Florence Nightingale's Notes on Nursing
“The nurse ought to be the patients’ defender and keeper”
Tomorrow, May 12, marks International Nurses Day—and Florence Nightingale’s (1820-1910) birthday. You might know her as the “lady with the lamp” who tended to ill soldiers during the Crimean War—but she did so much more than that.
Nightingale’s research and activism drove sanitary reforms that dramatically decreased mortality during the war and after; later, she founded the first modern professional nursing school. She was also a respected statistician and an early feminist—a Victorian woman who refused to marry so she could focus on her vocation.
In short, Nightingale was a fighter. As she wrote later,
The nurse ought to be the patients’ defender and keeper1
Nightingale’s weapon of choice was the pencil: Along the way, she took an extraordinary number of notes. In fact, her collection of papers at the British Library is second only to William Gladstone’s in size.2 Those who worked with her recalled that she always had a pencil and notebook close at hand.3
So, as we honor nurses this week, let’s take a look at Florence Nightingale and the notes she took as she advocated for modern nursing.
Nightingale’s Commonplace Book
Born into a wealthy British family, Nightingale was not expected to have a profession—certainly not nursing, which carried an unsavory reputation at the time as it usually fell to untrained, working class women with no authority in the hospital.4
Still, Nightingale was lucky to have a father who believed women should be educated at a time when that was not often the case. So, he took it upon himself to give Florence and her sister an education.
Drawing on his own education from Trinity College, her father taught the sisters geometry, geology and languages like French and Italian. As an accompaniment to her education, Nightingale kept a commonplace book to record what she learned.
Against her family’s expectations, the young Florence was moved to become a nurse from a young age. She felt this as a calling—a spiritual visitation akin to the religious callings she also experienced.5
Despite her family’s protests, while traveling, Nightingale secretly spent time at the Deaconess Institution at Kaiserswerth where she received her first training as a nurse.
While there, she took notes on the deaconess’ schedules. For example, Nightingale observes:
They must only sit up every 3rd night & must have coffee for their watch.
Showing an early proclivity for assembling data points, Nightingale also creates a chart of information about the deaconesses. It includes the following categories:
Name
Parents & Dwelling
Age
How she announces herself
Account of her life/ Day of Blessing
Tests money & character
Dr. & health
Account of her Time / where she has been sent, where she has served
Day of Entrance
Conduct & Education during the Probationary…
At this point, Nightingale had proven herself as a nurse and her family gave up the fight, allowing her to take the position of Superintendent of the “Upper Harley Street Establishment for Gentlewomen during Temporary Illness.”
Whether she knew it or not, Nightingale was training to revolutionize nursing. Once she heard about the devastating conditions British soldiers endured during the Crimean War, she was ready to help.
Nightingale’s Notes from the Crimean War
When Nightingale arrived at the Military hospital in Scutari, she knew something was terribly wrong. Soldiers were dying in droves, but not from the wounds received in battle. Rather, they were afflicted by something far more insidious: the hospital’s sanitary conditions.
Shockingly, the Scutari hospital had been built above a sewer and the barracks had terrible ventilation. No wonder so many soldiers died from typhus, cholera, and dysentery.
In other words, the hospital was more deadly than the battlefield. During Nightingale’s first year at the front, 19,000 soldiers died from illnesses, while only 4,000 died from battle wounds.6 By the end of the war, Nightingale managed to dramatically reduce mortality rates from illness to those comparable with a city like Manchester.7
Along the way, Nightingale took copious notes on the nurses she worked with, deciding whom to dismiss or keep. The highest compliment a nurse could earn from Nightingale was to be “perfectly sober.” Later, she would return to these notes to write references.
The reforms Nightingale proposed were necessary, though challenging to coordinate. She pushed for clean water, proper ventilation, and sanitized bedding. Beds, she argued, should be appropriately spaced to aid in ventilation; she drew maps of how she wanted them arranged.
Nightingale returned from war a national hero determined to use her fame to improve medical conditions in England.
Nightingale’s Writing Notes
Nightingale set to work conducting research, gathering statistics to support her arguments about sanitary reforms. Her writings total over 200 books, pamphlets, and reports.
Her belief in the scientific method was as passionate as her belief in God. Those two forces guided and structured her work. And so, in order to help as many people as possible, she gathered as much data as she could. She would base her recommendations on facts. Here she lists the following information:
Proportion of men at the different periods of service
and
Proportion of Deaths among Troops serving at home8
Much like W.E.B. Du Bois, Nightingale recognized that a good data visualization could convey information much more effectively than a series of numbers or a paragraph of prose.
Nightingale’s Data Visualizations
Nightingale was looking for a way to represent the data she had gathered when she stumbled upon William Farr’s 1852 radial diagrams showing temperature and mortality rates during London’s cholera outbreak.
Nightingale suspected that her data would work well in this format—that teaming up with Farr would allow her to present her information more powerfully.
The so-called “Nightingale Rose Diagram” emerged from this collaboration. It clearly shows how soldiers were dying not from battle wounds, but from preventable diseases. The blue sections that dominate the graphic, represent preventable (what she called “zymotic”) diseases; the smaller red areas represent deaths caused by battle wounds.
All of this work would transform hospital sanitation standards. Nightingale took these public health successes, as well as a fund of money created by her supporters, to found the first modern professional nursing school: the Nightingale Training School for Nurses at St Thomas’ Hospital in London, which opened in 1860.
Under her guidance, the school redefined nursing. Nightingale had transformed it into respectable, skilled work, and a viable profession. Two centuries later, nurses remain a vital part of our healthcare system and a rapidly growing profession. In part, we have Nightingale and her notes to thank for that.
In addition to the lady with the lamp, I’ve come to think of Nightingale as the lady with the pencil. Ultimately, she saved exponentially more lives with her writing than she ever did with her lamp.
Notes on Nightingale’s Notes
Cultivate habits of observation: In her writings, Nightingale repeatedly advises nurses to hone their observational skills. In Notes on Nursing, she describes how a father taught his son to observe by walking him quickly past a toy-shop window and asking him to recall what he had seen. Then, they would write down their observations and return to the toy-shop to grade themselves.
Gather facts and look for patterns: Observation is important, but so is gathering data from as many sources as possible. Nightingale pored over statistical information and transcribed it in her notebooks. Her innovations in statistics were so impressive that she became the first female member of the Statistical Society of London in 1858.
Visualize your notes: Sometimes it’s easier to see patterns when we create visualizations out of numbers and sentences.
Noted is fueled by you. Your ❤️s and comments inspire me. As always, I would love to know your thoughts.
Yours in note-taking,
Cited in McDonald, Lynn. Florence Nightingale Papers, Wilfrid Laurier University Press, 2002, Vol 12, p. 5.
Bostridge, Mark. Florence Nightingale: The Woman and her Legend. Penguin UK, 2009, p. 4.
Cited in Bostridge, Florence Nightingale, p. 6.
McDonald, Lynn. Florence Nightingale: An Introduction to Her Life and Family: Collected Works of Florence Nightingale, Volume 1. Wilfrid Laurier University Press, 2002, p. 19.
See Helmstadter, Carol. Nursing before Nightingale, 1815-1899. Ashgate Pub, 2011.
Helmstadter writes,
Respectable women or ‘proper persons’ were not interested in hospital nursing because it was considered a menial job, consisting mainly of housework and cleaning up after the patients.
McDonald, Volume 1, p. 29.
McDonald, Volume 1, p. 29.
I'm so glad you've written about her like this! Her data-viz work in particular is groundbreaking and it was only recently that it started getting the acclaim it deserved - Scientific American did a piece on it in 2022 that got a lot of attention:
>>"Nightingale's stories showcased how poor sanitation and overcrowding caused unnecessary death. She constructed her arguments from easy-to-understand comparisons. For instance, Nightingale brilliantly framed army mortality by contrasting it with civilian mortality. She showed how, for example, peacetime soldiers living in army barracks died at higher rates than civilian men of similar ages. Her graphics made it impossible to deny the realities represented by the data: army administration needed dramatic reform.
Nightingale's diagrams received broad coverage in the press. Within months after the first batch was published, the issue of overcrowded barracks was debated in both houses of Parliament, which moved to reform the sanitary conditions of the army. This resolution was backed by four subcommissions focused on sanitary construction, health codes, a military medical school and military statistics. Within a couple of years the quality of British Army data soared under the leadership of a Nightingale ally. The new data-collection operation—eventually lauded as the best in Europe—also proved the success of the sanitary reforms: mortality from preventable disease among soldiers declined to less than that in the comparable civilian population."<<
The radial diagrams are cool!