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Nightingale 2020: A Contemporary Reflection

      The year 2020 marks not just the International Year of the Nurse, as proclaimed by the World Health Organization, but also the 200th anniversary of the birth of Florence Nightingale. Throughout the year all nurses should take time to reflect on the many ways Nightingale was a pioneer in advocating for improved health and safety of the population through environmental changes, introducing concepts of prevention and promotion of social justice. Few nurses have read her “Notes on Nursing” or pursued any of her extensive writings, and contributions related to data-driven public health initiatives. In truth, not just her legend but much of the history of nursing is neglected in formal nursing education programs. Pediatric nurses assume Nightingale has limited relevance for them as her notoriety is linked to her work with solders during the Crimean War. Her emphasis on sanitation, fresh air, nutrition, and combined empathic and skilled care changed the image of the nurse from the doctors' helper to an independent decision-maker and care provider.
      To celebrate the life and work of Florence Nightingale, I would like to recommend some resources to read. My first recommendation is Florence Nightingale, Nursing and Health Care Today by Lynn
      • McDonald L.
      Florence Nightingale, nursing, and health care today.
      . Dr. McDonald is one of the foremost authorities on the writings of Nightingale and has crafted a very impressive 16 volume set based on the collected writings of Nightingale. These writings include books, articles, pamphlets and previously unpublished correspondence gathered from more than 200 archives worldwide. She wrote many other books as well. In her most recent publication, cited above, she included one chapter dedicated to the topic of pediatric nursing.
      • McDonald L.
      Florence Nightingale, nursing, and health care today.
      notes that Nightingale personally had limited pediatric nursing experience from her training at Kaiserswerth and the occasional child at the Harley Street Hospital. Her letters indicate a fondness for children and a unique ability for putting children at ease by telling stories. Nightingale regularly sent presents, toys, and greenery at Christmas to the children's ward at St. Thomas's hospital. Despite her limited professional experience in pediatric nursing, she regularly was consulted regarding the care of children. Children's hospitals worldwide sought advice from the experienced nursing staff of the children's ward at St. Thomas.
      Infancy was a fragile period during Nightingale's era and the death rates for children prior to age 5 years was high. McDonald quotes Nightingale as saying “the life duration of babies is the most ‘delicate test’ of health conditions”. Contemporary health care continues to use the infant mortality rate as an important marker of the overall health of a society (). Notes on Nursing emphasized that “children were much more susceptible than grown people to all noxious influences” (as cited in
      • McDonald L.
      Florence Nightingale, nursing, and health care today.
      ). Nightingale was part of the pioneering community of health care statisticians and collaborated with William Farr in 1865 as he worked on a paper on child mortality. She solicited input from nursing leaders and put forward the goal of learning why the death rates among children were so high.
      Nightingale recognized that health promotion and disease prevention were essential for child health, not to mention adequate housing, cleanliness, nutrition and parental knowledge of early childcare. It was the hope of Nightingale that this content would be taught to new mothers by midwives, nurses and women doctors, but in reality, little teaching was done. Some families during the mid-1800s employed an assistant to provide care to the mother and infant during the first month after birth. Nightingale noted that these assistants were more like maids than nurses. She wrote her Notes on Nursing, not as a textbook for nursing students, but to provide guidance to help assistants and family members people care for themselves and their families. Newer editions of the book included a chapter on minding baby.
      Beginning in the 20th century the majority of pediatric nurses worked in hospitals. It is interesting to note that Nightingale advocated for children not being in hospitals.
      She wrote her Notes on Nursing, not as a textbook for nursing students, but to provide guidance to help assistants and family members people care for themselves and their families. Nightingale was often consulted on the design of pediatric hospitals and included a full chapter on children's hospitals in the final 1863 edition of Notes on Hospitals. Pediatric hospitals were to include special features such as space for exercise, gardens and schooling. One architect was informed by Nightingale to design “a large garden ground, laid out in sward and green hillocks and such ways as children like (not too pretty for children to be scolded for spoiling it)”(as cited in
      • McDonald L.
      Florence Nightingale, nursing, and health care today.
      ).
      When consulted regarding a children's hospital to be built in Manchester, England, Nightingale advised that “the proportion of nurses to children ought to be considerably more than double that of nurses to adults in a hospital…no children should be left alone”(as cited in
      • McDonald L.
      Florence Nightingale, nursing, and health care today.
      ). Nightingale was also concerned about having good children's nurses and noted the difficulty in finding them. Nightingale felt that all caregivers of children, nurses or mothers need keen observation skills. The accuracy of these observation skills was “the real test of a nurse, whether she can nurse a sick infant” (as cited in
      • McDonald L.
      Florence Nightingale, nursing, and health care today.
      ). Key observations included pulse, secretions, breathing, sleep, and wounds. A love for children also was required of pediatric nurses.
      In the twenty-first century, the majority of pediatrics involves well-childcare or primary health care. Another significant contribution made by Nightingale was her addressing what is currently referred to as the social determinants of health. Nightingale advocated for pure air and water, cleanliness, and light to promote health. Egyptians promoted the successful practice of regularly washing newborns' eyes for the first month of life to prevent blindness (
      • McDonald L.
      Florence Nightingale, nursing, and health care today.
      ). Nightingale's early advocacy for social policies to promote good nutrition and access to health care contributed to many health care policy issues. In the late 18th and early 19th century indigent families were often sent to live in “workhouses” where sanitation was poor, and infirmaries were the only source of health care. Nightingale's writings sparked health reform and improved the unsanitary conditions. Her focus on hygiene was instrumental in reducing the number of deaths from infections and communicable diseases such as dysentery and tuberculosis.
      In a second resource A Brief History of Florence Nightingale and her Real Legacy, a Revolution in Public Health (2017) by Hugh Small, Nightingale's work related to health care policy is discussed thoroughly. The author provides an interesting life span overview of Nightingale's life and passions for social justice and improved health care. Charles
      • Dickens C.
      A tale of two cities.
      , her contemporary and fellow social activist, aptly referred to the status of life in the mid-19th century as “the best of times and the worst of times” (Tale of Two Cities). While England was experiencing a high level of economic prosperity, the majority of the population lived in conditions as deplorable as the barracks of Scutari. In most cities less than half of the children lived to adulthood. “Piped water supplies were often drawn from the river at the same point the sewage entered it” (
      • Small H.
      A brief history of Florence Nightingale and her real legacy, a revolution in public health.
      ).
      Small noted Nightingale's role in attacking the infant mortality rate and described her campaign for the Public Health Act of 1875 (p. 174). This legislation included a clause that required retrofitting housing to include sanitation. Her ability as a woman to influence legislation was remarkable for her time. Small attributed Nightingale's success to her reputation for an “honest assessment of the Crimean catastrophe” (p. 175), her support by the sponsor of the bill, James Stanfield, and her relationship to the prime minister.
      Small detailed how after Nightingale's successful campaign for sanitary legislation she refocused her attention on nursing. Nightingale was known to micromanage the development of nurses. From reports on the nurse training programs she would monitor select nurses' development, selecting those she could trust and then ensured that they were given important positions. Some nurses were selected for positions outside of the hospital. Amy Hughes was one who received special attention. As if to validate Nightingale's assessment of her potential, Amy became a district nurse (community health nurse) and author of a textbook for district nurses. Nightingale and Hughes collaborated on content for the book and Hughes dedicated the book to Nightingale. The textbook indirectly influenced the health of children and their families in the community as the vast majority of children were cared for by their mothers in the home following directions from the district nurse. District nurses, the forerunners of public health nurses in the United States, provided care to the poor sick in their homes as well as providing education to help the family improve their health.
      Promotion of cleanliness, safe drinking water, good nutrition, adequate living conditions and sanitation were the cornerstone of Nightingale's legacy to nursing practice and the health promotion of children and their families. Nurses provide a crucial link between the people in the community and the complex health care systems. In this International Year of the Nurse as nursing moves forward, pediatric and all nursing specialties need to celebrate the early pioneers like Nightingale who had a vision for what nursing would become, laid a solid foundation for advancing the art and science of nursing and contributed greatly to humanity.

      References

        • Center for Disease Control and Prevention
        Infant mortality.
        (Retrieved 12/20/19 from)
        • Dickens C.
        A tale of two cities.
        First Avenue EditionsTM, 2014
        • McDonald L.
        Florence Nightingale, nursing, and health care today.
        Springer Publishing Company, LLC, 2018
        • Small H.
        A brief history of Florence Nightingale and her real legacy, a revolution in public health.
        Robinson, 2017