-class society. 

 

As a child, Florence was prone to unexplained medical problems. She wore metal plates in her shoes during part of her childhood. Depicted from a childhood painting she wore what appears to be a partial supportive glove on her right hand. When Florence was six years old, a serious illness resulted in her being confined to her bed for an extended period.

Florence eventually concluded that nursing was her calling and divine purpose. However, when she told her parents about her ambitions to become a nurse, they were not pleased and forbade her to pursue this vocation. During the Victorian Era, where English women had almost no property rights, a young lady of Florence's social stature was expected to marry a man of means to ensure her class standing. Certainly, not taking up a job that was viewed by the upper social classes as lowly menial labor. 

Known as “The Lady with the Lamp,” and considered a founder of modern nursing and environmental nursing theory, Florence Nightingale was a passionate, innovative, and caring nurse practitioner and prolific writer.

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Extended Family and Courtships

 

In Victorian England, the extended family was a major focal point of entertainment. Visits from relatives were long, sometimes lasting months, which allowed Florence an opportunity to form close relationships with some of her cousins, one in particular named Hillary, as well as with her Aunt Mai, who was her father’s sister, married to Florence’s mother’s brother Sam Smith. Florence had a great admiration for another of her cousins Marianne, who she believed was perfect in every way. Florence refused a marriage proposal from Marianne’s brother who long pursued her. In turn, Florence’s refusal to marry caused a rift between Florence and Marianne, who believed that Florence had misled her brother into thinking she was interested in marriage.

Florence was also courted by Richard Moncton Milnes, who was a poet of comparable standing in society to that of the Nightingales. Although she seemed to have a great affection for Milnes, she refused him marriage based on her belief that marriage would provide the kind life that would prevent her from the work for which she believed she was called. She did remain in contact with Milnes, and in fact, he was later very active in soliciting money for the Nightingale Fund. He even named one of his daughters Florence after her.

Family Genealogy

Religion and Spirituality

Florence was a member of the Church of England, but in fact, her beliefs were not defined denominationally nor through the strict interpretation of the Bible. She was very religiously tolerant, believing that the religions of the world were all variations and interpretations of a similar premise. Her religion was more personally defined pragmatically. For Florence God was about laws and it was the job of mankind to understand them and do good works concerning them. These good works were at the center of her religion and her belief in them must have provided much of the drive that was apparent in a very strong work ethic. Hers was the kind of commitment that Catholic nuns made to work in God’s service, but in her case without the trappings of vows. Florence’s knowledge of religion was vast and in-depth. She understood the mystics and saints and was particularly interested in the religious orders of women. She maintained communications with certain religious leaders and was spiritually mentored by Madre Santa Colomba, a superior general of a religious group who Florence later met while traveling in Rome. Florence believed God spoke to her through Madre Colomba and during introspective periods, she would recount the lessons of her Madre.

Early Nursing Years

 

From a young age, Florence was active in philanthropy, ministering to the ill and poor people in the village neighboring her family’s estate. Florence was often called upon to care for family members when they were ill. She did so willingly and seemed to derive enjoyment from being the caretaker. When her grandmother became seriously ill, Florence remained with her until her death. During that time, Florence wrote to her cousin Hillary expressing her comfort in dealing with death. Determined to follow her true calling despite her parents' objections, in 1850 Florence enrolled as a nursing student at the Institution of Protestant Deaconesses in Kaiserswerth, Germany.

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In the early 1850s, after nursing school graduation, Florence returned to London, where she obtained a nursing job in a Harley Street Hospital for ailing governesses. The institution was intended to provide care to those ladies in society who had limited means but were not destitute to the point of qualifying for the free care given to the poor. Many of these women were former governesses who had been employed in large estates. Her performance there so impressed her employer that she was promoted to superintendent. The committee of wealthy women, who controlled the institution, made demands related to restricting Catholic clergy from visiting the residents. Florence pushed back, threatening to resign. With her promise to always accompany the clergy during their visits, the committee relented. Nightingale was able to get major repairs approved by the committee, and once she assumed the position of superintendent, changes were made that resulted in a reduction in expenses. 

 

Around this time, Florence also volunteered at the Middlesex Hospital and was challenged with a cholera outbreak and unsanitary conditions conducive to the rapid spread of the disease. Florence made it her mission to improve hygiene practices, which significantly lowered the death rate at the hospital in the process.

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Florence Nightingale’s Turkish Lamp - Florence Nightingale Museum London

Crimean War

 

In October 1853, the Crimean War broke out (1853-1856), a conflict that took its name from the Crimean Peninsula on the Black Sea. The war pitted Britain, France, Turkey, and Sardinia against Russia, whose ruler, Czar Nicholas I, was attempting to expand his influence over the Middle East and the eastern Mediterranean at the expense of the declining Ottoman Empire. The British and French, in turn, saw Nicholas’ power grab as a danger to their trade routes and were determined to stop him. 

Thousands of British soldiers were sent to the Black Sea, where food and medical supplies quickly dwindled. By 1854, more than 18,000 soldiers had been admitted into military hospitals. At the time, there were no female nurses stationed at hospitals in the Crimean Peninsula.

 

After the Battle of Alma, England was in an uproar about the neglect of their ill and injured soldiers, who not only lacked sufficient medical attention due to hospitals being severely understaffed but also languished in appallingly unsanitary conditions.

Pioneering War Years

 

In late 1854, Florence received a letter from Secretary of War Sidney Herbert, asking her to organize a corps of nurses to tend to the sick and fallen soldiers in Crimea. Given full control of the operation, she quickly assembled a team and within a short time, Florence was on a ship with 38 women headed for the Crimea. The group included women with little experience, some with limited hospital experience, and others were Catholic and protestant religious sisters with varied experience.

 

Although they had been warned of the deplorable conditions there, nothing could have prepared Florence and her nursing team for what they saw when they arrived at Scutari, the British base hospital in Constantinople. The hospital sat on top of a large cesspool, which contaminated the water and the building itself. Patients lay in their excrement on stretchers strewn throughout the hallways. Rodents and insects scurried past them. The most basic supplies, such as bandages and soap, grew scarce as the number of ill and wounded steadily increased. Even water needed to be rationed. More soldiers were dying from infectious diseases like typhoid and cholera than from injuries incurred in battle. The soldiers’ wounds were unattended, adhering to their clothing and often gangrenous, resulting in many amputations. These surgeries were rudimentary and sometimes performed without anesthesia. 

Florence and her nursing team met with great resistance from the military medical staff in Crimea. Dr. John Hall, who was the chief medical officer, did not believe women had a place in the care of soldiers and that Florence was a spy, reporting back to the officials in England, which was somewhat true as she wrote many letters to Sidney Herbert, informing him of the unbearable conditions, the incompetence of those in charge, and the lack of supplies and services. At first, Hall’s resistance prohibited Florence and her nurses from entering the wards. It took a bloody battle and subsequent influx of hundreds of soldiers into the hospital to end the wait and provide the nurses with an opportunity to begin doing what they had come to do –nurse the soldiers. Much time was lost as they awaited the opportunity to begin providing care.

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The most important practical lesson than can be given to 

nurses is to teach them what to observe.

~Florence Nightingale
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Once allowed to enter the wards, the no-nonsense Nightingale and her team quickly set to work. She procured hundreds of scrub brushes and asked the least infirm patients to scrub the inside of the hospital from floor to ceiling. Nightingale herself spent every waking minute caring for the soldiers. In the evenings she moved carrying a Turkish lamp through the dark, damp halls of the hospital where hundreds of men lay in appalling conditions. The soldiers, who were both moved and comforted by her endless supply of compassion, took to calling her "the Lady with the Lamp." Others simply called her "the Angel of the Crimea." She attended almost all the surgeries that resulted in amputations. The early hours of the morning were spent writing letters which included the families of soldiers. These letters provided information about the condition and care of soldiers and served as death notices with reassurance that everything possible had been done, while ‘death came peacefully’.

In addition to vastly improving the sanitary conditions of the hospital, Florence instituted an "invalid's kitchen" where appealing food for patients with special dietary requirements was prepared. She also established a classroom and library for intellectual stimulation and entertainment. The addition of kitchens led to better nutrition and laundry facilities were established. Believing that the soldiers, given the opportunity, would send money home to their families, resulting in opening a post office, and there was a coffee house and areas where the men could read or play table games. The overall improvements went far beyond those documented in storybooks about the Lady with the Lamp. They represented a woman of means, who put herself in an unimaginable and extraordinary situation of desperate proportions. It was a combination of intelligence, influence, tenacity, and an unconditional belief in good over evil that drove her to accomplish what would be considered nearly impossible for women even today.

 

Though much improved with the level of care given by Florence and her nursing team, medical supplies came slowly. A major issue that impeded progress was the conflicting reports the government was receiving about the conditions of the soldiers and the facilities: reports by medical personnel that indicated things were fine and in good order. It took a sanitary commission, sent to Crimea in March of 1855, to assess and bring to light the reality of the situation. It was not until then that the desperately needed changes were implemented, resulting in a significant decrease in the number of deaths.

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Recognition and Appreciation

 

Florence remained at Scutari for a year and a half. She left in the summer of 1856, once the Crimean conflict was resolved, and returned to her childhood home at Lea Hurst. To her surprise, she was met with a hero's welcome, which the humble nurse did her best to avoid. The previous year, Queen Victoria had rewarded Florence’s work and dedication by presenting her with an engraved brooch that came to be known as the "Nightingale Jewel", and by granting her a prize of $250,000 from the British government.

Florence decided to use the money to further her cause. In 1860, she funded the establishment of St. Thomas' Hospital, and within it, the Nightingale Training School for Nurses. Florence became a figure of public admiration. Poems, songs, and plays were written and dedicated in the heroine's honor. Young women aspired to be like her. Eager to follow her example, even women from the wealthy upper classes started enrolling at the training school. Thanks to Florence, nursing was no longer looked down upon by the upper classes. Nursing was viewed as an honorable vocation.

Based on her observations during the Crimea War, Florence wrote Notes on Matters Affecting the Health, Efficiency and Hospital Administration of the British Army, a massive report published in 1858 analyzing her experience and proposing reforms for other military hospitals.

Her research would spark a total restructuring of the War Office's administrative department, including the establishment of a Royal Commission for the Health of the Army in 1857. Florence was also noted for her statistician skills, creating coxcomb pie charts on patient mortality in Scutari that would influence the direction of medical epidemiology.

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Nightingale’s Holistic Environmental

Nursing Theory

 

Florence described nursing as a divine calling to serve others. Her philosophy was about healing, not just caring for the sick. Her philosophy reflected a change in nursing that persists today in that she believed caring for the whole person (holistic nursing) required integration and collaboration with medicine, environment, family, and society. She felt the nursing model must be adapted to fit the needs of individual patients, thus promoting more personalized medicine. Florence saw that people are multidimensional, being composed of biological, psychological, social, and spiritual components and it is important to address each of these components to create a holistic approach.

She believed that the patient’s environment could be altered in such a manner to allow self-healing to occur, as poor or difficult environments led to poor health and disease. Florence was concerned about both the elements that entered the body (food, water, medications) as well as external elements (ventilation, light, noise control, stimulation, and room temperature). She saw ventilation as one of the most important healing elements.  Her focus on improving the patient’s environment, in turn, helped their internal biological terrain promote healing.  

Her holistic nursing model was a four-step process:

  • Observation

  • Identification of the needed environment alteration 

  • Implementation of the alteration

  • Identification of the current health state 

 

This process is repeated as frequently as necessary to achieve the overall goal of improving health. The model includes health promotion, illness prevention, health restoration, and rehabilitation as appropriate states in which the model can be implemented. Her nursing goal was to place the patient in the best possible condition for nature to act and the body to self-heal. Thus, nursing is the activity that promotes self-healing and health which occur in any caregiving situation. 

Later Life

 

While at Scutari, Florence had contracted the bacterial infection brucellosis, also known as Crimean fever, from which she never fully recovered. By the time she was 38 years old, she was homebound and routinely bedridden and remained that way the rest of her life. However, fiercely determined and dedicated as ever to improving health care and alleviating patients’ suffering, Florence continued her work from her bed. Residing in Mayfair, she remained an authority and advocate of health care reform, interviewing politicians and welcoming distinguished visitors from her bed. In 1859, she published Notes on Hospitals, which focused on how to properly run civilian hospitals.

Throughout the U.S. Civil War, she was frequently consulted about how to best manage field hospitals. Nightingale also served as an authority on public sanitation issues in India for both the military and civilians, although she had never been to India herself.

In 1907, she was conferred the Order of Merit by King Edward, and received the Freedom of the City of London the following year, becoming the first woman to receive the honor. In May 1910, she received a celebratory message from King George on her 90th birthday.

Florence Nightingale was a prolific writer. In addition to the reports she generated, which were filled with explicit detail, she wrote extensively about a variety of topics. Much of her philosophy about religion, politics, family, society, nursing, and hygiene in both England and India is documented in the thousands of letters she wrote. These letters have been reviewed, categorized, and along with other works by Florence, assembled into several volumes under the direction of Lynn McDonald, a professor of sociology in Canada. The 16 volume Collected Works of Florence Nightingale was the outcome of having reviewed more than 200 Nightingale archives. McDonald’s work, which took more than a decade to complete, is most certainly a tribute of the highest order to Florence Nightingale. Much of the rancor found in some of the previously written biographies is disputed and debunked in McDonald’s work.

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Death and Legacy

 

In August 1910, Florence fell ill but seemed to recover and was reportedly in good spirits. However, a week later, on August 12, 1910, she developed an array of troubling symptoms. She died around 2 p.m. the following day, Saturday, August 13, at her home in London.

Characteristically, she had expressed the desire that her funeral be a quiet and modest affair, despite the public's desire to honor Nightingale who tirelessly devoted her life to preventing disease and ensuring safe and compassionate treatment for the poor and the suffering. Respecting her last wishes, her relatives turned down a national funeral. The "Lady with the Lamp" was laid to rest in her family's plot at St. Margaret's Church, East Wellow, in Hampshire, England.

Although Florence Nightingale died on August 13th, 1910, at the age of 90, her legacy continues. Two years after her death, the International Committee of the Red Cross created the Florence Nightingale Medal, which is given to excellent nurses every two years.

In May of 2010, the Florence Nightingale Museum at St. Thomas’ Hospital in London reopened to honor the hundredth anniversary of Nightingale’s death. The museum is divided into three areas – first, Florence’s early life and her struggle to become a nurse, second, her role in the Crimean War, and finally, her legacy to medicine, her influence on nursing today, and the continuing significance of her work.

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The Florence Nightingale Pledge

 

I solemnly pledge myself before God, and in the presence of this assembly, to pass my life in purity, and to practice my profession faithfully. I will abstain from whatever is deleterious and mischievous and will not take, or knowingly administer, any harmful drug. I will do all, in my power to maintain, and elevate the standard of my profession, and will hold in confidence, all personal matters, committed to my keeping and all family affairs, coming to my knowledge, in the practice of my calling, with loyalty, I will endeavor, to aid the physician in his work, and devote myself to the welfare of, those committed to my care.

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