Notes on Nursing

“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 use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet—all at the least expense of vital power to the patient.”

This passage gives a baseline definition of nursing that is more inclusive and holistic than typically thought. While many consider nursing the administration of medicine and supplemental care, Nightingale argues that nursing is primarily an art of creating the proper conditions for the human body to heal and flourish. Fresh air, light, and sanitation are all the proper concern of the nurse because they relate to the patient's health, and the patient can't be restored to proper health without these necessities of human life.

“How much sickness, death, and misery are produced by the present state of many factories, warehouses, workshops, and workrooms!”

Here, as in many other places, Nightingale emphasizes that illness isn't a mystery but an expected result of (in many instances) the environment. The poor conditions of many factories and places of industry directly and unnecessarily contributed to the poor health of many people. As with a large portion of her advice, cleanliness in all places where people spend any significant time is of the utmost importance.

“We should hear no longer of ‘Mysterious Dispensations,’ and of ‘Plague and Pestilence,’ being ‘in God’s hands,’ when, so far as we know, He has put them into our own.”

While not denigrating belief in God at all, Nightingale is clear that reason has a proper role alongside faith, specifically regarding physical health. She understands the reality that secondary causes govern the world and that human action has a real effect. We should take all available measures to promote health, and we shouldn't consider illness simply a mysterious and inevitable outcome.

“No one would undervalue vaccination; but it becomes of doubtful benefit to society when it leads people to look abroad for the source of evils which exist at home.”

This passage emphasizes the good of vaccines, yet it qualifies their value to clarify that they're not a panacea. In addition to vaccination, other measures are essential. The effectiveness of vaccines can lull people into a false sense of security when instead they're meant to be one piece of a whole to ensure health, including the health of the home.

“Now, do tell us, why must a child have measles?”

This statement builds on Nightingale’s earlier insistence that we shouldn't assume illness is inevitable. In her time, an illness like the measles was assumed to be unavoidable and a matter of course in a child’s life. To the contrary, the author argues that with proper care and prevention even something as widespread and dangerous as measles is avoidable.

“From the most colossal calamities, down to the most trifling accidents, results are often traced (or rather not traced) to such want of some one ‘in charge’ or of his knowing how to be ‘in charge.’”

One of the nurse's fundamental duties is to ensure a proper chain of command for a patient's care. While many nurses are content to do simply what's presented to them in due course, Nightingale clarifies that someone must always be “in charge.” Only a clear plan for the patient's care enables proper choices in a consistent and unwavering manner.

“People say the effect is only on the mind. It is no such thing. The effect is on the body, too. Little as we know about the way in which we are affected by form, by colour, and light, we do know this, that they have an actual physical effect.”

Nightingale pushes back here against the idea that a sick patient desires change and variety simply for its own sake. She denies this premise and insists that variety in surroundings is a basic need and benefits recovery and recuperation .The effect on the patient's mental health will flow into the physical health of the body, and thus things that would be “simply for the mind” are often helpful in a real, physical manner.

“A little needle-work, a little writing, a little cleaning, would be the greatest relief the sick could have, if they could do it; these are the greatest relief to you, though you do not know it.”

Often, things that the healthy take for granted are crucially important for the sick. In this case, the distraction that a hobby provides benefits the patient in a soothing and comforting way. Physical activity, which can often be impossible or extremely difficult for someone who is ill, benefits the patient in the same way it benefits those who are healthy except that the sick can appreciate it more.

“The patient’s stomach must be its own chemist. The diet which will keep the healthy man healthy, will kill the sick one.”

Patients themselves are often the best judge of what foods are best for their diet. While certain food and drink may objectively be best, what's actually best will likely change from patient to patient and from day to day. Patients' taste and tolerance at various stages of their illness and recuperation are the most effective signs as to which foods will contribute to their health as opposed to exacerbating their symptoms.

“Let experience, not theory, decide upon this as upon all other things.”

Throughout her treatise, Nightingale refers to the need for the nurse to have experiential knowledge. This isn't to downplay the importance of academic and theoretical knowledge; her point is that experience is the greatest and most necessary teacher. Only those who allow each situation to guide them are effective in this line of work.

“It is the unqualified result of all my experience with the sick, that second only to their need of fresh air is their need of light; that, after a close room, what hurts them most is a dark room.”

Expanding on the thesis that she established in the initial chapters, Nightingale continues to emphasize the importance of basic human necessities. Here, she addresses the importance of light and the harm that sequestering a patient in a dark environment can do. Like most living creatures, humans need sunlight to flourish, and it's especially beneficial for a patient’s mental health (which, as she mentioned before, directly affects the patient’s physical health).

“Another great difference between the bed-room and the sick-room is, that the sleeper has a very large balance of fresh air to begin with, when he begins the night, if his room has been open all day as it ought to be; the sick man has not, because all day he has been breathing the air in the same room, and dirtying it by the emanations from himself.”

This passage addresses the difference between the room where one should sleep and the room where one spends all day in sickness. Ideally, these would be two different rooms so that the patient sleeps in a room filled with fresh air, not the sick air they expel during the day. While Nightingale acknowledges that the use of multiple rooms for different purposes is often impossible, nevertheless she always mentions the ideal situations for recovery as those that help reduce exposure to unsanitary conditions.

“No ventilation can freshen a room or ward where the most scrupulous cleanliness is not observed.”

While fresh air is necessary, it won't make any difference to a space that isn't perfectly clean in other ways. A cool breeze and influx of clean, fresh air can't make up for a filthy or unhygienic room. Nightingale reminds the reader that fresh air won't be beneficial if other conditions aren't maintained to a high standard.

“Very few people, be they of what class they may, have any idea of the exquisite cleanliness required in the sick-room.”

Writing at a time when the understanding of germ theory was only just beginning, Nightingale addresses the general lack of knowledge in this field. Most people, she says, scarcely understand how to keep a space truly clean to the level necessary for the sick to avoid further illness. Only the cleanest and most sanitary conditions are appropriate for those already ill because of filthy or unsanitary conditions.

“In almost all diseases, the function of the skin is, more or less, disordered; and in many most important diseases nature relieves herself almost entirely by the skin. This is particularly the case with children.”

Many would consider the skin to be an afterthought in the case of illness. However, Nightingale points out that the skin is the largest organ of the body and is therefore important to keep clean. She adds that the skin is the means by which the body protects itself and expels many toxins. Especially in children, the skin can be a remarkable indicator of health.

“I would appeal most seriously to all friends, visitors, and attendants of the sick to leave off this practice of attempting to ‘cheer’ the sick by making light of their danger and by exaggerating their probabilities of recovery.”

In addition to various environmental factors, the patient’s visitors are a significant factor in their recovery (or lack thereof). While many well-meaning friends and relatives want to visit patients to cheer or encourage them, Nightingale is sure that few things are more harmful. The attempt to downplay the seriousness of a patient’s illness can backfire and even prevent the patient from attempting to do everything in their power to facilitate their own healing. Well-meaning advice from friends and family is often utterly useless to those who are sick. The phrase “misery loves company” is not just a meaningless cliché but indicates how those who suffer really feel. Sometimes, what's needed isn't advice but sympathy.

“The most important practical lesson that can be given to nurses is to teach them what to observe—how to observe—what symptoms indicate improvement—what the reverse—which are of importance—which are of none—which are the evidence of neglect—and of what kind of neglect.”

Observation is crucially important for nurses because their care absolutely depends on their knowledge of all the details about a patient. While their knowledge may not be as broad and in-depth as that of a doctor, their ability to observe and take notes on a patient is vital to the patient's recovery. As nurses spend the most time with the patient, their observations are the most accurate and useful in the patient's journey back to health.

“Almost all superstitions are owing to bad observation […].”

The lack of observation, Nightingale observes, leads directly to misinformation and superstition. When the truth isn't based on observable facts, false diagnoses can be made. When diagnoses and attempted cures are based more on guesswork and extrapolation than on directly observable conditions, superstitious notions can proliferate regarding illness, recovery, and patient care.

“So the ‘peculiar power’ of one nurse, and the want of power of another over her patient, is nothing at all but minute observation in the former of what affects him, and want of observation in the latter.”

One nurse's special “genius” is only the consequence of much experience and careful observation. Since many are careless and lack the capacity to observe in the manner that Nightingale deems necessary, those who are capable of insight and careful observation are generally considered to have some innate talent that can’t be taught. To the contrary, the necessary skills can absolutely be learned, and what's often taken to be “inborn talent” is a skill that can (and should be) honed.

“Let people who have to observe sickness and death look back and try to register in their observation the appearances which have preceded relapse, attack, or death, and not assert that there were none, or that there were not the right ones.”

Careful nurses observe their patients and use their observations in future situations. Nightingale argues that sickness and death don't come upon a patient without any warning or signs. Proper attention and observation lead to a wealth of knowledge that can help nurses recognize the warning signs of impending illness or death in future cases.

“Undoubtedly a person of no scientific knowledge whatever but of observation and experience in these kinds of conditions, will be able to arrive at a much truer guess as to the probable duration of life of members of a family or inmates of a house, than the most scientific physician to whom the same persons are brought to have their pulse felt; no enquiry being made into their conditions.”

Here, Nightingale revisits her assertion that experience is the greatest teacher. She insists that one who has carefully observed the patient by being in their presence can better give a diagnosis than even the best doctor who only just seen the patient. Regardless of the doctor's theoretical knowledge, observing a patient's progress over time leads to the most complete assessment of the patient's condition and the way that the illness is progressing.

“It is often thought that medicine is the curative process. It is no such thing; medicine is the surgery of functions, as surgery proper is that of limbs and organs. Neither can do anything but remove obstructions; neither can cure; nature alone cures.”

In this passage, Nightingale returns to a statement she made early in the work: Health and healing are natural processes. The purpose of medicine isn't to cure illness but to remove all obstacles for the body to heal itself. Viewing the body, medicine, and the process of healthcare in this way helps appropriately condition patient care.

“What is it to feel a calling for any thing? Is it not to do your work in it to satisfy your own high idea of what is the right, the best, and not because you will be ‘found out’ if you don’t do it?”

Nursing is a field that's more a vocation or even a calling than it is purely a profession. The nature of the work—being intimately involved in the lives of others—makes it more easy and effective to do when one feels an innate calling to the service that is nursing. Nightingale even states that one who doesn't feel this calling shouldn't be a nurse.