FLORENCE NIGHTINGALE (1820-1910), the heroine of the Crimean War, is still best known as the major founder of the modern profession of nursing and as a hospital reformer. Yet her broader contribution to public health care and social reform--notably of a public health care system based on evidence and featuring health promotion and disease prevention--is still scarcely known, although it is recognized by leading experts. With the benefit of hindsight we can see her as a major architect of the modern health care system. Nursing leader Monica Baly referred to Nightingale as the 'greatest Victorian of them all' and observed in Nursing and Social Change (1995):
Had Miss Nightingale's advice on the
Poor Law been taken and her plans
accepted there might have been a
universal health service before 1948.
Nightingale's achievement in introducing professional nursing into the dreaded workhouse infirmaries was one of the greatest contributions of her long life, and it is not possible to imagine a National Health Service without it. Prior to her reforms there were no trained nurses for workhouse patients only 'pauper nurses', or women inmates who were not themselves sick, notorious for stealing their patients' food and gin, no permanent medical staff, only visiting doctors, while shared beds were but one of the santitary defects. Nursing itself, and hospitals as institutions, would have improved without Nightingale, for many people were working on them. But no one else was bold enough to take on the workhouse infirmaries, the 'real hospitals of the sick poor', as they have been called, for they held five people for every one in an ordinary hospital.
Visitors such as Louisa Twining (1820-1912) sought to eliminate abuses in the workhouses and doctors formed an Association for the Improvement of the London Workhouse Infirmaries, which sought various improvements. But Nightingale's vision (shared with her colleague Dr John Sutherland) was much bolder: that the care given in the workhouse infirmaries should be just as good as that in the best nursed civil hospitals in the suburbs. The realization of that vision began in 1865, in the Liverpool Workhouse Infirmary, with nurses and a superintendent, Agnes Jones, who had trained at the Nightingale School at St Thomas' Hospital. It was funded by Christian philanthropist William Rathbone.
Nightingale's strong faith and the 'call to service' she experienced in 1837, at the age of sixteen, is critical to understanding her motivation and the methodology she evolved, which shaped her work. Initially she interpreted her 'call to service' to mean nursing, then not a profession at all but a lower-class and ill-paid occupation. Her family would not permit her to nurse, a source of great frustration, as she tried to act on this call. However, she was allowed to visit hospitals and workhouses, and this she did in her early twenties. A little later she came to understand the call to mean to save lives, for which nursing was but one possibility. Indeed, when she discovered that administrative blunders and bad hospital siting and construction cost so many lives she increasingly directed her attention to these issues.
Nightingale's workhouse visits were to have a great impact. In particular, her tour of the great Marylebone Workhouse in the early 1840s 'broke her heart', as she later wrote. She realized she could do nothing to change the wretched conditions she saw but resolved to do something when she could. The opportunity did not arise until well after her return in 1856 from the Crimean War. She was now feted as a heroine, a status she abhorred, but found useful for getting people's attention and assistance. In January 1864 the Liverpool philanthropist William Rathbone offered to fund a 'lady visitor' at the Liverpool Workhouse Infirmary. Nightingale persuaded Rathbone that skilled nursing was needed, not merely a lady visitor, and nominated Agnes Jones (1832-1868) who had trained at Kaiserwerth and St Thomas' Hospital. …