• The Problematic Myth of Florence Nightingale

    Sarah DiGregorio on the Little-Known, Radical History of Nursing and the Danger of Biases in Medicine Today

    “No matter whether this treatment is carried out by sorcerers, priests, doctors, or old women, we find examples of the historic ancestry of modern nursing and the earliest forms of the art.”
    Lavinia L. Dock, RN, and Mary Adelaide Nutting, RN, A History of Nursing, 1907

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    If you think that Florence Nightingale invented nursing, you’re not alone. Just about every mainstream source, from the History Channel to Wikipedia, cites Nightingale, an upper-class lady of Victorian England, as the founder of modern nursing. Her legacy pervades both the general public’s understanding of nursing and nursing itself: May is National Nurses Month because Nightingale’s birthday is May 12th, and the World Health Organization dubbed 2020 the Year of the Nurse and Midwife to mark Nightingale’s 200th birthday. (Of course, 2020 turned out to be the year of the nurse in ways no one anticipated.)

    But, like most lone-hero narratives, this one is not entirely true: For one thing, Nightingale herself trained with a group of German deaconess nurses, something she could hardly have done if she invented nursing. She did become famous for advocating for nursing as a trained profession, but as she did so, she shrank nursing into a restrictive, exclusionary Victorian corset, constructing a version of nursing that conformed to rigid social mores, one divided by class, race, and gender—a reimagining of nursing palatable to British colonialism.

    The idea of Nightingale, the lady with the lamp, as the prototypical nurse—this mythic origin story—has served to further white supremacy in nursing and to strip nursing history of its truer, broader kaleidoscopic power. The real history of nursing is utterly radical in its vastness—and in what it says about the care we owe each other. Maybe that radicalness is why that history has been so elided, even as nursing historians have sought to bring it forward.

    In fact, nursing doesn’t have one origin story, but uncountable origin stories. Nursing is a thread running through all human history. Here is a highly unscientific and not-even-close-to-comprehensive tour: One of the first nursing schools was established more than 2,000 years ago in Ancient India, where health care was conceptualized as four equally critical pillars: The patient, the nurse, the medicine and the physician. Several hundred years later, the Roman empire built military hospitals staffed with professional nurses because it was understood that the empire rose or fell on the health of its soldiers.

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    In what is now Istanbul, during the Byzantine empire, large, sophisticated hospitals were staffed with licensed nurses and the care was available to all. In what is now Saudi Arabia, a nurse named Rufaida Al-Aslamiya was instrumental in the birth of Islam, caring for Mohammed and his followers as they marched on Mecca.

    In the United States, enslaved people used traditional African healing practices when they nursed, both as forced labor and of their own accord—and African-American ways of understanding health and healing has helped to define American nursing, even when not properly credited.

    The idea of Nightingale, the lady with the lamp, as the prototypical nurse—this mythic origin story—has served to further white supremacy in nursing and to strip nursing history of its truer, broader kaleidoscopic power.

    The sweeping history of nursing proves that if there is a human tendency to tear apart, to hurt and destroy, there is also a human instinct to mend, to organize skilled care, to reach out to each other. So the idea that nursing arose only in relatively recent times, as a profession dedicated to assisting physicians within hospitals, is entirely backward. Nursing came first.

    Four thousand years ago, in a Neolithic Stone Age community in what is now Bach Lien Village, Vietnam, a baby boy was born with Klippel-Feil syndrome, a rare congenital condition in which neck vertebrae are fused together. As he grew, the boy curled. His spinal column became progressively compressed, until he was paralyzed from the waist down, with very little use of his upper body. His head twisted to the right; he could not feed himself. Chewing and swallowing were probably difficult.

    Nevertheless, even after becoming almost completely immobile as a teenager, he lived until his mid-twenties. Someone, or many someones, must have nursed him intensively. They brought him food and water, fed him, bathed him. They would have had to help him with positioning and tend to his skin, to prevent pressure sores and infections. Without nursing care, he would have died within days. When the young man died, he was buried in the fetal position, because of the curve in his spine.

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    When archeologists found him in 2007, they noticed that he was the only one in the community buried in this way. Then they saw the fused neck vertebrae, and the extreme slenderness of his leg and arm bones that comes with paralysis. Lorna Tilley, PhD, an archeologist on the dig, had previously worked in nursing. The young man’s body spoke to her, and she started to piece this case together with other evidence of prehistoric nursing.

    Tilley was captivated by what these bones were saying, but when she looked back at previous archeological studies, she found that while survival from illness or injury was sometimes noted, there was often little to no analysis or even acknowledgment of the prehistoric nursing care that would have made this survival possible. Informed by her work in both archaeology and health care, she developed a model called the bioarcheology of care, a framework for understanding how our earliest ancestors nursed one another.

    In Anthropology News, Tilley and her coauthor, Alecia Schrenk, argued for the importance of understanding ourselves this way: “Our past contains important lessons for our present if we are willing to pay attention,” they wrote.

    An archeological focus on health-related care completely overturns the notion that society has evolved by embracing a winner-takes-all, “survival of the fittest” approach to health and welfare policy. A defining hallmark of the human species is our capacity to support each other in times of need.

    Of course, modern professional nursing, with its scientific knowledge and evidence-based practices, is very different from ancient nursing. But modern nursing’s origins—the organized impetus behind it—can be traced all the way back to the skilled hands that tended to that paralyzed boy. Even when nursing is missing from general history books and archeology studies, it is still there. You can see it sometimes only in outline, in relief: in every heroic tale of survival, there is an invisible hand that stopped the bleeding.

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    Nightingale is probably the most famous nurse who ever lived, but she had a less-celebrated contemporary named Mary Seacole. The two women’s motivations for wanting to nurse in the Crimean War of 1853–56 were parallel, but the legacies of their wartime nursing are remarkably different. Those differences are telling, even today. Both Nightingale and Seacole were experienced nurses, though with vastly different styles and goals. Both were deeply moved by patriotism and compassion to nurse British soldiers during the notoriously bloody war fought mainly on the Crimean Peninsula, in what is now Russian-occupied Ukraine.

    One became heralded as the founder of modern nursing; the other was mostly forgotten—or condescendingly referred to as “the Black Nightingale,” her story asterisked in relation to others’. In The Satanic Verses, Salman Rushdie remarks upon this contrast: “Here is Mary Seacole, who did as much in the Crimea as another magic-lamping lady, but, being dark, could scarce be seen for the flame of Florence’s candle.”

    Seacole, who was born in Jamaica under colonial British rule, learned healing practices from her mother, and worked as a nurse in many contexts, including being hired by the British Army to treat an outbreak of yellow fever on the island. When she heard that Florence Nightingale was organizing a group of nurses to care for British soldiers in Crimea, Seacole wanted to join up. “What delight should I not experience if I could be useful to my own ‘sons,’ suffering for a cause it was so glorious to fight and bleed for!” she writes in her autobiography, Wonderful Adventures of Mrs. Seacole In Many Lands, referring, as she often did, to the British soldiers as her sons and to herself as their mother. “I made up my mind that if the army wanted nurses, they would be glad of me.”

    Seacole sailed to London to volunteer, only to find herself stonewalled and rejected by Nightingale’s associates. Seacole, who was biracial, wrote of the grief of this moment:

    I was so certain of the service I could render among the sick soldiery, and yet I found it so difficult to convince others of those facts…Did the ladies shrink from accepting my aid because my blood flowed beneath a somewhat duskier skin than theirs? Tears streamed down my foolish cheeks, as I stood in the fast-thinning streets; tears of grief that any should doubt my motives.

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    So as Nightingale set off for the British hospitals near the front with her official group of all-white nurses, Seacole went also, but on her own. She made her way to the outpost of Balaclava, near the fighting, and there, she set up a shop/clinic/restaurant to aid the British soldiers. She called it the British Hotel.

    Sometimes her dual role as a nurse and provisioner is used to argue that she wasn’t a “true” nurse—because she was also selling chicken broth and cake and claret. But she did not have unlimited funds or a government salary. She could have sold wares and remedies anywhere, but she stated that she went to Crimea to nurse, and she did—even if she was not given the official title or the respect of a nurse.

    One became heralded as the founder of modern nursing; the other was mostly forgotten—or condescendingly referred to as “the Black Nightingale,” her story asterisked in relation to others’.

    Seacole rose each day at around 4 a.m., plucked and cut up chickens for dinner, swept the floor, rolled out pastry, mixed medicines, and boiled coffee. At daybreak, men would begin to come by for coffee. Then there would be a morning rush of sick and injured people. For many hours a day, she dosed out medicines and treated broken bones, wounds, and frostbite in winter while also roasting chickens and selling boots and linens.

    Her British Hotel served both lunch and dinner, and the kitchen closed at 8 p.m. Seacole was careful to note this closing time, and that she did not tolerate drunkenness, cards, or dice, likely because she knew of the rumors, later spread by Nightingale, that her establishment was a place of loose morals. (After the war, in a letter to her brother-in-law, Nightingale even suggested that the British Hotel was hardly better than a brothel.)

    Despite these many obstacles, Seacole was undeterred, driven to use her expertise to mend bodies. After the Battle of the Chernaya, on August 16, 1855, she described the scene: “The ground was thickly cumbered with the wounded…all wanting water, and grateful to those who administered it….I attended to the wounds of many French and Sardinians and helped to lift them into the ambulances….”

    When the besieged city of Sevastopol fell, she was there. “I dressed the wound of one of the officers, seriously hit in the mouth; I attended to another wounded in the throat, and bandaged the hand of a third, terribly crushed by a rifle-bullet.”

    Like Nightingale, Seacole believed that her identity as a woman, a kind of ur-mother, was key to her ability to nurse, but unlike Nightingale, she wasn’t wedded to the idea that she was beneath male physicians. She wrote of her collaboration with physicians on the sick wharf of Balaclava, where the wounded waited to be evacuated:

    With so many patients, the doctors must be glad of all the hands they could get. Indeed so strong was the old impulse within me, that I waited for no permission but seeing a poor artilleryman stretched upon a pallet, groaning heavily, I ran up to him at once, and eased the stiff dressings. Lightly my practiced fingers ran over the familiar work, and well was I rewarded when the poor fellow’s groans subsided….I stooped down and raised some tea to his baked lips.

    She waited for no permission. What could they do? Send her home? She was there in no official capacity and received no wage.

    Seacole’s nursing in Crimea did not receive nearly as much notice as Nightingale’s, but she did become a public figure in her own right. In 1855, the Morning Advertiser wrote of her wartime nursing with admiration:

    Her powders for the latter [diarrhea] epidemic are now so renowned, that she is constantly beset with applications, and it must be stated, to her honor, that she makes no charges for her powders. She is often seen riding out to the front with baskets of medicines of her own preparation.

    Meanwhile, Nightingale was also nursing through the war, most notably organizing hygiene and public health practices to clean up the hospitals, which had been so overcrowded and filthy that about 40 percent of all patients died. After Nightingale cleaned them up, and the British government sent a commission to remove dead animals from the water supply, mortality plummeted to about two percent. One of Nightingale’s most enduring public health accomplishments was her original use of statistics to show how these sanitary measures resulted in fewer infections and deaths.

    Nightingale knew that she had been hired to lead a political experiment and that some of the British Army physicians would have been happy to see her fail. Some officers found her disturbingly unladylike: for instance, she attended surgeries on naked men. The mere presence of her and her group of nurses was considered a subversion of the order of things in multiple ways. Nightingale was navigating Victorian anxieties around propriety, hierarchy, and women’s work outside the home, all on behalf of the British government and in a war zone.

    Nightingale responded to the delicacy of her political situation with absolute deference to the British social order. She wanted, badly, to prove that some women—certain trained, sober, proper, white Christian women— could be a new kind of nurse, essential to the health of the nation. She believed that the British Empire had a god-given duty to improve the world by bringing the “uncivilized” into “civilization.” Writing in the online journal Nursing Clio, Natalie Stake-Doucet, PhD, RN, pointed out that Nightingale “was a staunch supporter of British colonialism, even with the knowledge of the death and destruction left in its wake.”

    As nurse historian Carol Helmstadter describes in her book, Beyond Nightingale, Nightingale meticulously re-created the social order within her nursing workforce. She envisioned nursing as distinct from medicine, with a female-only chain of command, but she still maintained that nurses were in service to physicians, who were at the top. She, upper-class lady nurse superintendent, took orders from them. Her middle- class head nurses came next in the hierarchy, and the working-class assistant nurses were at the bottom. She could not, would not, usurp male medical authority in the hospital, and she took this stance of total obedience as far as it could go.

    If a physician had not ordered water for a dying man, Nightingale would not give the man water. If a patient craved a sweet or a cordial or a biscuit, and it had not been ordered by a physician, Nightingale would decline. Obedience was the priority; providing appropriate care was important, but secondary. Nightingale’s nurses were not allowed to establish rapport with the patients, because of Victorian anxieties over sex.

    Nursing, in reality, is so intimate, so relationship-based, so resistant to strict categorization and hierarchy, so rooted in moments of universal vulnerability, that it is potentially subversive.

    They were not allowed to read to the patients, either—Nightingale had been explicitly tasked with ensuring that no religious or political proselytizing would occur. Helmstadter writes of this oppressive dynamic: “Nightingale locked all the nurses—Sisters, ladies, and working class—into the nurses’ quarters at 8:30 every night and slept with the key under her pillow.”

    After the war, Seacole returned to England to find she was bankrupt as a result of having gone to Crimea. A letter to the editor of the Times in 1856 from a Crimean War veteran read, “While the benevolent deeds of Florence Nightingale are being handed down to posterity with blessings and imperishable renown, are the humbler actions of Mrs Seacole to be entirely forgotten, and will none now substantially testify to the worth of those services?”

    Eventually, British Army officers held a benefit to raise money for Seacole, and she wrote her autobiography, but she would die in relative obscurity. One group always remembered her well: In 1954, the Nurses Association of Jamaica named its headquarters the Mary Seacole House.

    In 2016, there was a drive to rectify Seacole’s disappearance from the narrative by placing a bronze statue of her on the grounds of St Thomas’ Hospital in London, the hospital where Nightingale established a school of nursing. One Nightingale scholar was so upset by the plan for the statue that she established a society with the goal of derailing the project, even though it had the backing of the Royal College of Nursing. It was a bizarre level of resistance to a statue—or maybe it wasn’t. Nevertheless, Seacole stands at St Thomas’ now, cast in bronze, striding forward, her eyes fixed on the horizon.

    Nightingale, of course, was both remembered and mythologized, and her emphasis on hierarchy and propriety has permeated nursing—as seen in the often extreme rigidity of nursing education, even today, with some nursing students doing their clinical training penalized for wearing the wrong socks or having a visible tattoo or natural Black hair.

    Why has Nightingale held such singular power, given that the true history of nursing is far richer and more complicated than the Nightingale lone-hero myth? Helmstadter argues that Nightingale’s model quickly became dominant, but not necessarily because it was the most effective: “It was the class-structured British model, made glamorous by the socially elite Nightingale, which would become the transnational archetype after the war.”

    In other words, it was the very fact that Nightingale’s nursing replicated a restrictive social structure that made it so durable. Perhaps this is because nursing, in reality, is so intimate, so relationship-based, so resistant to strict categorization and hierarchy, so rooted in moments of universal vulnerability, that it is potentially subversive, especially when done by people of all backgrounds, races, and classes. Think of Seacole: making cakes, prescribing medicines learned from her Jamaican mother, not waiting for permission. Nightingale tamed nursing, and for some people, that was a great relief.

    So what is radical about the true sweep of nursing history? Mark Lazenby, PhD, APRN, puts it this way: “Nursing is a profoundly radical profession that calls society to equality and justice, to trustworthiness and to openness. The profession is, also, radically political: it imagines a world in which the conditions necessary for health are enjoyed by all people.” Whether you are a nurse or not, imagine it. Imagine a world in which the conditions necessary for health are enjoyed by all people. Nurses have a unique ability to bring such a world to fruition, if they choose it. The rest of us do too.

    When we understand nursing as the skilled modern expression of a fundamental, universal and ancient human instinct, we can also understand ourselves differently: Maybe it is not inevitable that we dominate each other, organize ourselves into false hierarchies. Maybe we don’t have to live according to a cruel and distorted fantasy of survival of the fittest written into laws and policy that leave people behind.

    Instead, we could organize ourselves around the very old, very powerful idea that everyone, everywhere deserves care. Maybe we were made for that.


    Taking Care

    Taking Care: The Story of Nursing and Its Power to Change Our World by Sarah DiGregorio is available via Harper.

    Sarah DiGregorio
    Sarah DiGregorio
    Sarah DiGregorio is the critically acclaimed author of Early: An Intimate History of Premature Birth and What it Teaches Us About Being Human and Taking Care: The Revolutionary Story of Nursing, coming in May 2023. She is a freelance journalist who has written on health care and other topics for the New York Times, Washington Post, Wall Street Journal, Slate, Insider, and Catapult. She lives in Brooklyn, New York, with her daughter and husband.

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