What do we do about Florence Nightingale?

Natalie Stake-Doucet's indictment of Florence Nightingale as the “racist lady with the lamp” in Nursing Clio (Stake-Doucet, 2020) has created profound sense of dislocation among champions of both the discipline and its iconic heroine. Some denounce what they see as efforts to impugn the impact of a woman who transformed the care of the sick across the globe. Others hastily rewrite convocation and commencement addresses to avoid any hint of controversy. Some cheer a recognition of yet more of Nightingale's deeply held biases and assumptions. And a few hope there might be a middle ground by claiming Nightingale's racist and colonialist impulses reflected nothing more than her place a woman of her time in the Imperial Empire that was Great Britain. My intent in this essay, however, is to move beyond reactions and trace the antecedents that support Stake-Doucet's analysis. My argument is historiographical: That is, it draws on what historians have long argued about the data that supports their histories of nursing. And it presents another direction that the discipline might consider as it moves into its future. The issues that we now face are not new. Different nurses in different times have sought to address issues of justice, equity, and an openness to a diversity of practitioners and patterns of practice. But we face them today with new questions, new analytic tools, and a new sense of urgency. Historians have long recognized that Nightingale represented a global, colonizing healthcare project that created a powerful place for middle-class white women at the apex of a racialized hierarchy. But we are now being asked to consider the long term, certainly structural but too often hidden implications of her successful crusade. We know how, to paraphrase Joan Lynaugh and Claire Fagin, a group of clinicians of the wrong gender, the wrong class, with the wrong educational background transformed the historical experience of health and illness (Lynaugh & Fagin, 1998, p. 184). We now ask: At what cost? And we wonder: How might such answers help at least crack the historically persistent structural barriers that invite some into the nursing enterprise, leave others out, and create nearly insurmountable hurdles for those that construct different meanings about the discipline's place in the world. The seminal work of the 1970s and 1980s firmly established the analytic categories of race, class, and gender as central to understanding the history of nursing. The two most important studies in the historiography of nursing in the United States—Susan Reverby's Ordered to Care: The Dilemma of American Nursing (Reverby, 1987) and Darlene Clark Hine's Black Women in White: Racial Conflict and Cooperation in the Nursing Profession (Hine, 1989)—dealt with the segregated paths of white and black women, respectively took into nurses training schools and then out to practice. But both charted the ways in which Nightingale's vision of nursing as respectable work for white, middle-class women seeking an alternative life path to the conventions of marriage and motherhood, affected the aspirations, identities, and the realities of the lives of all women who chose to train and practice as nurses. My own research for American Nursing: A History of Knowledge, Authority and the Meaning of Work (D'Antonio, 2010) sought to tell the histories of white and black women nurses together and added men who would nurse to the analytic frame. If anything, Nightingale's vision classed, gendered, and racialized comes into sharper relief. Perhaps, I argue, Nightingale's greatest contribution was not just the creation of a new work path for some women, but for abruptly closing the door on the aspirations of men who had as long a tradition of nursing in the military, in disasters, and in religious orders (cf., Sabin, 1997). Thus, historians have argued for decades that nursing has been historically structured by gender, segregated by race, and, at least for those with some financial resources, determined by class. And, for decades, nurses themselves have recognized the need for remedies that might address these imbalances. These remedies have focused on outcomes. How might the numbers of those who nurse better reflect the numbers of those in the populations they serve? How might we, in the United States, in particular, finance nursing education at all levels? How might we increase the numbers of nurses of color? Of different backgrounds? Of men? But while we were counting, two other analytic threads have been slowly gaining ascendency. The first has been subsumed under the broad heading of colonial and postcolonial studies. Born of the European loss of empire in a transformed post-World War II world, its historians and theorists interrogate the political, social, and human consequences of the control of lands, people, and cultures by the Imperial power of the metropole (center). Its analyses focused on the establishment and maintenance of hierarchies of power not only in politics and economics but also in ways of knowing and doing. Nightingale, of course, represented the metropole in her work in the Crimea. But, as recent colonial scholarship argues, if she were the creature of empire, she was not just its tool. She, and succeeding generations of nurses and midwives actively occupied positions as “intermediaries,” simultaneously translating official colonial directives into specific lessons and practices more easily understood by those with whom they directly worked, and by providing data up the proverbial chain of command about changes needed, and, in the end, shaping public health policy (Johnson & Khalid, 2010). Their role in the colonial enterprise conferred real status and authority. But as colonial historians focused on relations of power in empire, legal scholars began exploring more particularly how race infused those of seemingly normalized codes of conduct, relationships, and decision-making here in the United States. What became known as critical race theory (CRT) sought to explore how outcomes—particularly in race, but also in gender—are less the result of explicit individual intentions and more the effect of complex, subtle, and intersecting social and structural dynamics that reinforce established hierarchies and systems of power. CRT has, of course, become a lightning rod for conservative dissent in the United States. But, as scholars, we ignore its methodological power at our peril. My own reading and use of CRT asks that I move beyond an individual as an historical actor: It asks that I attend as much to the context in which such an individual lived, worked, and absorbed lessons about power, prestige, status, and politics. As we know, Nightingale certainly moved in such an environment not only at the apex of an educated white women's privilege but also as a consummate politician who knew how to manipulate the male levers of power at Whitehall. But others did as well. Mary Seacole, a British-Jamaican “doctress” whose autobiography The Wonderful Adventures of Mrs. Seacole in Many Lands, established her claim to not only the nursing of soldiers in the Crimea but also her place in the pantheon of nursing heroines, is but the most well known. More recent scholarship points to the work of other hospital reformers and to religious nursing orders, both in England and in the Crimea (Helmstaedter & Godden, 2016; Nelson & Rafferty, 2010). Of course, we are now dangerously close to continuing to reify individuals—although different individuals than Nightingale. CRT offers us another way out: Listen to the stories—both those told and those untold—and analyze their meanings to particular communities. My conundrum, for example, was about how to handle the extensive documentation about its 1950s decision to desegregate kept by the while-only North Carolina State Nurses Association (NCSNA). The depth and breath of this data stood in stark contrast with silences in the minutes of the State Association of Negro Registered Nurses, the association with which the NCSNA engaged in years-long discussions. The sharp differences in language—desegregation versus integration—certainly stood as significant in and of itself. But as I thought about the intersection of theory and data, I came to see how nurses and nursing existed within more complicated communities than those of just race, class, and place. Power and visibility were important in the stories told by both groups; but it was a kind of power and visibility that would play differently to their very different audiences. So what do we do about Florence Nightingale? How are we to understand her impact and her flaws within new colonial and raced frameworks? One possible answer is why do we have to do anything. Can we accept that Nightingale was as complicated, as flawed as any other consequential historical actor? We certainly can. But then we would miss an opportunity to think more deeply about her legacy. What does it mean that Nightingale embodied hierarchical relationships of power? How did this structure systematic arrangements about who could access the privileges of nursing? What assumptions do we still hold (consciously and unconsciously) that have yet to be examined and tested? Which communities have the most salience in the decisions we make? These—and many, many others—are not mere academic exercises. Our willingness to ask and attempt to answer them will mark our generation's ability to address the issues of justice, equity, and diversity that we now confront. The authors thank Cynthia Connolly for her careful critique of an earlier version of this commentary.