An Interview with Ann F. Varela and Manuel F. Varela: Florence Nightingale—More than just nursing.

Dec 20, 2021 by

Florence Nightingale

To be ‘in charge’ is certainly not only to carry out the proper measures yourself but to see that everyone else does so too.”

—Florence Nightingale

Let us never consider ourselves finished nurses…we must be learning all of our lives.”

—Florence Nightingale

How little can be done under the spirit of fear.”

—Florence Nightingale

1) Florence Nightingale’s name is almost synonymous with nursing, but she made many contributions that have been neglected during her career. Let us start at the beginning—when and where was she born?

Popularly known as the “Lady with the Lamp,” Florence Nightingale was crucial in nursing care education and sanitary reform in healthcare facilities worldwide.

At the Villa Colombia in Florence, Italy, Florence Nightingale was born on May 12, 1820; the city of her birth was the inspiration for her name. The name of one of the sirens in Greek mythology was the inspiration for her older sister’s name, Parthenope. Her parents, Frances (Fanny) Smith Nightingale and William Edward (Shore) Nightingale, were raised in well-off British families. Nightingale’s father became a wealthy landowner after he had the good fortune of inheriting two estates. It was then that he altered his surname from Shore to Nightingale. Her mother took pleasure in social circles and desired the same for her youngest daughter. Still, Nightingale’s aspirations were quite different from her mother’s, as she wanted a future that allowed her to fulfill what she believed to be her divine purpose. She wished to attain self-sufficiency, prominence in some field of activity, and obedience to God through service to humanity.

For their early years, the Nightingale girls had a governess providing their primary education. Their Cambridge-educated father provided Parthenope and Florence with excellent instruction in the romance languages such as German, French, and Italian, along with a classical education emphasizing history, philosophy, and literature. Nightingale appealed to her father to learn mathematics, but a deeper exploration of mathematics was not considered proper for young women at that time in history. By the time she was seventeen and yearning to be trained as a nurse at the Lutheran Hospital of Pastor Fliedner in Kaiserwerth, Germany, the Victorian Era was merely beginning. Nightingale was about the same age as Queen Victoria. Young women were expected to marry well, live a leisurely life, and experience plentiful social opportunities, not labor-intensive ones.

While touring Europe with family friends, Nightingale had an opportunity to study the different hospital systems. In 1850, Nightingale started her training in Alexandria, Egypt as a nurse at the Institute of St. Vincent de Paul, a hospital run by the Roman Catholic Church. Nightingale’s wishes came true in 1952 when she returned to London, where she nursed ailing governesses in a Middlesex hospital. Within a year, she became superintendent of the Institution for Sick Gentlewomen (governesses) in Distressed Circumstances, an unpaid position.

Nightingale was now a self-reliant woman in 1854, asserting herself and organizing other nurses for service in the Crimean War. After gaining the respect of the military doctors, Nightingale and her team of nurses used a large endowment of private money to obtained desperately needed supplies. Soon after, the military field hospital conditions were drastically improved concerning sanitation. A governmental sanitary commission also made improvements, and the death rate declined by about sixty-six percent.

2) Florence Nightingale kept data and numbers—she analyzed data and kept pictorial representations—Venn Diagrams, polar area diagrams, and charts and graphs. What kinds of data did she record and analyze?

In 1854, Nightingale received a request from the Secretary of War, Sidney Herbert, who badly needed nurses to treat the wounded British soldiers serving in the Crimean War. Nightingale collected and analyzed data on death. Her statistical analysis would change the course of history.

In 1856, Nightingale served as the head nurse during the Crimean War, a military conflict between the Russian Empire and an alliance between several nations, including England, France, and the Ottoman Empire. Afterward, Nightingale wrote about her nursing experiences tending to the war wounded. At the beginning of wartime service, she was shocked regarding the conditions of the wounded British and Turkish soldiers. They suffered from filth, disease, and squalor when she and her nurses arrived at the front. In her wildly popular 1859 book called Notes on Nursing: What it is and What it is Not, Nightingale provided practical advice on improving sanitation practices.

In order to make critical parts of the book readable to those who may have been poor or impatient readers, she elected to use visual aids in the form of diagrams to bring her points across more readily. One of her most famous graphics was the polar area diagram, which later became known as the “Nightingale Roses” or the so-called coxcombs, probably because of the diagrams’ flower-like appearances. See Figure 1. The use of the term coxcombs as originating from Nightingale to describe her graphics has been disputed. Indeed, in her writings, she would call them simply diagrams, and she used them in an attempt to persuade policymakers.

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Figure 1. “Coxcomb” pie chart by Florence Nightingale on the causes of mortality in the British Army.

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In this diagram, fashioned by Nightingale after the Crimean War, the numbers of wounded British army soldiers who died were plotted as a function of time, in this case, every month. The polar area diagram can be envisioned as a sort of like a bar graph that’s been bent into a circular pie chart but with the data reflected in the sizes of the monthly segments called sectors. In Figure 1, in the sectors depicted, their sizes represent the numbers of deaths recorded over two full years, between April of 1854 to March of 1856. On the right-hand side, death numbers in the wounded population were recorded between April 1854 to March 1855, slightly more than a year. The diagrams indicate that in July 1854, the British army troops arriving in the Crimea suffered an outbreak of cholera in Bulgaria, an epidemic lasting well into March of 1855 and reaching a peak of 1,174 individual cholera deaths per 1,000 troops in January 1855. Their mortality rates averaged 160 per 1,000 for each of the two years that the data were chronicled.

For comparative purposes, the corresponding death data documented in the city of Manchester, England, in the center of the diagram on the right, are shown. These latter data amounted to about 12.4 deaths per 1,000 Manchester citizens for each year. In Figure 1 on the left, mortality data are shown beginning in April 1855, when Nightingale implemented a series of sanitary reform measures. After the intervention, it can be seen from the data on the left-hand side of the diagrams that the death rates substantially decreased, reaching the same sort of levels that Manchester, England, had experienced. Nightingale’s rose diagram was interpreted to mean that improvements in sanitary practices could dramatically improve survival rates in war wounded. The data would be pioneering because it demonstrated the effectiveness of good nursing practices in the clinical wards, establishing an enduring policy enjoyed in modern times.

3) In a sense, Florence Nightingale was the mother of “evidence-based nursing” as she seemed to see the relationships between hospital conditions and recovery. What did she find?

During the Crimean War, Nightingale’s approach to nursing, her evidence-based methodology, was unprecedented. Using data to guide healthcare practices, her novel method for nursing would revolutionize nursing and usher in an era characterized by drastically reduced death rates in soldiers wounded during a battle. She was the first in medical and military history to directly connect the states of sanitary conditions of a military hospital and the survival rates from infection.

Nightingale and her nursing staff were stationed near a Turkish military hospital for British soldiers in Scutari, see Figure 2, near modern Istanbul. At Scutari, Nightingale would conduct one of history’s most dramatic pioneering studies demonstrating that improving sanitation practices saved the lives of the hospital’s wounded. In November of 1854, Nightingale and her 38 nurses first arrived at the Scutari Army Barracks, also called Selimiye Barracks, a six-mile-long complex of corridors. They were horrified by the filthy state of the facility. Nightingale would later write an account detailing how the Scutari Barracks lacked basic laundry, surgery, or food preparation facilities. What is more, the hospital at Scutari had been understaffed, lacking enough doctors but having no nursing services at all. Perhaps even more shockingly, the entire facility had been steeped in piles of bureaucratic paperwork, ensuring that any badly needed supplies, like food, clothing, bedding, and even medicines, would never be adequately dispersed to the wounded to do any good.

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Figure 2. Nightingale at a medical ward in Scutari Hospital.

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With proper sanitation virtually nonexistent at Scutari, an outbreak of cholera and typhus emerged. The outcome of this constellation of failures in proper care for the war wounded at Scutari was that more deaths in the military personnel occurred due to infection than from immediate war wounds, a statistic that Nightingale herself made known, using her famous rose diagrams. According to the statistics compiled by Nightingale, wounded military personnel died at a rate of approximately six times more from infection than from battle wounds. The death numbers were staggering. According to Nightingale and her polar diagrams, of the total deaths, 3,168, only 83 were deaths due to battle wounds, while a staggering 2,761 deaths were due to preventable causes.

4) Improper sanitation seemed to be one area of concern for her. What were her findings and conclusions?

Nightingale carefully documented the appallingly filthy conditions at Scutari. The war-wounded patients lacked basic sanitation in the hospital, and their immediate living surroundings in the army barracks were not hygienic. She also carefully recorded the same sort of death data after new measures were invoked. Nightingale implemented a series of sanitary measures at Scutari before the end of the Crimean War. These practices included measures like cleanliness, antiseptic techniques, and personal hygiene. Nightingale used rudimentary scrub brushes for cleaning the hospital wards where the patients were housed at Scutari. The patients’ clothes were washed regularly. The dressings that covered the wounds were changed periodically. Proper cooking measures were implemented to provide the wounded with safe food.

With the improved practices in place at Scutari, the changes in the death results were dramatic. Before the sanitary reform, about 43% of the deaths among the wounded at Scutari were from infection. After implementing reform measures in sanitation at Scutari, only 2% of the deaths were from infection. She had demonstrated that, on the one hand, poor food and unsanitary conditions led to unnecessary deaths amongst the British soldiers in the Crimean War. Strikingly, Nightingale also concluded that implementing proper sanitation and cleanliness could dramatically reduce the number of deaths from infection of war-wounded military personnel.

5) “Bedsores” was another area of concern—and their impact on patient recovery—What were her contributions, and what did she find?

It seemed that the issue of bedsores was a point of contention for Nightingale on more than one front. An encounter occurred on the home front. In a letter dated March 25, 1853, written to her father, Nightingale updated him about Mary Shore, her grandmother, who was on her deathbed in her home in Tapton, England. For almost two weeks, Nightingale cared for her dying grandmother, writing how she treated Mary’s bedsores with a solution of silver nitrate and reporting to her father that his mother was “comfortable for death.”

She addressed the bedsore problem on the war front in the wounded at Scutari. In her Notes on Nursing, Nightingale maintained that even standard sanitary nursing practices were insufficient for nursing patients back to health. She invoked the example of the bedsores, writing that the handicraft of nursing meant more than simply sanitation. Nightingale had noted that even a patient housed in a hospital ward akin to a “sanitary palace” could still be left bleed to death or die from their bedsores.

Indeed, when Nightingale and her nurses first arrived to care for wounded patients in the military hospitals during the Crimean War, she noted the patients’ bedsores. Many of these military patients at Scutari were covered with bleeding, suppurating bedsores! Nightingale took note of these sores. They were open, with their skin having been rubbed off due to neglect. The bedridden patients were not moved frequently enough to prevent the sores.

Instead of learning nursing from a book, the bedsores incidence was used to study the nursing handicraft firsthand in the wards. Furthermore, Nightingale implored her readers to consider proper nursing care, with appropriate sanitary methods, beyond the military patients. She held that appropriate nursing must also be conducted in the non-military populations, civilians living in the cities, and, for example, in pediatric patients.

Thus, Nightingale implored that readers consider the plight of the hospital patient, all of whom could succumb to the detrimental effects of bedsores, a sign of neglect. Logically, Nightingale made the case that, whether young or elderly, military or civilian, the hospitalized patient must be provided with clean living conditions, clean bedding, a clean body, an environment free from startling noises, with healthy food, appropriate lighting—not too much or too little—proper bed covering, and fresh air and warmth. The comfortable well-cared-for patient must be free of bedsores!

6) At the end of her life, she was diagnosed with brucellosis (or so it seemed). What exactly is this, and might the diagnosis be different today?

In the late 1850s, Nightingale had succumbed to the so-called Crimean Fever, an illness that frequently confined her to bed for extended periods; a condition that lasted well into the 1880s, leading to chronic depression. Various causes for Nightingale’s illness have been postulated. At first, it was suggested that she had neurasthenia, a nerve disorder no longer considered in recent times. It was also postulated that Nightingale suffered from stress-induced anxiety neurosis, lead poisoning, lupus, post-traumatic stress disorder, and chronic fatigue syndrome. During the Crimean War, several forms of fever were recognized, including relapsing fever, typhus, and typhoid fever.

However, one of the leading explanations is that Nightingale had an infectious disease called brucellosis, caused by a microbe, a bacterium known as Brucella melitensis. See Figure 3. The idea that Nightingale suffered from brucellosis has its origins with D.A.B. Young, who in 1995 proposed the notion, which Barbara M. Dossey strongly supported in 1998. The bacterium can be transmitted to human patients by consuming unpasteurized dairy products from animals or by contact with animal urine, blood, or exposure to animal placentas in the workplace, like an animal slaughterhouse, a veterinary clinic, or an animal farm feedlot. Thus, brucellosis infection is known as a zoonosis type of disease. Brucellosis has been known by different names, such as Bang’s disease, named after a microbiologist named Bernhard Bang, who had conducted pioneering investigative studies of the illness. Brucellosis has also been called the fever of Crete, the Malta fever, the rock fever of Gibraltar, and the Mediterranean fever. In modern times, the Mediterranean fever is the leading designation of the original Crimean fever term. These names for brucellosis originated from specific regional locations that experienced outbreaks. The illness has sometimes been referred to as the undulant fever to denote the wave-like shape of a graph showing the fever temperatures of patients as a function of time.

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Figure 3. Ryu staining of Brucella melitensis (A) and Caulobacter crescentus (B) for comparison were visualized by phase-contrast microscopy. The bacteria were treated by the Ryu staining method. A flagellated bacterium is enlarged in dotted squares. (C) Negative-staining EM images of the sheathed polar flagellum of B. melitensis stained with uranyl acetate 2% and labeled with anti-LPS antibody conjugated to ± 15 nm gold particles. Bar, 500 nm.

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Once a human being acquires the causative agent from exposure to affected animal products, the microbe enters the patient through tiny breakage points in the human airway and digestive tracts membranes. The Brucella melitensis bacterium avoids destruction by surviving in macrophages, traveling inside these human cells to other organs and tissues of the patient’s body. The Brucella melitensis microbe can affect many of the body’s areas. These human locations include lymph nodes, the liver, heart, and bone marrow. Inflammation against the invading microbe can occur in various tissues throughout the body, causing arthritis, meningitis, endocarditis, and encephalitis.

Nightingale’s bout of brucellosis is believed to have lasted well over 30 years. Indeed, had she been diagnosed with the illness in modern times, there is no doubt that antimicrobial agents such as rifampin, streptomycin, or doxycycline antibiotics would have alleviated the illness after a few weeks of treatment. Brucellosis in the U.S. is much reduced because dairy farm animals are vaccinated, dairy products are routinely pasteurized, infected slaughterhouse animals are destroyed, and infected animal herds are quarantined. On a worldwide basis, unfortunately, about a half-million cases occur annually.

7) Nightingale worked in Turkey and led efforts to improve nursing in India and Australia to enhance patient care. Nevertheless, she, like many other female scientists, never has received the recognition she deserved. Any thoughts on this?

As was described above, Nightingale, assigned near Turkey at Scutari, initiated world-changing efforts to collect data, analyze it, and make a case for changes in nursing care of the wounded and other hospitalized patients. These efforts in caring for the military wounded and the afflicted civilian populations would alter military and medical history courses. With new sanitary reform measures now in place, beginning with the Crimean War, all future wars would consequently be fought with greater efficiency as wounded troops could be saved and sent back to their fronts to continue fighting. In the general populace, infection in the healthcare settings, and thus death rates of civilians, would decrease because of sanitary reform pioneered by Nightingale.

With her new data-based method of reform established, Nightingale, suffering from her debilitating illness, worked from home and turned her attention to the plight of the British Army and the citizens of India. See Figure 4. In 1863, Nightingale published an extensive 2,000-page report titled Suggestions on a System of Nursing for Hospitals in India and later a widely disseminated pamphlet called Observations. She also published a paper titled “How People May Live and Not Die in India,” presented at a scientific conference held in Edinburgh in 1863.

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Figure 4. Florence Nightingale working from her home.

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In her written descriptions, Nightingale considered the death numbers in the late 1850s of the British Army personnel in India addressing their Sepoy rebellion from England. In India, the British forces, whose military data had been recorded, indicated a frighteningly tremendous mortality rate from cholera. True to form, Nightingale wrote of the primary cause of the cholera deaths in India: lack of proper sanitation. She noted that the British army had placed its latrines (toilets) and garbage dumps in poorly chosen locations, and these conditions were ripe for cholera contamination of the army’s drinking water. Further, Nightingale continued, the army barracks were overcrowded, if not filthy. The barracks were rife with gambling and alcoholism. The hospitals were contaminated with contagion, and the bedding was infested with insects. The summer heat did not help matters, either, permitting optimal growth conditions for the cholera-causing bacterium, Vibrio cholerae, to run through the crowded human populations in India. See Figure 5.

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Figure 5. Vibrio cholerae bacteria. The bacteria were visualized with the Gram stain method under light microscopy.

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In her writings, Nightingale also considered the 200 million citizens of India, especially the children, many of whom were dying from cholera. In her Notes, Nightingale wrote of the children in India dying after being fed watered-down dung milk, useless as nutrition but likely useful for cholera transmission. The mothers of the children died as well, leaving behind siblings who were now orphans in a developing country. Nightingale then pointed out that one need not go as far away as India to understand the gravity of the problem. Similar sorts of conditions existed in Lancashire, England, as well, in 1875. For example, she pointed out that the children who worked in the city factories and were fed coffee or tea failed to develop adequately, while those factory children who were fed natural milk thrived.

Nightingale drew up carefully laid out plans for a public health service program to institute practical measures to reverse these death trends in her various accounts. India must have clean and safe drinking water, she wrote. Adequate sewage treatment facilities were badly needed. Proper medical care and clean hospitals were required. Healthy food was needed with better farming and irrigation practices. Sadly, Nightingale’s pleas for sanitary reform were met with deaf ears, if not hostility, for the entirety of her life. The British authorities were embarrassed by the scandals and tried to limit who read Nightingale’s written word. Those government officials, whether Indian or British, who were sympathetic to Nightingale’s suggestions, themselves encountered vigorous political and religious pushback, if not complacency or resignation. In her lifetime, she would not see true reform on these home or military fronts. As Nightingale saw it, true reform would not arrive until years after the world’s most famous nurse’s death on August 13, 1910.

8) What have I neglected to ask?

The appellation of the “Lady with the Lamp” stems from Nightingale’s frequent nighttime visits to the beds of hospitalized patients, an angel in the night bringing mercy to the afflicted and suffering. See Figure 6. Nightingale would be extensively written about after her death, with tributes in the form of books, articles, films, documentaries, theatre, monuments, and museums. Various navy ships, military aircraft, religious holidays, healthcare facilities, and an asteroid (“Florence 3122”) have been named after Nightingale. Nightingale’s portrait would be featured on British currency bills and other banknotes. Much of Nightingale’s written works would be published posthumously and studied by generations of scholars.

Figure 6. Lithograph of an 1891 painting by Henrietta Rae of Nightingale as the Lady with the Lamp providing comfort to the suffering.

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At Scutari, Nightingale would meet briefly with another famous nurse, Mary Seacole, and the two would have, as written by both nurses, a friendly meeting. Others, however, would make a partisan issue out of the encounter, with players on their respective schools of thought weighing in with their agendas in a seemingly biased fashion. Unfortunately, therefore, unbiased historians may never sort out the true nature of their relationship.

Another encounter between Nightingale and a British medical officer has been elaborated upon in many written works. In this particular case, much has been written on the account and supported by extensive data. Dr. John Hall, who would later be Sir Hall, and Nightingale reportedly clashed regularly. Hall was the highest-ranking medical officer in charge at Scutari. It is reported that before Nightingale’s arrival to the camp, Hall had already inspected its various hospitals and proclaimed them has having passed the inspections. Hall and Nightingale, and their respective followers, fought over many issues. They disputed over who had the authority and where it was to be exercised. They argued about food safety, access to supplies, and protocols for medical care. Hall’s physicians were clearly on his side and treated Nightingale and her nurses with contempt. The relationship between Hall and Nightingale has been described as “endless bickering and backstabbing.” Hall had successfully driven a wedge between Nightingale and Mother Bridgeman, a Catholic nun whom Hall had befriended. The Hall- Nightingale rift would last for the duration of the Crimean War, if not their lifetimes.

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