Florence Nightingale: Relevant as today's news

Eight years and one week ago today was a special day at the Florence Nightingale Museum in London. (Today is the 104th anniversary of her death.*) At a press event, we unveiled an extraordinary discovery, a previously unknown photograph of Florence Nightingale. To put this in perspective, Nightingale was so reclusive that barely more than two dozen known portraits of her are known to exist, despite the fact that photography was invented and came into fashion during her lifetime. In my 18 years with the museum, we often received prints—and even some original artwork—based on the few long-known Nightingale portraits. To put the discovery in perspective, although the National Portrait Gallery in London opened just after the Crimean War to serve the public interest in portraits of great Britons, it took many years for the gallery to acquire its first original portrait of Nightingale.

So the scarcity-induced value of the newly discovered photograph made August 6, 2006, a very exciting day for all involved in the museum. The photograph was taken around 1858 by William Slater, a pharmacist who lived and worked close to the Nightingale family home in Hampshire, in the south of England. Hidden away until after the death of a direct descendent of Slater, the photograph was donated to the museum by generous beneficiaries.

Reproduced by courtesy of the Florence Nightingale Museum Trust, London

At the time, I apprised the press on how new and fresh the photograph was—that it showed Florence Nightingale in an informal and relaxed setting, very different from the slightly austere post-Crimean studio images we had become accustomed to. It is a contemplative image. Nightingale is reading a book in the garden of her home at Embley Park, under the shade of a tree. A private note she wrote two decades previously, at the age of 16, revealed to posterity that it was there she had her first “call from God.” It was not yet apparent that her calling was to become a nurse, but as she gathered information, it gradually dawned upon her, and her calling became so strong that she was able to overcome the barrier of social stigma faced by aristocratic Victorian women and, as a result of her nursing work in the Crimean War, forged a new profession.

I found it quite remarkable that such a candid image could suddenly appear without us having known about it previously. Mark Bostridge, author of the then-recently published Penguin biography Florence Nightingale: The Woman and Her Legend—the photo graces the book’s front cover—had been involved in identifying the photograph and had spoken with its inheritors. About the lack of Nightingale portraits, Bostridge observed, “She regarded any personal publicity as detrimental to the causes of public health for which she worked so tirelessly after her return from the Crimean war.”

To our surprise and delight, the image was syndicated and the story of its discovery published across the world—from Zimbabwe to China. A thumbnail of the image appeared on the front page of The Guardian newspaper in England with a longer story inside. In the print edition of the paper, the story was published alongside news about a series of rocket attacks on northern Israel—“Israel’s bloodiest day yet as Hezbollah hits troops and Haifa.”

I discussed the juxtaposition of the Nightingale story with the report of conflict in the Middle East with Sir Robert Crawford, a museum trustee and then-director of the Imperial War Museum.** The juxtaposition was fitting, he observed, in light of the fact that, nearly 150 years earlier, Nightingale’s rise to fame had resulted from the effort that she and her nurses had brought to alleviate suffering of wounded soldiers.

Eight years to the day after the long-delayed unveiling of Nightingale’s photograph to the public, I began writing this post in a café in Antigua, Guatemala. Over coffee, I struck up a conversation with David, a young Swiss student on his travels, and talk turned to Florence Nightingale. He had not heard of her, he said, but he did tell me about some research he had done at school on the origins of the Red Cross. The Red Cross emblem, positioned on a white field, originated at the First Geneva Convention in 1864 and is the inverse of Switzerland’s flag, which has a white cross on a red background. As such, it is a tribute both to Henry Dunant, founder of the International Committee of the Red Cross, and the principle of neutrality in war, of which the Swiss nation has long been proud.

Dunant had witnessed the horrors of war firsthand in Italy, where, in 1859, he observed the aftermath of the Battle of Solferino. In a book he wrote about his experiences, published eight years after the Crimean War, he cited the example of Florence Nightingale as a principle inspiration for his humanitarian work in wartime, and the International Committee of the Red Cross was created shortly afterward, in 1864.

Returning to my temporary home in Antigua, I looked up the latest information on the Red Cross and the Red Crescent and found the following tweets by Peter Maurer, president of the International Committee of the Red Cross (ICRC), which he made during a three-day visit to Gaza: 1) “I have a deep feeling of shock at what I’ve seen and anger that we weren’t able to prevent what has happened.” 2) “I was shattered to see the human impact of the conflict in #Gaza. I was angered and felt compassion for all those that lost loved ones.”

Today, eight years after the unveiling of the Nightingale photograph, conflict in the Middle East continues. I regard this post as an opportunity to pay tribute to courageous and skillful nurses, on both sides of the conflict, who are responsible for saving countless lives and are helping to begin the long and painful process of healing, one person at a time.

By the way, this October, members of the Honor Society of Nursing, Sigma Theta Tau International from Indianapolis, Indiana, USA, join me on a Florence Nightingale tour to England, where we will visit her homes, including Embley Park, where the photograph was taken.

* Coincidentally, today is my 50th birthday. I am half the age of my grandmother, Hilda Austin, who celebrated her 100th in April. One of the greatest inspirations in my life, she was a nurse in England, and I dedicated my STTI-published book, Illuminating Florence, to her. Grandmother Hilda was born in 1914, the year the First World War broke out and the subject of Mark Bostridge’s latest book, The Fateful Year. He is, of course, also the latest biographer of Florence Nightingale. As you can see, I have a love for and a fascination about resonant dates.

** The Imperial War Museum, established as the first museum of peace, documented exhaustive details about suffering inflicted during the First World War, in the hope that such a conflict would never again occur. The war, which began 100 years ago this year, was so terrible that it was said to be “the war to end all wars.”

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. Those that promote products or services will not be posted.

Nightingale and the Great British Cup of Tea, Part Two

As I was saying before having my cuppa (see previous post), we can find the same principle at work when we look at that beverage. (To refresh your memory, the principle to which I’m referring is that a remedy under one set of circumstances might not apply under other circumstances.) A case in point can be found in the Project Gutenberg online version of Florence Nightingale’s Notes on Nursing (1860). Here is the quote in question: “… it is however certain that there is nothing yet discovered which is a substitute to the English patient for his cup of tea; he can take it when he can take nothing else, and he often can’t take anything else if he has it not.”

The key point here is not the wonderful effect of tea per se, but the effect Nightingale notices in terms of, specifically, English patients. To interpret this, we need more information. Nightingale wrote this in 1859, and it was published in 1860. During the previous decade, she had ample firsthand nursing experience with English and non-English patients. She wrote Notes on Nursing for English people. She did not anticipate foreign translations, of which there have been more than 10. Evidence for this is that, in correspondence with her publisher, no mention is made of translations. By saying “the English patient,” Nightingale is clearly implying that, during illness, people of other nationalities do not find tea to be such an important drink. My point here is not to analyze in detail specific properties of tea, but rather to observe that British people react to tea differently than other nationalities, something Nightingale clearly understood.

Tea has been used as a “rescue” drink by British people for generations. Nightingale thought its powers were a bit exaggerated. These are her words: “When you see the natural and almost universal craving in English sick for their ‘tea,’ you cannot but feel that nature knows what she is about. But a little tea or coffee restores them quite as much as a great deal, and a great deal of tea and especially of coffee impairs the little power of digestion they have.”

If you are British, tea is something you understand naturally. There are, broadly, two sorts of tea drunk in England: builder’s tea and fine—or “posh”—teas, such as Earl Grey. Both are essentially black tea. The former, orangey in color, is cheaper and is drunk invariably with milk and sugar. When the Normandy landings took place in World War II, the British, after fighting on the beaches, stopped to brew tea. The American response was a sense of shock at British eccentricity, as if the Brits were stopping to drink posh tea at 5 p.m., rather than continue fighting. I think it would be obvious to any Brit that Tommy Smith would be drinking builder’s tea out of a sense of sheer bloody necessity, and I believe this is essentially what Florence Nightingale was talking about.

Tea remains something of an in joke in British culture to this day, to the extent that it was featured in the cult comedy-horror film “Shaun of the Dead,” which made it into Quentin Tarantino’s list of top 10 films of the ’90s. In this film, the protagonist’s stepfather is turning into a zombie, so his family’s response is to go home and have a cup of tea.

I have come across many personal anecdotes of nurses giving tea to patients in moments of crisis. In the public domain, my favorite, from the Victoria Wood’s 2013 BBC documentary “A Nice Cup of Tea” (second of the two), is an interview with a World War II volunteer nurse. Incidentally, Wood noted with some nostalgia that the younger generation of British people rarely has time to fit tea drinking into their day, so perhaps that great and honorable tradition is finally dying off. Now would be a good time, therefore, to understand what tea means to patients, before the tea-drinking tradition finally vanishes—in England, at least.

In summary, the case I am making is not so much about tea, specifically. The point is, there are some things that work for certain groups of patients and not others. I would have expected Nightingale to pick up on something so culturally significant for my home country as tea. And she did. What we can learn from this is that an understanding of cultures and diversity can provide nurses with a key to better patient care.

Who would imagine how much an Argentine patient, sick in hospital abroad, would be lifted by being offered a cup of hierba mate? On the other hand, when I worked at the Florence Nightingale Museum in the London borough of Lambeth, I was aware that 147 languages, apart from English, were spoken there. I would be challenged to name a quarter of them, despite the fact that I am a historian and linguist. Cultural diversity must also be an immense challenge for nursing. Tea is an interesting starting point for this important discussion.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. Those that promote products or services will not be posted.

Florence Nightingale and the Great British Cup of Tea

The title of this piece is somewhat misleading, because, although I will be indeed come to Florence Nightingale and tea drinking by patients, the issue I am concerned with here is somewhat more philosophical. It is a question of what Nightingale’s statements on patients and tea mean to us in terms of her relevance.

We have only just passed another anniversary of Florence Nightingale’s birth, and we are, in fact, now only six years away from its bicentenary observance. It seems to me that her relevance is quite a valid issue. How might this relevance be organized? What does it rest on? And even, is it realistic at all in this modern, high-tech world that Florence Nightingale should be relevant to nurses? And finally, what has this got to do with tea?

There are two basic reasons—in my view—why Nightingale is so appealing as a symbol of nursing worldwide: On the one hand, her life makes a dramatic and engaging nursing story that inspires and communicates well about the essence of caring, and, on the other, her thinking underpins some of the very principles of nursing practice today.

Let’s look at this second point. In reading 20th-century archives, we see that Nightingale’s importance to nursing was often lauded in general terms, but without much systematic referencing, while practitioners of epidemiology and statistics were beginning to laud Nightingale’s contributions to their areas, with discussions carefully referenced to her writings. Then, toward the end of the 20th century, a global trend took the majority of nurse education away from the hospital and into the university—incidentally, something Nightingale had not approved of in the 19th century. It looked as if her relevance was waning in one of her key constituencies of influence.

But now, for more than two decades, entirely new and scholarly statements have increased appreciation for Florence Nightingale’s relevance to nursing. Among these, I particularly want to highlight the work of Barbara Dossey, PhD, RN, AHN-BC, FAAN, and Louise Selanders, EdD, RN, FAAN. Dossey has given us new biographical insight into Florence Nightingale as a holistic nurse, while, since 1993, Selanders has restated Nightingale’s thinking systematically in terms of an environmental adaptation model. Five years ago, the International Council of Nurses reissued Nightingale’s Notes on Nursing, with a foreword by the International Alliance of Patients’ Organizations.

If I could summarize this work, I would say that there is now a much clearer conception of the value and modern relevance of Nightingale’s nursing principles. Also, as Dossey has shown, the underlying philosophy of patient care has intricate links to Nightingale’s religious and spiritual views. The main thrust of this nursing history research work is to look at principles and to give Nightingale’s ideas a more theoretical perspective that is in tune with modern nursing theory and practice.

In other words, we are looking at the “universal truth” of Florence Nightingale’s nursing thought. It is certainly true that Nightingale’s thoughts on nursing have universal appeal, and this is clearly evident in the work of the scholars I have mentioned. Without making too extensive a claim, I define “universal” as passing the tests of time and space—from Florence Nightingale in 19th-century England to all corners of the globe today. I will give one example that I think passes the universal test. Nightingale’s statement that hospitals should do the sick no harm is in that category, and it seems just as relevant today as it was a century and a half ago, when it was written.

I am getting close to the point about tea. It is a mechanism for talking about another category of truth: contingent truth. It is more challenging to frame Florence Nightingale’s relevance based on contingent truth, because, by its nature, contingent truth is more elusive. You could talk about Nightingale’s attitudes regarding observation of the unique circumstances of every patient and the importance of intelligent processing of these signs by nurses. Alternatively, you could say, based on the reams of research she produced in the decades following the Crimean War, that her relevance is in the minute details of patient care. The case for Nightingale’s scientific nursing research, effectively summarized by her statistical diagrams, has been well-made already.

However, I am still not quite satisfied. I am looking for a specific and concrete case to demonstrate an idea. The idea I would like to test is that something that is a remedy under one specific set of circumstances (which we could call Group X of patients) might not apply under other circumstances (to Group Y of patients), in which Groups X and Y are separated by time and space.

Perhaps, one of the nicest examples I can think of is quite obscure. It comes from Nightingale’s reports on the health of the Maori people and correspondence more than 150 years ago with Sir George Grey, British governor of New Zealand. It should be noted that, at no point, did Nightingale go to New Zealand. The only information she had to draw on was official reports and answers to questions she sent to the colonial government.

The “Maori depopulation question” was a euphemism for the catastrophic effects of colonialism on indigenous health. Nightingale was asked for advice, and one of her conclusions was that the standard approach to health employed by missionaries and the colonial government was to blame. For example, the Manchester cotton clothes given by the British to the Maori people to replace traditional dress were not necessarily healthier. In fact, under many circumstances, Nightingale considered, they were damaging to the health of the Maori people. Nightingale noted that a traditional Maori feather dress was probably much warmer than Manchester cotton. This was just one small example identified by Nightingale of how traditional lifestyles were being altered to the detriment of health.

She also had much to say on the subject of diet. I was fortunate that Lady Jocelyn Keith, that distinguished researcher of the Stout Research Center at Victoria University in Wellington, showed me the accumulated research on the subject 25 years ago. We then put together an exhibition on the subject at the Florence Nightingale Museum. Despite this fact, the episode I mention above remains obscure, and few people have much idea that Florence Nightingale’s thinking on the effects of colonialism was so subtle and advanced, or that she understood that cultural differences can affect the universality of notions about health care.

We can find the same principle at work when we look at tea. But, I’ve taken longer to introduce this topic than I intended, and that discussion can wait. Right now, Englishman that I am, I’m going to break for a cup of tea and write a follow-up post a little later.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing Sigma Theta Tau International. Comments are moderated. Those that promote products or services will not be posted.