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Volume 5, AUTUMN

FLORENCE NIGHTINGALE AND THE DEVELOPMENT OF PUBLIC HEALTH NURSING

MONICA E. BALY, PHD

My view you know is that the ultimate destination of all nursing is the nursing of the sick in their own homes. I look to the abolition of all hospitals and workhouse infirmaries. But it is no use to talk about the year 2,000
FLORENCE NIGHTINGALE

Florence Nightingale was a passionate sanitarian. She belonged to that group of mid-Victorian radicals who distrusted orthodox medicine and put their emphasis on cleanliness, hygiene, clean air, and water (1). Indeed, there was much to distrust at a time when much of medical practice was still in the grip of the Aristotelian theory of the imbalance of the humors. Authorities like Barry Smith (2) have criticized Florence Nightingale for clinging to the theory of miasma when the new thinking was pointing to the germ theory. However, Koch did not discover the tubercule bacillus until 1880; so in the 1850s, Miss Nightingale was in good company when she insisted that disease was spread by foul drains and contaminated water, which of course she associated with smell and "miasma." Like her friend Edwin Chadwick (the famous sanitarian, author of "The Sanitary Condition of the Labouring Population of Great Britain" [1842], and founder of the Royal Sanitary Institute), she advocated the right thing for the wrong reason. She and people like Chadwick resisted the germ theory because they feared that nurses and doctors, attributing all ills to "germs," would cease to care about cleanliness and hygiene. Dr. Bernays gave lectures on chemistry to the Nightingale nurses in the 1870s. Miss Nightingale thought he was leading them astray with talk of "germs." She said, "He should stop worrying about his germ theory and smell the foul air, [at St. Thomas's Hospital]" (3).

Dr. Henry Acland, Regius Professor of Medicine at Oxford, member of the General Medical Council, and a friend of the Nightingale family, was interested in the training of both nurses and midwives. Miss Nightingale wrote to him:

Experience teaches me that nursing and medicine must never be mixed up. It spoils both. ... If I were not afraid of being misunderstood I would say that the less knowledge of medicine that the hospital matron has the better [1] because it does not improve her sanitary practice; [2] because it would make her miserable and intolerable to the doctors. (4)

The Nightingale training intended to produce not assistants for doctors, but young women who would teach sanitary practice and instill ideas of hygiene and good living into patients, hospital workers, and doctors. Cleanliness was considered next to godliness, and the nurse was viewed as a moral agent. This message comes across strongly in Miss Nightingale's Notes on Hospitals. The nurse's duty, she wrote, was to ventilate and warm the ward, to ensure cleanliness, comfort, and hygiene; above all, she was to set a good example as she walked those airy, well-spaced, lofty Nightingale wards in the new hospitals built on Miss Nightingale's own pavilion system.

Notes on Nursing - which was written in 1859, before the Nightingale School was founded - is mainly about the practice of hygiene. On its first page, Miss Nightingale says,

I use the word nursing for want of a better. It has been limited to signify little more than the administration of medicine and the application of poultices. It ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper choosing and giving of diet - all at the least expense of the vital power to the patient. (5)

Since then many people have used the word "nursing" for want of a better, and many have suggested an extended role for the nurse; however, most patients would agree that these are the duties they want a nurse to perform. Time and again Notes hammers home the message that the nurse's duty is to prevent illness and suffering.

The causes of the enormous child mortality are perfectly well known, they are chiefly want of cleanliness, want of ventilation, careless dieting and clothing, want of white-washing. ... The remedies are just as well known; among them is certainly not the establishment of a Child's hospital. (6)

She goes on to say that the hospital may be wanted but its lack is not the cause of child sickness.

In Chapter Two, "Health of Houses," she sets out the five essential points in securing health in houses -namely, pure air, pure water, efficient drainage, cleanliness, and light. Miss Nightingale goes on to cite the disastrous consequences of contaminated water.

There is no way of putting a stop to this terrible loss of life except by putting an end to these privies and cesspits, and bringing in drainage and water closets, as has been done in many of the very worst districts in London. (7)

Florence Nightingale was writing at a time when the infant mortality rate was 156 per 1000, while the overall death rate was 35 per 1000. The main killers were tuberculosis, diarrhea, cholera, typhus, typhoid, diphtheria, scarlet fever, whooping cough, and measles (8); all these declined before specific measures were available for their treatment. These improvements in health are often attributed to advances in science. As Professor McKeown has pointed out, the inescapable conclusion is that the major influences on this shift were, in fact, improved hygiene and sanitation. Miss Nightingale was right. The introduction of the water closet was all-important. The one disease that declined after the application of a specific measure was smallpox. Miss Nightingale did not accept this, because vaccination seemed to upset the miasma/hygiene theory. In that, she was wrong - and continued to be wrong, as were many others.

In 1860, when Miss Nightingale started training nurses at St. Thomas's Hospital, she was uncertain about how it should be done and who would make the best nurses; indeed, she changed her mind many times. Training was based in a hospital despite Miss Nightingale's misgivings. When appealing for support for this program, Sir Joshua Jebb, Chairman of the Nightingale Fund Council, stressed that its object was

to afford the means of acquiring a thoroughly practical and scientific training to women desirous of becoming nurses. ... Hospital nurses were chosen because it was the object most prominently put forward by the subscribers [to the Nightingale Fund] and it is to hospital infirmaries that those patients resort who are in most need of assistance. (9)

Sir Joshua was wrong. Hospitals provided only 11,000 beds; most of the sick were cared for in their own homes, in Poor Law institutions, or in prisons and asylums. Miss Nightingale knew this, but she had to bow to the wishes of the Fund's subscribers and she could see no other way of training nurses except by basing them in a general hospital. However, several times she suggested that the Nightingale Fund might be better used to train nurses to care for the sick poor in their own homes.

In 1861 Miss Nightingale started corresponding with William Rathbone of Liverpool. Rathbone was a wealthy ship owner who had inherited a family tradition of philanthropy and liberalism. His family had been Quakers, but Rathbone was, like Miss Nightingale, a Unitarian. At this time he was honorary visitor to the District Provident Society in one of the poorest districts of Liverpool - a city that had been much affected by the upheavals of the industrial revolution and an influx of poor Irish labor. During her last illness, Mr. Rathbone's wife had been cared for by Mrs. Robinson, a London hospital nurse. Rathbone was so impressed by the relief this woman brought to the distressed house that he retained her to go into one of the poorest districts in Liverpool, to try "in nursing the poor to relieve suffering and teach them the rules of health and comfort" (10).

After a month Mrs. Robinson returned, saying that she could no longer bear the misery of what she saw. But Rathbone persuaded her to stay, and she did - for four years. Now Rathbone turned his attention to extending his experiment and sought to employ a trained nurse in each of Liverpool's 18 districts. However, in 1861, where could one find 18 trained nurses willing to do such work? He wrote to the famous Miss Nightingale for advice. She was interested and considered the request "as if she were going to be the superintendent herself." At St. Thomas's no nurses were available, but she suggested that Liverpool should train its own nurses for the hospital and for work in the homes of the poor. She also suggested that the Liverpool hospital committee should build a nurses' home (always Miss Nightingale's first prerequisite for training). Rathbone provided the money, and Sir Joshua Jebb, well-known for his design of model prisons, was invited to supervise the construction.

Rathbone found two ladies of impeccable gentility, the sisters Mary and Elizabeth Merryweather, and sent them to the Nightingale School as observers. It seems doubtful that they observed much, because Miss Nightingale later wondered "whether they knew anything about nursing." It is ironic that Nightingale also criticized their ideas of rigid discipline, since she had herself described to Rathbone the discipline to be enforced in the nurses' home - which might have been more appropriate for Sir Joshua's model prisons. The next year, Miss Nightingale sent several of the early Nightingale nurses to Liverpool. There is no evidence, however, that they made any mark. Most left for other work. Later, as she changed her mind about nurse training, Miss Nightingale became disillusioned with the Liverpool scheme.

Under the leadership of the Rathbone family, each of the Liverpool districts had a District Nursing Committee made up of philanthrophic ladies and gentlemen (including a number of clergymen). Each committee had a Lady Superintendent - who was not a nurse, but who controlled and supervised the nurses allocated to the district. The following extract from a letter shows the power of these ladies and their attitude to nurses.

Under the Superintendent there is a Lady Inspector who goes and enquires for herself into the general conduct and efficiency of the nurse. Some Lady Superintendents prefer all untrained nurses; others [would prefer trained nurses but] cannot afford the expense. It is desirable not to fetter the ladies who supply the funds. ... Relief is sometimes more needed than nursing care. (11)

The crux of the problem was the existence of so much grinding poverty that the principal need was for immediate welfare such as food, shelter, and blankets; thus the nurses were deflected from their task of nursing and were used simply used as dispensers of charitable relief. This was the root of the controversy about the proper task of the district nurse and who should control her that erupted two decades later. Nevertheless, the Liverpool experiment became well known and Rathbone was accepted as an authority on district nursing.

In 1874, Sir Edward Lechmere (of the English Branch of the Order of St. John of Jerusalem) proposed that London should inaugurate a system of district nursing. By now Rathbone was a member of Parliament for a Liverpool constituency and was therefore spending part of the year in London. He and Miss Nightingale were asked for advice. From their almost daily correspondence, it is clear that Miss Nightingale laid the charges and Rathbone fired them. With her typical passion for statistics, Miss Nightingale persuaded the committee to do a survey of the nursing needs of London and appointed one Miss Florence Lees to the task. Miss Lees had had a distinguished nursing career in the Franco Prussian War of 1870 and was a friend of the Crown Princess of Prussia. She had been an observer at the Nightingale School and had been critical of the lack of scientific training there. Miss Lees convinced Rathbone and Miss Nightingale that district nursing required a corps of educated women, who would be supervised not by a non-nurse "lady" but by a highly trained, educated nurse. Of course, this idea was controversial, because throughout the country, district nursing associations were run by the aristocracy and squirearchy, who controlled the nurses they engaged, employed, and could dismiss. It says a great deal for Rathbone that, despite his background of ladies' committees and lay control, he accepted Miss Lees's ideas, even though this led to a rift within his own family. Back in Liverpool, his second wife and other members of the family were busy running district nursing schemes on the old plan - that is, the nurses were under the firm control of a lay committee with a superintendent of nurses.

In 1874, Miss Lees provided a masterly survey of the nursing situation in London that is still available to the modern researcher. Her report was highly critical of what she found, including the nursing at St. Thomas's hospital; clearly a new approach to district nursing in London was needed. A number of district nursing associations were in operation. Some were run by religious organizations. But most failed to meet the community's nursing needs and, as in Liverpool, the nurses' work was confused by the constant demand for almsgiving.

Eventually, in 1874 - thanks to the support of the Duke of Westminster, a national appeal, and Miss Nightingale's letters to The Times - the Metropolitan and National Nursing Association was founded. Miss Nightingale had written to The Times in strong terms:

A district nurse must first nurse. She must be of a yet higher class and of a yet fuller training than that of a hospital nurse because she has no hospital appliances at hand at all and because she has to take notes of the case for the doctor who has no one but her to report to him. She is his staff of clinical clerks, dressers and nurses. (12)

The Association started with a Central Nurses' Home in Bloomsbury Square, London, that provided the office for the superintendent and comfortable accommodation for five district nurses. Miss Lees became the first superintendent, and the Nightingale Fund Council offered to train "special probationers" as district nurses. These "specials" did a year's training at St. Thomas's and then had six months' training in district nursing in Bloomsbury. They had lectures on subjects that general nursing training omitted, such as the care of mothers and their infants after childbirth, sanitary reforms, drainage, water supply, infectious diseases, and the teaching of health care. It is significant that the general hospitals did not deal with many of the main health hazards of the day, such as infectious diseases. Mrs. Wardroper (see Humane Medicine 4:47), the matron of St. Thomas's, was not enthusiastic about the prospect of nurses "going on the district" and actively discouraged it. The nurses attracted to the work, however, were often highly articulate and literate; they have left us vivid pictures of the state of peoples' health in the slums of London in the last decades of the nineteenth century.

The new type of educated district nurse from Blooms-bury was appreciated by the public, though not always by the doctors (who feared that she "would take the bread out of [their] mouths"). There was also trouble with chauvinistic committees, who did not understand that the objective of district nursing was not to dispense welfare but to educate poor families and to provide good nursing care. Miss Nightingale wrote scathingly about this confusion, denouncing the chairman of the Metropolitan and National Nursing Association: "He mistakes the function of such a society for those of a London School Board or the Charity Organisation Society" (13).

In 1878, Miss Lees married the Reverend Dacre Craven, who shared her views and was a great supporter of her work. They continued to work for the cause of district nursing until the end of their lives. Florence Craven produced model lectures that show a high degree of medical learning, and a manual for district nurses whose contents, still relevant, kept it in use well into the twentieth century. Miss Nightingale wrote the preface and also read the proofs (14).

In 1887, the women of England were determined to honor Queen Victoria on the occasion of her Golden Jubilee. Committees were set up and funds were raised. After another statue had been raised to Albert and a necklace presented to the Queen, 70,000 was left over. There were many claimants to this Jubilee Fund, but the Queen was interested in nursing and greatly admired Miss Nightingale. Florence Craven was a friend of her beloved daughter, Victoria, the Crown Princess of Prussia. It was eventually decided that the money should be used for "the welfare of nursing" and particularly for the nursing of the poor in their own homes. A committee was set up to advise the Queen. Many people put up schemes, but in the end the plan drawn up by Miss Nightingale and Rathbone prevailed. The latter was recognized as the founder of district nursing in Liverpool and London. The money was given

for the training, support and maintenance of women to act as nurses for the sick and poor and the establishment (if thought proper) of a home or homes for nurses and generally the promotion and provision of improved means of nursing the sick poor. (15)

A Provisional Council was set up, with the Duke of Westminster as its chairman. Miss Nightingale, still too ill to serve on the Council herself, was represented by her cousin, Henry Bonham Carter (secretary of the Nightingale Fund), and by Florence Craven. Rathbone, as its secretary, became the driving force of the Institute. The Council decided that the new Queen Victoria Jubilee Institute for Nurses would base its training scheme on the Metropolitan and National Association. This body would become the Central Training Home; it was located in Bloomsbury and the nurses lived there. Other "homes," in Scotland and Ireland, had their own Councils. A new syllabus was drawn up. Florence Craven, as the superintendent, evidently wrote the syllabus, while Rathbone and Miss Nightingale made comments and additions. The Council laid down rules for affiliation to the Institute. It hoped to persuade district nursing associations throughout the country to affiliate with the Queen's Institute and to accept its rules for training, general supervision, and inspection, along with the new uniform.

The rules, which remained in force for many years, set out the qualifications that must be met before a nurse could be placed on the Roll of Queen's Nurses (16):
  • Training at some approved general hospital or infirmary for not less than one year.
  • Approved training in district nursing for not less than six months, including training in the care of mothers and infants after childbirth.
  • For nurses in country districts, at least three months' approved training in midwifery.
The Institute's rules also specified that in large towns the nurses should reside in a "home," under the charge of a trained superintendent. This was Miss Nightingale's rule; in a letter to The Times, she made it clear that parents need not fear that their carefully nurtured daughter was being exposed to the dangers of a city. This rule also reflected another of her major tenets: "Ward training is but half training. The other half consists of women being trained in habits of order, cleanliness, regularity and moral discipline [in the Nurses' Home]."

The Council also decreed that patients would be nursed under the direction of medical practitioners and "while not excluding cases where patients are able to make some small contribution, the services of the nurses [were] to be strictly confined to the poor." These rules created some difficulty. Should nurses ignore need when the patient could not afford a doctor? What about people in the islands of Scotland, where there was no doctor? For their part, the doctors were skeptical about free services to the poor. In the spirit of the times, they argued that the poor should be encouraged to join a Provident Society, save "for a rainy day," and be prepared to pay their doctor. This controversy was still going on when, in 1898, Charles Booth published a survey showing that one-third of the population was living below the poverty line and that the burden of poverty - particularly among the old, the unemployed or unemployable, casual workers, and "deserted women" -was beyond the scope of private charity or exhortations to thrift (17). That survey, inter alia, led to the National Insurance Act of 1911.

The Institute promulgated another rule that caused considerable trouble: nurses were strictly forbidden to interfere in any way with the religious opinions of patients and their families. Several district nursing associations had been founded by religious institutions that wished to bring religion of a specific denomination to the poor as their nurses gave care. Miss Nightingale's hand can be seen behind this particular Institute rule. In the Crimea she had learned that blatant proselytizing among the helpless sick brought both nursing and health teaching into disrepute. Once, in exasperation, she had written, "I would far rather than establish a religious order, open a career highly paid. ... My principle has always been that we should give the best training we could to any women of any class, of any sect, paid or unpaid" (18).

Thus, for a variety of reasons, some of the district nursing associations did not welcome the Queen's Institute, and some rejected the idea of affiliation. Some did not see the need for trained nurses; like the ladies of Liverpool, they viewed the nurse as a welfare worker who should function under the direction of a committee of upper-class ladies. Others rejected outright the idea that their nurses should be inspected by a Queen's inspector. Still others rejected the concept of a nurse sitting an examination. Nurses, they claimed, were born, not made by training and learning.

Much of the opposition derived from the inferior position of women and the changing class structure. Many of the Queen's nurses came forward because of the new educational opportunities for girls. In a country with more than one million fewer men than women, many women were seeking a respectable paid career. Thus the early years of the Institute were full of controversy about affiliation. The powerful central committee in London included three Royal princesses and many members of the aristocracy connected with the Royal court. At times these committee members went out into the shires as emissaries to their aristocratic but unenlightened brethren; sometimes they were received with approval, but sometimes they were rebuffed.

Miss Nightingale became interested in district nursing in rural areas, where she believed living conditions were as unhealthy as in the towns. In 1884, one Mrs. Malleson put forward a scheme for rural district nursing. Miss Nightingale and Florence Craven helped draw up a prospectus from which sprang the county nursing scheme. In 1890, after affiliation with the Queen Victoria Jubilee Institute, this program employed county superintendents educated by the Institute. It was the backbone of rural district nursing in England until the introduction of the National Health Service in 1948 (19).

By the turn of the century, 750 Queen's nurses were listed on the Roll in England and the idea had spread overseas; colonial governors, hoping to start a similar scheme, sought advice from the Institute. At one time, the Institute proposed "two or three Colonial Inspectors in London who would be constantly travelling to help in organising local associations in the colonies and to advise and inspect those already established" (20).

In the end, no formal organization was set up, because the Institute did not have the money or the personnel for such a venture. Later, when the Institute did have money, the sun had set on the British Empire and less formal contact was required.

In 1897, Lady Aberdeen, wife of the Governor General of Canada, decided to start a Queen Victoria Order of district nurses in Canada modelled on the Queen's Institute in the United Kingdom. In a letter to the Duke of Westminster, she asserted that Queen Victoria had given permission for nurses in Canada to wear the badge of the Institute. Thereafter, a series of indignant letters and telegrams flowed between Lady Aberdeen and the president of the Institute, who held that no one had sought the permission of the Institute and that, in any event, the Institute could not control the training of nurses in Canada. The president reminded Lady Aberdeen that, in the United Kingdom, each county had a separate Council and charter and that Canada should be treated in the same way. Eventually, after more telegrams, Lady Aberdeen received permission to use the badge, but it was suspended on a ribbon of a different color and the nurses wore a different uniform. Thus was founded the Victorian Order of Nurses in Canada, who remained in contact with their colleagues in England and attended joint conferences.

A similar scheme was started in Australia. Thereafter, the Institute made available a number of Queen's nurses to act as advisers to various countries wishing to start schemes of public-health nursing. After World War II, in response to urgent needs in developing countries, Queen's nurses played an important role in establishing nursing services in Malta, Africa, the West Indies, and the Far East.

Exhorted by their prestigious Council, prodded by their superintendents, inspired by Miss Nightingale and Rathbone, the early Queen's nurses went forth to carve out an empire. In 1892 Amy Hughes, superintendent of the Metropolitan National Nursing Association and a friend of Miss Nightingale's, sent a Queen's nurse to a school in Chancery Lane, London, to examine and treat the schoolchildren. The authorities hoped this would improve attendance. The parents, many of whom could not afford other medical care, probably liked it as well. Later, the scheme was extended; thus the Queen's nurses became the first school nurses. At their best, these nurses truly were "all-purpose health workers." They gave advice to all age groups, helped with surgical operations on the kitchen table, put rooms "in nursing order," prescribed diets, nursed the sick, coped with casualties, rehabilitated the convalescent, took patients on outings, ran libraries, comforted the dying, and helped raise funds for their own salaries. But it could not last. By the beginning of the twentieth century, people had begun to doubt whether one training could cover all aspects of health care.

In 1893, Miss Nightingale, then 73, complicated matters by starting a scheme for "health missioners" in Buckinghamshire. Miss Nightingale's sister, Parthenope, had married Sir Harry Verney (after Florence Nightingale herself had refused him "for the sake of the work"). Sir Harry, like William Rathbone, was a Liberal Member of Parliament. (Both were sometimes known as "Miss Nightingale's Member.") He was also a landowner and the inheritor of the splendid ancestral house at Claydon. After Parthe's death in 1890, Miss Nightingale spent more time at Claydon. (Visitors can still inspect the rooms kept for her.) She took an interest in the welfare of the estate, especially in the health of the rural poor. During this time, she conceived the idea of a separate group of health workers, whom she called "health missioners." In 1891 she wrote to her nephew, Frederick Verney, chairman of the North Buckingham Technical Education Committee, outlining her ideas for a corps of health missioners who would take health into the home.

We have, tho' they be but a sprinkling, in one or two great towns and in London, excellent Town District Nurses but for obvious reasons they would not be suitable for your proposed work teaching health care. It hardly seems necessary to contrast sick nursing with this. The needs are quite different; Home Health bringing requires different, but not lower, tho' apparently humbler qualifications and more varied. ... They require initiative and real belief in sanitation and that Life or Death may lie in a grain of dust or a drop of water or such other minutiae which are not minutiae but Goliaths and the Health Missioner must be David and slay them. (21).

The last part of this sounds like the germ theory, and Miss Nightingale seems to have forgotten that the district nurses were supposed to "teach health." She persuaded the Committee to start a training scheme under the direction of the area Medical Officer of Health. Of the sixteen ladies who attended the course of lectures, twelve took the examination, six passed, and the County Council appointed three to be full-time "health visitors."

In 1893 Miss Nightingale's paper "Sick Nursing and Health Visiting," which describes the work of the British health visitors, was read at the Chicago Exhibition:

The scheme contemplates the training of ladies, so-called health missioners, so as to qualify them to give instruction to village mothers in:
  1. The sanitary conditions of the person, clothes and bedding, and house.
  2. The management of the health of adults, women before and after confinements, infants and children. (22)
In the 1890s, health visitors' principal work involved environmental health and the control of infectious diseases. As more authorities started to train health visitors, they began to take an active interest in infant protection, although child-life protection would not become an official part of their duties until 1918. In 1907, a Notification of Births Act (adoptive) directed health visitors to enter the home to offer advice and assistance to nursing mothers. In the same year, the establishment of the School Health Service added to their responsibilities; here their duties often crossed with those of the district nurse. Also, when the health visitor was doing maternity-welfare work, she came into conflict with the midwife; the quarrels that ensued were aired in the nursing press of the day.

The early health visitors were quite distinct from nurses. Miss Nightingale said that health visitors must create a new profession, and to some extent they did. In England at the beginning of the century, every local authority was a petty kingdom and a law unto itself. In some areas, health visitors did infant-welfare work, school nursing, and child-life protection (according to a permissive Act of 1908); in other areas, district nurses did everything. Some of these were well trained, like the Queen's Nurses; some were not. To add to the confusion, some authorities employed social workers, whose duties overlapped with those of health visitors The Ministry of Health was not established until 1919; even then, the Ministry had little power to sort out the confusion.

As Medical Officers of Health began to appreciate the value of health visitors, their training was moved into Colleges of Further Education in the universities. These attracted a number of nurses, particularly district nurses. Also, because of its emphasis on maternity and child welfare, the new profession of health visiting attracted those with training in midwifery, as well as those who were just weary of the discipline of hospital life. More and more health visitors were nurses first. In 1962, nurse training became a compulsory prerequisite, even though that was not what Miss Nightingale had intended. It does explain the peculiar dichotomy in public-health nursing in England: one group is trained to give health education and the other to do sick nursing, both with a common basic nurse training, but with separate postgraduate education. Today, members of both groups are attached to groups of general practitioners or health clinics. The health visitor has not worked herself out of a job, as once was thought possible; new health problems continually arise in new or previously unrecognized vulnerable groups such as ethnic minorities, drug addicts, battered wives, abused children, the homeless, and, most recently, AIDS victims. New forms of pollution bring their own problems. Miss Nightingale's vision of the health visitor as a David slaying Goliath is still valid. Although the dramatic fall in the infant mortality rate in the past hundred years is due to several causes, Miss Nightingale's vision has played an important part.

In 1978, the World Health Organization, like Miss Nightingale, looked forward to the year 2000 and the prospect of health for all through primary health care, envisioning

essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community, and at a cost the community can afford to maintain. ... It is the first level of contact of individuals, the family and the community with the national health system, bringing health care as close as possible to where people live and work, [that] constitutes the first element of continuing health care process. (23)

Of nursing, the World Health Organization has said, "Nurses' potential lies in their role as providers of primary health care services in community settings, clinics, schools and industries as well as hospitals" (24).

Miss Nightingale would have agreed with this sentiment. One might argue that, of all Miss Nightingale's contributions, her emphasis on public health and sanitation brought the greatest benefit to the England of her day. She returned from the Crimea with a passionate desire to prevent unnecessary suffering, and all her efforts were directed toward that end. She collected statistics to prove that the environment was the setting and the cause of some disease; she designed hospitals not as attractive buildings but as structures designed to discourage cross-infection; she helped reform the Army Medical Service in order that soldiers should have better doctors; and she improved hospital nursing, not to provide careers for women, but to give the sick a better service. Above all, she had the vision to see that the most powerful means of improving health was to bring health teaching into the home.

Monica E. Baly, PHD
19 Royal Crescent
Bath, BA1 2LT England


REFERENCES

  • Bynum W, Porter R. Medical Fringe and Medical Orthodoxy 1750-1850. London: Croom Helm, 1988.
  • Smith B. Florence Nightingale: Reputation and Power. London: Croom Helm, 1982.
  • Nightingale F, commenting on the Report on the Sanitary State of St. Thomas's Hospital, 1878.
  • Cope Z. Florence Nightingale and the Doctors [quoting a letter to H Acland, 1869]. London: Museum Press, 1958, p. 121.
  • Nightingale F. Notes on Nursing. London: Duckworth, 1952 (first published 1859), p. 15.
  • Ibid., p. 17.
  • Ibid., p. 29.
  • McKeown T, Lowe CR. An Introduction to Social Medicine. London: Blackwell Scientific Publications, 1966, p. 14.
  • Blades and Blades. Statement of the Appropriation of the Nightingale Fund. 1863.
  • Rathbone E. William Rathbone: A Memoir. London: Macmillan, 1904, p. 156.
  • Langton C/Nightingale F. G L R 0, 11 January 1896.
  • Nightingale F. The Times, 14 April 1876, p. 6.
  • Nightingale F/Carter HB. B L Add Mss 47719 F 42, 23 July 1874.
  • Craven DF. A Guide to District Nursing and Home Nursing. London: Macmillan, 1890.
  • The Royal Charter for the Queen Victoria Jubilee Institute for Nurses. 1889.
  • Rules for Affiliation to the Institute. (This was before the Midwives Act 1902, which required all midwives to have six months' training and to be certified by the Central Midwives Board.)
  • Booth C. Life and Labour of the People of London. 17 vols, 1889-1902.
  • Nightingale F/Farr W. 13 Sept 1866.
  • Baly ME. A History of the Queen's Nursing Institute. London: Croom Helm, 1987.
  • Note on Colonial Branches attributed to W. Rathbone. Queen's Institute archives.
  • Nightingale F/Verney F. B L Add Mss 59786 F 93, 17 October 1891.
  • Nightingale F. Address to the Chicago Exhibition, 1893.
  • World Health Organization. Declaration. Alma-Ata, 1978.
  • World Health Organization. 39th Assembly. The Role of Nurses and Midwifery Personnel: The Strategy of Health for All. WHO: Geneva, 1985.