Saturday, December 3, 2011

Florence Nightingale

Florence Nightingale

Caring Actualized:
A Legacy for Nursing

❖ Introducing the Theorist
❖ Early Life and Education: The Seeds of Caring Planted
❖ Spirituality: The Roots of Nightingale’s Caring
❖ War: Caring Actualized
❖ The Medical Milieu
❖ The Feminist Context of Nightingale’s Caring
❖ Ideas about Nursing: Expressions of Caring
❖ Nightingale’s Assumptions
❖ Summary
❖ References
❖ Bibliography


     Florence Nightingale transformed a “calling from God”and an intense spirituality into a new social role
for women: that of nurse. Her caring was a public one, expressed in and committed to people improving
the quality of their lives. “Work your true work,” she wrote, “and you will find God within you.”A reflection
on this statement is to be found in a wellknownquote from Notes on Nursing (1859/1992),
“Nature [i.e., the manifestation of God] alone cures . . . what nursing has to do . . . is put the patient in
the best condition for nature to act upon him” (Macrae, 1995, p. 10). Although Nightingale never
defined human care or caring in Notes on Nursing, there can be no doubt that her life in nursing exemplified
and personified an ethos of caring. Jean Watson (1992, p. 83), in the 1992 commemorative edition
of Notes on Nursing, observed, “Although Nightingale’s feminine-based caring-healing model
has transcended time and is prophetic for this century’s health reform, the model is yet to truly come
of age in nursing or the health care system.” This chapter reiterates Nightingale’s life from the
years 1820 to 1860, delineating the formative influences on her ideas about nursing. A biographical approach
was used to examine her education, travel, and spiritual background, her Crimean experiences,
the medical milieu, and her views on women, all providing historical context for her ideas about nursing
as we recall them today. Part of what follows is a well-known tale, yet it remains a tale that is irresistible,
casting an age-old spell on the reader, like the flickering shadow of Nightingale and her famous
lamp in the dark and dreary halls of the Barrack Hospital, Scutari, on the outskirts of Constantinople,
circa 1854–1856. And it is a tale that still carries much relevance for our nursing practice today.


        A profession, a trade, a necessary occupation, something to fill and employ all my faculties, I have
always felt essential to me, I have always longed for, consciously or not. . . .The first thought I can remember,
and the last, was nursing work. . . .
—Florence Nightingale, cited in Cook
(1913, p. 106)
   Nightingale, the second and youngest daughter born to Fanny Smith, age 32, and William Edward Nightingale, age 25, came into this world on May 12, 1820.
She was born in Florence, Italy, the city she was named for, in Villa Colombia, and christened in its
drawing room. The Nightingales were on an extended European tour, begun in 1818 shortly after
their marriage. This was a common journey for those of their class and wealth. Their first daughter,
Parthenope, had been born in the city of that name in the previous year.
    W. E. N., as Nightingale’s father was referred to affectionately, was by nature retiring and studious. He
had fallen for his opposite in the vivacious Fanny Smith, who was ambitious and socially minded with
great aspirations for both daughters. Fanny was from a distinguished, wealthy, liberal family, Unitarian in
religious outlook. Fanny’s father, William Smith, was a well-known politician of the age, who sat for 46
years as a member of Parliament, in the House of Commons. Sir Thomas Cook (1913), Nightingale’s
first and official biographer, describes William Smith as follows: “A stout defender of liberty of thought and
conscience, a persistent opponent of religious tests and disabilities,” and in religion, a Unitarian (Cook,
Vol. I, 1913, p. 5). He is also described as “a leading Abolitionist; he championed the seated factory workers;
he did battle for the rights of Dissenters and Jews” (Woodham-Smith, 1983, p. 2). These themes
were to resonate throughout Nightingale’s life.
       Smith’s daughter, Fanny, however, was of a more outgoing
nature. She chose to attend the Anglican Church, rather than the Unitarian, primarily for social
reasons, and when recalling her upbringing as one of 10 siblings, she noted, “We Smiths never
thought of anything all day but our own ease and pleasure.”
Nightingale’s father was also a professed Unitarian.
Both parents were part of the class known as the “landed gentry,” rich though not titled. Her family on
both sides was enormously wealthy, educated, well traveled, and part of an elite inner circle of influential
people of the day.
       The Nightingales owned several homes—a country home called Lea Hurst in Derbyshire; a town
house in London; and Embley Park, a large and lavish home located in Hampshire, outside of London. It
was Fanny’s opinion that Lea Hurst was too small.
“Why, it only has 15 bedrooms!”she was heard to observe. W. E. N., an amateur architect, took an active
hand in the design of his houses (Cook, 1913; Huxley,
       A legacy of humanism, liberal thinking, and love of speculative thought was bequeathed to Nightingale
by her father. His views on the education ofwomen were far ahead of his time. W. E. N. undertook
the education of both his daughters. Florenceand her sister studied music; grammar; composition;
modern languages; Ancient Greek and Latin; constitutionalhistory; and Roman, Italian, German, and
Turkish history; as well as mathematics (Barritt,1973). Cook describes the following:
Among Florence’s papers were preserved many sheets in her father’s handwriting, containing
the heads of admirable outlines of the political history of England and some foreign
states. Her own note-books show that in her teens she had mastered the elements of Greek
and Latin. She analyzed the Tusculan Disputations.Phaedo,
the Crito and the Apology. She had studiedGreek, Roman, and Turkish history. She had
analyzed Dugald Stewart’s Philosophy of the Human Mind. Her father was in the habit,
too, of suggesting themes on which his daughters were to write compositions. It was the
system of the College Essay. “Florence has now taken mathematics,” wrote her sister in 1840,
“and, like everything else she undertakes, she is deep in them and working very hard.”(Cook,
Vol. I, 1913, p. 13)
        From an early age, Florence exhibited independence of thought and action. The sketch (Figure 4–1)
of W. E. N. and his daughters was done by one ofFanny’s sisters, a beloved aunt, Julia Smith. It is
Parthenope, the older sister, who clutches her father’s hand and Florence who, as described by her
aunt, “independently stumps along by herself”(Woodham-Smith, 1983, p. 7).
Travel also played a part in Nightingale’s education.
         Eighteen years after Florence’s birth, the Nightingales and both daughters made an extended
tour of the Continent, covering France, Italy, and Switzerland between the years of 1837 and 1838. In
1847, Nightingale went to Italy and France with close friends, the Bracebridges, where they were to
witness the revolutions of 1848. In 1849, again with the Bracebridges, Nightingale traveled to Egypt and
then on to Athens in 1850 (Sattin, 1987). From there,Nightingale visited Germany, making her first acquaintance with Kaiserswerth, a Protestant religious community that contained the Institution for the
Training of Deaconesses, with a hospital school, penitentiary, and orphanage. A Protestant pastor,
Theodore Fleidner, and his young wife had established this community in 1836, in part to provide
training for women deaconesses (Protestant “nuns”) who wished to nurse. Nightingale was to return
there in 1851 against much family opposition to stay from July through October, participating in a period
of “nurses training” (Cook, Vol. I, 1913; Woodham-Smith, 1983).
     Life at Kaiserswerth was spartan. The trainees were up at 5 A.M., ate bread and gruel, and then
worked on the hospital wards until 12 noon. Then they had a 10-minute break for broth with vegetables.
Three P.M. saw another 10-minute break for tea and bread. They worked until 7 P.M., had some broth,
and then Bible lessons until bed. What the Kaiserswerth training lacked in expertise it made up in a
spirit of reverence and dedication. Florence wrote, nursing” (Wiedenbach,
1970 [emphasis added]). She further stated: “To formulate one’s central purpose in nursing is a
soul-searching experience. Has each of you, I wonder, undergone it, and are you willing and ready
to present your central purpose in nursing for examination and discussion when appropriate?” (Wiedenbach,
1970, p. 5). In her elaboration of the second component, “prescription,”
Wiedenbach explained that it “specifies both the nature of the action that will most likely
lead to fulfillment of the nurse’s central purpose in nursing, and the thinking process that determines it.”
She categories nursing as a practice that is disciplineand goal-directed: “[P]resumably, the nurse has
thought through the kind of results she wants to obtain from what she does, gears her action to obtaining
them and accepts accountability not only for what she does but for the outcome of her acts as
well. Nursing action, thus, is a deliberate action” (Wiedenbach, 1970, p. 5).
It is in the explanation of “deliberate action” that Wiedenbach illustrates the linkage of these components
with the concepts of her philosophy. 

She delineates three kinds of deliberate action:
1. Mutually understood and agreed upon
2. Patient-directed
3. Nurse-directed

        Each of these three may have a very different effect on the patient—a fact that the nurse needs to
recognize before she acts. “. . . The kind of action she will resort to, depends, I think, on her clarity about
her central purpose in nursing, and consequently on the way she may view the patient at any particular
moment that she is caring for him” (Wiedenbach,1970, p. 6).
Wiedenbach then presented an example of a nurse’s bed-bath assignment to illustrate her point.

Note the incorporation of her philosophical concepts:

     Her action may be considered to be mutuallyunderstood and agreed-upon, if it reflects that
she respects the patient’s dignity, worth, autonomy and individuality, and she makes sure
that [the patient] is psychologically receptive to her giving him the bath before she starts the
procedure. This kind of action suggests that the nurse’s central purpose in nursing is to facilitate
the patient’s effort to respond capably to the bed-bath what she desires to give him.
The effect of this kind of action on the patient will, in all probability, be positive. He presumably
understands that she is about to do or is doing and is in accord with her efforts and action.
(Wiedenbach, 1970, p. 6) Using the same example, she explains “patientdirected”
as assisting according to the patient’s needs and directions:
This kind of action implies that the nurse’s central purpose in nursing is to be accessible
to the patient to give whatever help he indicates he wants in relation to his bed-bath. Thus
she supports what she assumes to be his desire for independence. (Wiedenbach, 1970, p. 6)

       She explains “nurse-directed” action in the bed-bath example as follows:
[T]he nurse respects the patient’s dignity and worth, but not particularly his individuality
and autonomy. She gives him the bath without consulting him about it, and thus implies that
she, the nurse, knows best what the patient needs. For this kind of action, the nurse’s central
purpose would seem to be to do for the patient (or with him) what she thinks he needs
to have done for or with him. Prescription thus represents a directive to the nurse for effecting the kind of results she desires.
        It is inextricably tied to her central purpose in nursing. Consequently, once she has
formulated her central purpose and has accepted it as her commitment she not only has
established the prescription for her nursing, but is ready to implement it within the realities
of the clinical situation. (Wiedenbach, 1970, p. 7) Wiedenbach professed that there are “realities” in
nursing practice that are “physical, physiological, emotional and spiritual that are at play in a situation
in which nursing action occurs at any given moment”(Wiedenbach, 1970, p. 7). She describes these
as follows:
    The Agent, who is the nurse or her delegate, and who supplies the propelling force for any nursing
action that may be taken. The Recipient, the patient, who receives the agent’s
action or in whose behalf the action is taken The Framework, which comprises all the extraneous
factors and facilities in the situation that affect the nurse’s ability to obtain the kind of results
she wants to obtain, through her nursing.

    The Goal, which represents the end to be attained through the activity which the nurse plans or undertakes
in behalf of the patient. And— The Means, which comprise the activities and devices
through which the nurse is enabled to attainher goal. (Wiedenbach, 1970 p. 7)
Wiedenbach expressed in her presentation the need to elaborate on features of the realities because of
their strong influence on effective nursing practice. She described the nurse as the agent who supplies
the “propelling force for the overt actions that determine the effectiveness of her practice”(Wiedenbach,
1970, p. 8). She emphasized the responsibilityof the nurse, . . . not only for clarifying her central purpose
in nursing and her prescription for fulfilling it, but also for recognizing the responsibilities
that are hers by virtue of her resolve to fulfill her central purpose and implement her prescription.
(Wiedenbach, 1970, p. 8)

Four responsibilities of the agent (nurse) that she considered to be outstanding are:

1. To reconcile her assumptions about the realities in the clinical situation with her central purpose
in nursing. (This presumes not only that she has clarified her central purpose in nursing for herself,
but that she respects the need to validate her assumptions before acting on them!)
2. To specify the objectives of her practice in terms of behavioral outcomes that are realistically attainable.
3. To practice nursing in accordance with her objectives.
4. To engage in related activities which contribute to her self-realization as to the improvement of
nursing practice (p. 8).

The patient is viewed as the recipient of the nurse’s ministrations in a vulnerable position. She explains
that this is so because the patient subjects himself to another’s care. There is a risk of losing
one’s individuality, dignity, worth, and autonomy. However, according to Wiedenbach, the patient has
. . . one unassailable resource that he can use as a secret weapon! It is his sensitivity—his
feelings. [By the use of it] he can defeat or frustrate those responsible for his care, by thwarting
their efforts to obtain the results they desire from their efforts and ministrations.
(Wiedenbach, 1970, p. 9)
        Wiedenbach used an enema procedure as an example of this. The success of the procedure was directly
related to the patient’s (recipient’s) cooperation in receiving and holding the enema fluid. Because
of a lack of sensitivity about the patient’s feelings of autonomy, the nurse’s efforts were thwarted.
“The patient’s feelings, thus, were a powerful mechanism in his defense”(Wiedenbach, 1970, p. 9).
The next reality defined is the framework: In nursing practice, the framework constitutes
a complex of factors which, though [intangible] as a whole, have, nevertheless, potential
for limiting or expanding the scope of the nurse’s ability to function as she would like to
function at any given time. It derives from a combination of extraneous elements and circumstances
which imagined or real are present or are introduced into every nursing situation.
By their existence, they share the course of events. In addition, they influence not only
the care with which the nurse is able to achieve desired results from her nursing, but
also the ease with which the patient is able to benefit from the nurse’s ministrations. (p. 10)
       The arrival of fresh linen or the unexpected absence of a nursing staff member are two of many examples
Wiedenbach cited as factors that could “shape the course of events” (Wiedenbach, 1970, p. 10).
She views the framework as . . . a conglomerate that may include objects,
existing or missing, policies, setting, atmosphere, time of day, humans and happenings
that may be current, past and recalled, or anticipated.
       Depending on its makeup, it may promote, complicate, facilitate, alter, impair
or impede the nurse’s ability to function effectively in her practice.
She pointed out that not only must the nurse recognize that a “framework” always exists to be reckoned
with, but also, the patient must be aware of it and “we must strive to enable our patient to cope
with it capably as well”(Wiedenbach, 1970, p. 11). The fourth aspect of the realities is the goal. She
describes “goal” as the end to be attained through whatever the nurse undertakes in her practice. She
states: “In the context of a prescriptive theory, goal is included in any statement of purpose.” She uses the
example of an individual’s “capability” as a specified goal in any given situation that the nurse might strive
toward. However, in the context of realities, the goal “specifies the particular result which the nurse desires
to achieve through the particular activity she plans or initiates” (p. 11). One example she gives is
that of relieving a patient of discomfort when carrying out a procedure. She believes that “stipulation of

an activity’s goal gives focus to the nurse’s action, impliesher reason for taking it and paves the way for its
effective realization” (p. 11). She emphasizes that one cannot reach a goal simply
by articulating it. She cites three necessary and distinct steps. These are:

1. Goal in intent specifies the attitude that the nurse believes the patient must manifest in order to be
able to benefit from her ministrations. It is an attitude, consequently that she needs to foster or engender
consciously, as part of her effort to attain her activity’s goal. Goal in intent derives mainly
from the nurse’s central purpose in nursing. If her purpose, for instance, is to have the patient
benefit from her ministrations, her goal in intent will most likely be inducement of a receptive attitude
toward them, on the patient’s part. If, on the other hand, her purpose is to have the patient
become independent of her ministrations, her goal in intent might be inducement of an assertive
attitude on her patient’s part. (Wiedenbach 1970, p. 12)

2. Goal in application specifies the kind of framework that the nurse believes is essential to
achievement of the goal she has set for the activity she plans to undertake. I think it could be
called a supportive framework [environment]— which means that the nurse has available to her,
appropriate equipment with which to carry out the activity; that the physical environment is adjusted
to the patient’s tolerance and the nurse’s ease in functioning; and that the human elements
consisting not only of professionals but also of nonprofessionals who may also include the patient’s
family, are accepting of the nurse’s plan to engage in a particular activity in the patient’s behalf.
(p. 12) She explains that goal in application is often taken for granted but “needs to be recognized and respected not only as an integral part of the nurse’s practice, but as one that is crucial to her obtaining
the kind of results she desires from what she does” (p. 12).

3. Goal in execution specifies the relationship that the nurse desires to maintain between the realities
and her activity while she is actually carrying out the activity. I would designate it as a symbiotic
relationship. (p. 13) Wiedenbach elaborates on goal in execution in reference
to the nurse’s characteristics: Attainment of the goal calls for vigilance, sensitivity, and wisdom on
the part of the nurse, all the while that she is engaging in the activity; vigilance for signs of resistance in
the patient toward the activity; and sensitivity to untoward changes in the framework or in herself that
could prevent attainment of the activity’s goal and wisdom in dealing objectively and kindly with what
she is aware of in the situation so that the patient’s ability to benefit from the activity may be supported,
restored, or enhanced (Wiedenbach, 1970, p. 13). Wiedenbach reiterated the importance of these
three goals in action to effective nursing. Although their significance may not always be recognized,
“when the nurse makes their attainment a conscious part of her nursing, she is taking a major step toward
obtaining desired results in her practice” (p. 13).

The last of the realities is described as the means.
These are:

      The expedients that the nurse uses to achieve the objectives of her practice. They include
the whole gamut of skills, knowledge, techniques, procedures and devices that the nurse
may use to identify her patient’s experienced need for help[,] [a]dminister the help he
needs, or validate that the help she gave was indeed helpful. (Wiedenbach, 1970, p. 13)
Although Wiedenbach (1970) views the means as . . . indispensable resources the nurse relies
on, their value for the patient depends largely on the way the nurse uses them. It is the
nurse’s way of giving a treatment, for example, that enables the patient to benefit from it,
not just the fact that he is given a treatment. And it is her way of expressing her concern,
not just the fact that she is present or speaksthat enables him to reveal his fears. The nurse’s
way of using the means available to her to achieve the results she desires, in her practice,
is an individual matter, determined to a large degree, by her central purpose in nursing and
the prescription she regards as appropriate to its fulfillment. (p. 13)
    Wiedenbach summarized her presentation to the audience at Duke University (1970) by stating that:
This then is my concept of a prescriptive theory of nursing. Its components are, first of all,
a central purpose that suggests the nurse’s reason for being—the mission she believes is hers
to accomplish. Second, a prescription that suggests the action she deems appropriate to
the accomplishment of her mission. And third, the realities, which, by their pervasiveness,
challenge the nurse’s ingenuity and creativity as she endeavors to fulfill her central purpose

in nursing through her practice. Like all theory, a prescriptive theory, too, is
a system of conceptualizations invented for some purpose. The relationship to practice is
close and inseparable. Its value manifests itself when each nurse probes the depths of her
value system and beliefs, makes them explicit, uses them as the basis of her theory of nursing
practice, and reflects them in everything she does. (p. 14)