How a war with Russia led Florence Nightingale to revolutionise nursing

When Florence Nightingale arrived at the Scutari military hospital in Turkey in 1854, conditions there were almost as bad as on the battlefield. As Britain and its allies pushed back against Russian expansionism in the Crimean War – not far from recent fighting in today’s Russian invasion of Ukraine – the death rate for British soldiers soared, though many more were dying of preventable diseases than battle wounds.

The young English nurse saw soldiers festering in filth, many of them lying on the bare floor among the rats. Dirty bandages covered rotting wounds, and the neglected soldiers had to contend with lice, fleas and the stench of disease in the unventilated ward. There was about one bathtub per 150 soldiers, though that hardly helped: a dead horse had been left to rot in the water supply.

Nightingale and her team of 38 women immediately went to work on issues that others – including many of the doctors – saw as unimportant, such as sanitation and food quality. Instead of waiting for the 2,000-mile supply chain from England to deliver important goods, Nightingale went out into Constantinople – today’s Istanbul – and purchased soap, towels, clean linens and fresh food from local markets. She and her team quickly set to work disinfecting the hospital. Nightingale essentially became a hospital administrator, taking charge of procurement, hygiene and nutrition. Death rates declined, and Nightingale was hailed as an “angel”.

The “lady with the lamp” – as she was soon known for tending to patients at all hours of the night – would become the mother of modern nursing and one of the most admired women of her era. Yet even she was not exempt from the disregard and resistance toward nurses among the male professions of the military and medicine.

Her tendency to circumvent existing power structures irked more than one higher-up. “There is not an official who would not burn me like Joan of Arc if he could, but they know that the War Office cannot turn me out because the country is with me,” she wrote during the war. She would win over many detractors who soon witnessed her ability to get things done, whether it was securing fresh produce or obtaining basic supplies from Queen Victoria herself.

After observing the administrative failures at Scutari, Nightingale would dedicate her life to ensuring that what she witnessed during the war would not happen again, arguing that hygienic patient care was a necessity and not a luxury. She was a dedicated public reformer who spent much of her life advocating to make nursing a profession that would demand respect from both doctors and the public, and she would establish the first professional nursing school.

As we celebrate National Nurses Week, which began Friday and ends on the 202nd anniversary of Nightingale’s birth on Thursday (marked as International Nurses Day), many countries – including the United States – are facing a crisis in nursing. Much like Nightingale in the Crimean War, nurses are often forced to bear the brunt of structural failures over which they have little control. They are undervalued and overworked. The “Great Resignation” has hit the nursing field particularly hard, and nearly 200,000 nursing jobs are expected to go unfilled through 2030. A recent survey found that more than one-third of nurses plan to leave their jobs by the end of the year, and nearly half of them cited burnout as the reason.

The Covid-19 pandemic only exacerbated existing problems, particularly in hospitals, where the brunt of care often falls to nurses who are asked to work long hours for pay they consider insufficient. In demanding safety and dignity in their working conditions, nurses today are carrying on the mission begun by Nightingale: seeking to ensure that they are treated as professionals – not sacrificed as martyrs.

After more than a year and a half in Constantinople – across the Black Sea from the fighting in Crimea – Nightingale returned to Britain, but her work continued. Schooled in maths from a young age, she had a passion for statistics and wanted not only to understand what had led to so many deaths at Scutari but to present that information to the public in a way that was easy to grasp. The highly visual charts she would publish were revolutionary for their era. Instead of reciting dry scientific statistics, she used a colour-coded rose diagram to illustrate how deaths from preventable infectious diseases far outnumbered battlefield casualties in Crimea.

Many now hail Nightingale as a pioneer in data visualisation, and she became the first female member of the Royal Statistical Society, but her interest was rooted not simply in an intellectual pursuit. She wanted to use data in her quest for health reform. In a way that is strikingly modern, Nightingale believed patient care to be a social and political issue, understanding that high mortality and low income are closely tied (a phenomenon that persists today: poor Americans died of Covid-19 at much higher rates than their wealthy counterparts). As Nightingale once wrote in a letter: “Whenever I am infuriated, I revenge myself with a new diagram.”

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In 1860, she founded the Nightingale Training School for Nurses, which experts consider the first secular nursing school. (Nightingale had cobbled together her own education at several hospitals as a young woman.) “There was no training before,” says Lynn McDonald, a Nightingale scholar and professor emerita at the University of Guelph in Canada. “People who were called nurses before were just hospital employees who usually didn’t know very much and really did more of a cleaning job than anything else.”

Thanks to Nightingale, nurses undertook what we understand as patient care, something she had first outlined in her 1859 book “Notes on Nursing”. In it, she wrote: “I use the word nursing for want of a better. It has been limited to signify little more than the administration of medicines and the application of poultices. It ought to signify the proper fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet.”

Her school’s one-year program delivered the first formal training in modern nursing, teaching elementary science and medicine. Nursing had often been reserved for working-class women, but by elevating this work to a profession, Nightingale helped make it more acceptable for women from a range of backgrounds to become nurses.

Nightingale’s vision of nursing would soon migrate across the Atlantic to the United States, thanks in part to wide publication of her writings. The Union Army even consulted Nightingale on how to manage field hospitals during the Civil War. By 1873, little more than a decade after Nightingale opened her school in London, Bellevue Hospital in New York City had started one of the first US nursing programmes, basing its curriculum on Nightingale’s principles.

In the intervening century and a half, medical science has grown by leaps and bounds. (Germ theory was not yet popularised when Nightingale founded her school.) Nurses today go through several years of advanced education, and many nurse practitioners have responsibilities similar to those of doctors.

While training for nurses has vastly improved, the way they’re treated has not always reflected those changes. That's why so many in 2022 are turning to other fields entirely. “Nurses nowadays are still underpaid and still don’t get the respect,” McDonald said. “Those problems remain. They’ve obviously diminished greatly since [Nightingale’s] time, but they’re still there.”

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