What is the history of nursing with reference to Florence Nightingale?
Florence Nightingale is often credited for laying the foundations of professional nursing after the
Crimean War. Nightingale established that health is directly linked to environmental factors such
as fresh air, clean water, efficient drainage, and direct sunlight.
Nursing is the profession that focuses on providing optimal care for individuals in recovery so
that they can return to living a healthy life. Nurses are health care professionals that offer support
in the medical environment. They have varying levels of prescription authority. While they are
traditionally within the ordering scope of physicians, these care providers are often permitted to
practice independently in a variety of settings.
When it comes to the history of nursing, some early records of people providing medical care to
the sick and injured may be considered the very first nurses. For example, the Hippocratic
Collection that existed in the fifth century BC described male “attendants” who offered skilled
care and observation for patients. There was also a description of the nurse role in 600 BC in
India, recorded in Sushruta Samhita, Book 3, Chapter V.
Members of certain religious orders like monks and nuns also provided care traditionally. There
are Christian, Buddhist, and Islamic examples of this. Even today, modern nursing has some
religious roots.
During the Reformation of the 16th century, nursing as a profession experienced a major setback
for approximately 200 years when Protestant reformers shut down convents and monasteries,
which prevented nuns from fulfilling their nursing role. Even the traditional caretakers who
provided nursing care were removed from their positions.
Florence Nightingale is often credited for laying the foundations of professional nursing after the
Crimean War. Nightingale established that health is directly linked to environmental factors such
as fresh air, clean water, efficient drainage, and direct sunlight. This, along with her Notes on
Nursing, and her active involvement with injured and sick soldiers made her the world’s first
nurse theorist. She became a model of professional education, believing that nursing could
become a liberating professional option for women of her time.
Her recommendations were built upon the findings and successes of Mary Seacole and other
Jamaican “doctresses” who used hygiene and herbs to heal wounded soldiers. Another important
figure in the history of nursing is Agnes Hunt who served a pivotal role in the emergence of the
orthopedic hospital. She is considered the first orthopedic nurse.
In 1863, Red Cross chapters began appearing thanks to the establishment of the International
Committee of the Red Cross. They provided employment opportunities for nurses, making it a
full-fledged profession. Even Catholic orders such as Sisters of St. Mary, Little Sisters of the
Poor, St. Francis Health Services, Inc. Sisters of Mercy, and Sisters of Charity built hospitals that
offered nursing services during this time.
In the early 1900s, hospital-based training came to the fore. While a lot of nurses worked during
World War I, the profession truly developed during World War II. Now in this modern era, there
are now undergraduate and postgraduate degrees for nursing. Nursing research continues to
advance and develop. Nursing is now recognized as a distinct academic discipline. Nurse
education has also developed to the point where nurses may earn specialized credentials, which
further diversifies the field. Even the traditional roles of nurses are changing, and we can only
expect the field to evolve as new technologies are developed.
Beginning of Modern Nursing
In the realm of nursing, Florence Nightingale is the most well-known name. Her work was
crucial in developing modern nursing practice. She worked tirelessly to ensure that the patients
in her care had all they needed to get well.:Her Environmental Theory revolutionized nursing by
establishing sanitary working environments for patients and nurses.
Florence Nightingale, the creator of modern nursing, was an English social reformer and
statistician. During the Crimean War, Nightingale rose to fame as a manager and educator of
nurses, organizing treatment for wounded troops.:People often associate the beginning of nursing
with the work of Florence Nightingale. Let's go back in time to the beginning of modern nursing.
Florence Nightingale’s Early Life
Nightingale was born in Florence, Italy, on May 12, 1820, the city that inspired her name.
Nightingale was the younger of two girls from a wealthy British family who belonged to upper-
class social circles. Florence's older sister, Frances Parthenope, was named after her birthplace,
Parthenope, a Greek colony now part of Naples.
Florence Nightingale's family resided in Embley, Hampshire, and Lea Hurst, Derbyshire, after
returning to England in 1821. William Smith, an abolitionist and Unitarian, was Fanny's father
(and Florence's maternal grandfather).:William Edward Shore was Nightingale's father (who had
changed his surname from "Shore"), and Frances ("Fanny") Nightingale, née Smith, her mother.:
Nightingale's father was a wealthy landowner with two estates: one in Lea Hurst, Derbyshire,
and the other in Embly, Hampshire.:Mary née Evans, William's mother, was a niece of Peter
Nightingale. William acquired his estate at Lea Hurst from him and took on the name and arms
of Nightingale.:Being born into a wealthy household had several advantages, such as a decent
education for Nightingale.
Education of Florence Nightingale
Florence's liberal-humanitarian outlook was instilled in her by both sides of her family.
Nightingale's father educated her. "Florence benefited from their father's progressive ideas on
women's education," according to a BBC documentary.:History, mathematics, Italian, ancient
literature, and philosophy were among the subjects they studied.:
The modern term for Florence Nightingale education is classical education. Classical education
strives to revive a traditional and historic "liberal" education by reinstating a thorough study of
the liberal arts, natural sciences, and "great books.":The more scholarly of the two sisters,
Florence showed an outstanding talent for collecting and assessing material from an early age,
which she would use to great success later in life." On tour to Europe in 1838, Nightingale met a
significant figure who profoundly impacted her life.
Florence Nightingale’s Early Influences
Florence Nightingale got introduced to the English-born Parisian hostess Mary Clarke, whom
she connected with during a family trip to Europe in 1838. "Clarkey" was a lively hostess who
didn't care about her appearance.:While her beliefs didn't necessarily align with her guests, she
"couldn't bore anyone," according to Florence Nightingale.:Despite their 27-year age difference,
Clarkey and Florence remained close friends for 40 years. Clarke demonstrated that women
could be equal to men, something Florence's mother had not taught her.
Nightingale was a philanthropist from an early age, caring for the sick and impoverished in the
village adjacent to her family's land. In February 1837, while visiting Embley Park, Nightingale
had the first of several experiences that she believed were divine invitations.:They generated a
strong desire to devote her life to the service of others. Nightingale eventually realized that
nursing was her calling, and she considered it to be her divine destiny.
Her parents were unhappy when she told them about her plans to become a nurse and banned her
from pursuing the necessary training. A young lady of Nightingale's social position was expected
to marry a man of riches. This was to ensure her social standing.:During the Victorian Era,
English women had essentially no property rights, rather than taking up jobs that the higher
social classes regarded as lowly menial labor.
Despite her mother and sister's displeasure, she refused to accept the traditional position of a lady
of her rank as a bride and mother. In the face of hostility from her family and the limited social
code for affluent young English women, Nightingale worked hard to educate herself in the art
and science of nursing. Nightingale continued her journeys to Greece and Egypt with Charles
and Selina Bracebridge.:Nightingale rescued a small immature owl from a mob of children
torturing it in Athens, Greece, and named the owl Athena. Nightingale routinely carried the owl
in her pocket till it perished (soon before Nightingale left for Crimea)
The year 2020 marks the bicentenary of the birth of Florence Nightingale, the forerunner of
modern nursing, i.e., the ideal time to analyze and reflect on her contributions and the impact on
nursing professionalization. Based on Dewey’s premise, “The past is key to understanding the
present”. This theoretical reflection proposes to describe Florence’s contributions to holistic
critical thinking in nursing(1).
Nightingale left a legacy of teachings and cornerstones that underpin the profession to this day.
Her idealism runs through the historical trajectory of nursing through the records left, as current
as 200 years ago. The alignment of current trends with Nightingale’s theory and philosophy is
impressive.
Florence’s contributions are prominent in international literature, especially when her
fundamental principle is discussed in her writings, i.e., healing (healing process or healing act),
representing the gathering of all aspects of the body, mind and spirit, to achieve and maintain the
integration of a balance, which denotes holistic nursing care(2-4). Nightingale, in the distinction
between therapy and healing, explains that therapy can always be instituted, but healing is not
always possible. Removing the signs and symptoms of a disease does not heal the disease, and
involves only one dimension of care, the physical dimension, leaving the spiritual dimension in
the background(5-8).
In this sense, it is important to highlight that Nightingale introduced, in the context of care,
colors, light, music, pets, exercise, flowers as aspects to be emphasized in a favorable
environment in search of healing, reaffirming the bases of environmental theory and the premise
that the environment influences people’s health(5).
It is stated that, in order to become a nurse sensitive to holism, it requires the understanding, in
the care encounter in which it is present, of all the facets presented by patients. This genuine
presence requires nurses to first understand all aspects of themselves(3); in other words, it is
paramount, in the care process, that nurses also understand themselves in their entirety to, from
that, be able to understand patients in all their needs, be they physiological or spiritual.
In this way, spirituality in nursing is one of the pillars of holistic nursing, with emphasis on
characteristics such as: harmony, balance and interaction in a functional totality of its aspects;
qualities and potential of individuals and/or collectivity; person-centered or community-centered
care, focusing on it as an indivisible unit and in constant interaction with the environment;
comprehensive attention to the individual’s and/or the community’s basic human needs,
addressing biopsychosocial and spiritual aspects; use of technology applied to human health;
development of natural methods in order to improve their health(6-7).
Currently, nurses are being challenged to boost Florence’s ideals through critical thinking,
aiming to provide humane and competent care based on the best scientific evidence against the
backdrop of unprecedented changes, which have occurred worldwide, requiring nurses to be able
for critical and holistic thinking in clinical decision-making and care management in different
contexts of practice. Thus, it is important to highlight the fundamental concepts of the course
proposed by Nightingale in the 1850s. Her precepts, created with wisdom and from an expanded
world view, revolutionary for the time, echo through the decades, influencing science nurses
until today and that show their contributions to the constitution of nurses’ holistic critical
thinking(2).
Florence Nightingale’s legacy: central principles and concepts of environmental theory
Nightingale’s life trajectory was immersed in complexity, partially revealed in her 14,000 letters
and 100 books, reports, and bulletins. The precursor of nursing believed that nursing was her call
from God, her curious and passionate mind for nursing and her relentless desire to transform
opened doors challenging the social context, in which she encountered persistent opposition, as
she was always a visionary and courageous woman. Furthermore, she advocated that patients
receive civilized care, regardless of the social situation experienced(5).
Faced with this premise, this reflection article seeks to provoke the reader to reflect on
Florence’s trajectory, examining her legacy with the following question: does Nightingale’s
theory and principles contribute to the development of nurses’ holistic critical thinking today?
The answer is affirmative, since, in this context, holistic nursing is based on nursing knowledge,
theories, research, doing mediated by experience, intuition and creativity. Additionally, “it
includes as a function and objective of nursing care and contribute to the healing of people in
their entirety from birth to death”, as recommended by Florence Nightingale(6).
In 1859, Florence wrote Notes on Hospital, and, in 1860, Notes on Nursing. These compendiums
explained hygiene standards, treatment of injuries, ventilation and other concepts necessary for
building nursing science. Her standards on nutrition, sleep and exercise continue to guide health
promotion to the present day(3).
The three principles of Florence’s environmental theory are healing, leadership, and global
action. The principle considered basic was healing, and the secondary ones, leadership and
global action, were principles necessary to support healing at its deepest level. With regard to
Florence’s educational model, one must take into account the fact that it is based on the
anticipation of care and attention to patients’ needs, providing guidance for nurses to perform
activities in order to meet patients’ needs(8).
Florence Nightingale’s environmental theory is based on five points, which she believed to be
essential to obtain a healthy home, such as clean water and air, basic sanitation, cleanliness and
light, as she believed that a healthy environment was fundamental for healing. In her time, she
reported that noise was harmful and disturbed the rest of individuals, so the conversation of
caregivers should be avoided, as well as agitation, unnecessary questions. On the other hand,
Florence recommended nutritious food, beds and appropriate bedding and personal hygiene for
individuals(8).
In this theoretical and practical context, nursing was seen as a means of “putting the individuals’
structure in such a state that they have no disease or can recover from the disease”, placing
individuals in a condition in which nature can preserve or recover health - preventing or curing
illness or injury. Health, according to Florence, is defined as the ability of individuals to properly
use all their skills and competencies in the perspective of caring for themselves and others(3).
Florence defended a solid knowledge base in nursing and anchored in principles; if this were not
possible, it would be like building a house with a weak foundation, i.e., it will fall. This premise
becomes even more current when applied in nursing education, i.e., nurses trained with strong
bases and principles will have subsidies to provide quality care, applying their critical thinking to
making accurate decisions for the benefit of patients under their responsibility. Florence argued
that nurses should accurately observe their patients and report the real state of health in an
orderly manner to the physician(5).
Based on Nightingale’s principles, we can evidence her search for respect for humanity and
social justice, as she defended respect for the human person regardless of social class, physical
disabilities, hygiene conditions or occupation. While her family sought to include her in an elitist
culture, her spirituality called her to serve ordinary people. For Nightingale, a true nurse should
renounce class distinctions and always focus on the person(2).
Faced with soldiers wounded in the Crimean War, she insisted that each soldier be treated with
dignity and kindness, a radical departure from military custom. In light of this, we highlight the
efforts of hospital institutions to provide humane and patient-centered care. We can now observe
the focus on safety and meeting users’ real health needs, through quality programs and through
direct care provided by nurses, proposing to be closer to their patients(5).
Florence Nightingale: repercussions of her teachings for modern nursing
Modern nursing has (re) invented itself; however, it has retained numerous principles of
Florence’s environmental theory in its scientific bases. It also incorporated new technologies, to
guarantee the execution of human and singular care to human beings, always guided by the
science and art inherited from Florence Nightingale, prioritizing the comfort, the technique and
the environment suitable for healing patients.
Nightingale’s commitment to staying with patients in times of suffering is the very basis of
patient-centered care, which becomes a very current and necessary principle for the full recovery
of patients(5). For this, individualized care to patients’ needs needs to be implemented. Currently,
such care, also called nursing interventions or activities, ended up being researched and polished.
They were cataloged in the form of international classification of results and interventions, based
on the standardized language of nursing diagnoses, structured from the real or potential problems
of individuals, who need nursing assistance.
Florence addressed the organization of care delivery with a focus on obtaining a healing;
currently, we can find this determination in the Nursing Process, understood as a methodological
instrument used by nurses to organize and plan nursing care and structured in five stages:
research, nursing diagnoses, planning, implementation, and assessment.
Modernity has brought significant advances, which have strained the qualification of nurses’
being and doing; the insertion of new care and teaching technologies has been widely
implemented. In this direction, Florence’s teachings have left their mark, influencing the nursing
routine, as it has always emphasized the importance of nurses’ commitment to care, as well as
learning based on practice.
Numerous ways of doing nursing are currently presented as novelties, denoting the rescue of
innovations that Florence, in her time, created and implemented, only with the difference of
today taking on a new guise, such as risk stratification, prevention and control of infections,
cleanliness, fresh air, comfort, considering that the environment directly affects the health of
individuals through music, colors. The possibility of inserting pets or therapeutic animals are
practices indicated and implemented by Florence(8).
Therefore, in this process, innovating in nursing presupposes taking into account the principles
and concepts learned from Nightingale, in addition to the theories proposed by countless nursing
theorists. Care territories and contexts should be sought to, in this way, modify forms of care
devoid of scientific knowledge and the necessary structure for quality nursing care.
Thus, memories of the past related to the origins of care science must be preserved in order to
understand and modify the being and doing of nurses in the present and in the future. This is the
main objective of modern nursing. In this context, we highlight the importance of holistic
nursing and the development of critical thinking, so urgent today, in order to qualify teaching,
research, and care(2).
One of the greatest challenges of modern nursing is to meet human needs in their entirety. These
will be better identified by nurses who think and practice nursing in a holistic perspective,
developing professional training focused on critical thinking in their care contexts and practices.
Thus, said innovations in nursing will consist of the necessary and pressing rescue of Florence’s
teachings(2-3).
Thus, this brings us to the current world health scenario that we are experiencing with regard to
the health situation in the midst of Florence’s bicentennial. The scientific, human, ethical and
social commitment of nursing science in times of pandemic is reaffirmed, recognizing the value
of philosophy which, in turn, is even more necessary to maintain her environmental theory
principles today. It should be explored in depth in the spaces of training and assistance,
providing the basis for supporting nursing education and the development and practical
application of critical thinking of future nurses, aiming at qualitatively intervening in human care
with a view to prevention and healing diseases in general. Thus, Florence Nightingale’s
principles can directly reflect on the process of training and care in different contexts of teaching
and care.
Holistic nursing and nurses’ holistic critical thinking
Holistic nursing is based on nursing knowledge, theories, research, doing mediated by
experience, as well as intuition and creativity(6). In this perspective, nursing practice incorporates
theory, practice and subjective aspects, as well as intuition and creativity, which are decisive in
how this care model will be constituted.
Florence’s legacy with regard to holistic nursing, as well as critical thinking, is evident when we
analyze the historical path of meeting humanity’ needs, and has been at the forefront in providing
care and comfort to patients. Moreover, nursing was also concerned with health education for the
population. Florence encouraged her students to consider cultural and religious diversity, as well
as the values, needs and concerns of individuals in their uniqueness, without neglecting the
economic and social aspects that involve care(5).
Florence’s historical trajectory shows the importance of nurses capable of thinking critically and
holistically to deal with situations of adversity, as was the case in the Crimean War. Florence
experienced scenarios of uncertainties, adversities and care contexts for which she needed to
apply her highly developed critical thinking to the feminine patterns and patterns of her time(3).
Holistic critical thinking can be defined as thinking with quality, i.e., a judgment process
centered on deciding what to believe or what to do. In doing so, the critical thinker should not be
negative or cynical, but reflective and balanced, requiring people to express some kind of reason
or basis for whatever they are saying(9).
According to Florence’s view, nurses should think critically about patient care, doing what was
appropriate and necessary to help them heal, reinforcing the importance of developing in nurses
the critical and holistic way of thinking in the daily life of be and do nursing(8).
Starting from this way of thinking, at that time, evidence-based practice was carried out in a very
healthy way for the performance of nursing procedures and care, as research was still scarce.
Even so, Florence can be considered a pioneer in conducting research on evidence-based practice
and the application of critical thinking. Florence’s environmental theory strongly supported
nursing and also for the development of critical thinking, contributing to evidence-based nursing
practice and beyond these very important aspects of nurses’ training and clinical practice(5,8).
Like Florence, it is worth highlighting other nursing theorists, such as Watson, Horta, King and
Leninger, who impacted society by considering not only the physical aspects of a human being,
but also the interconnection between each individual’s body, mind and spirit. It must be
considered that, in the last three decades, nursing has gone from a model focused on
physiological and scientific aspects to a model focused on nursing science, care and healing,
seeking to consider the cultural aspects, values and beliefs connected to the act to care(10).
In Brazil, we can describe this movement as a paradigm shift from a biomedical-technicist model
to a care model based on the art and science of technical-scientific and humanistic care(10). This
movement boosted the emphasis on Florence Nightingale’s philosophy and teachings, awakening
in nurses the capacity and a need to think holistically using the brain, heart and hands in creating
healing environments, in order to effectively take care of the trinomial dimensional body-mind-
spirit.
Accordingly, it is possible to note a critical thinking strongly influenced by the contributions of
Florence’s legacy, which direct nurses towards a comprehensive and humanistic approach, in
which the ability to listen and to consider a person in their entirety predominates. In this
direction, nurses who develop holistic critical thinking in nursing training will have better
performance by applying cognitive, behavioral and habits of the mind and, consequently,
Florence Nightingale’s principles and theory. In this regard, it will be possible to care for
individuals as a unique human being, i.e., singular, in order to consider the needs related to the
physical body (physiological aspects), the mind (emotional aspects) and the spirit (spiritual
aspects)(10).
The scarcity of research published in Brazil addressing the influence of Nightingale’s theory on
nurses’ holistic critical thinking is one of the limitations of this reflection. This denotes a
knowledge gap to be filled, given the importance of this theme for nursing education and care.
Concerning the contributions of this study, the possibility of impacting professional practice
through knowledge and recognition of Florence’s legacy for training and professional practice is
highlighted, in addition to enabling students and nurses to understand Nightingale’s theory.
FINAL CONSIDERATIONS
This theoretical reflection ends with evidence of the fundamental importance of the contributions
of Florence Nightingale’s legacy to critical thinking in nursing. Moreover, it is seen that her
theory is decisive in filling the knowledge gaps related to the holistic dimension in carrying out
the nursing process, aiming at accurate clinical decision-making of students and nurses. It is
imperative that nurses apply Nightingale’s holistic philosophy and assumptions in nursing, as
patients expect compassion, in addition to specialized nurses focused on the totality of human
needs.
Nightingale’s legacy allows us to meet these expectations, as her philosophy includes
encouraging self-care, art and nursing science, covering related theories, in addition to research
and ethics. Nightingale demonstrated by example in her trajectory, spreading, in her scientific
productions that her fundamental principle was to care with a focus on prevention and healing
through the process that unites all the singular dimensions that constitute the whole of
individuals to achieve and maintain integration and balance. Thus, to guarantee this focus on
nursing training, the commitment that teaching and caring are verbs and actions to be conjugated
beyond the discourse and carried out in the genuine practice of being and doing by nurses is
reaffirmed.
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