Learning from Florence Nightingale: A slow ethics approach to nursing during the pandemic

1.

This year marks the 200th anniversary of the birth of Florence Nightingale. It has also been named The International Year of the Nurse and the Midwife by the World Health Organization. This special year brings into sharp focus the pivotal role played by nurses in health promotion and responses to diverse health needs across the lifespan (World Health Organization [WHO], 2020). Within months of Nightingale's birthday anniversary—on 12 May 2020—and weeks of the WHO special year announcement, the globe was gripped by the COVID‐19 pandemic, and nurses were engaging with some of the most challenging ethical issues of our time.

There was, initially, much concern about the ethics of allocating limited resources such as ICU beds (Vincent & Creteur, 2020). Ethical concern also focused on personal protective equipment [PPE] and professionals’ obligations to care when this is inadequate (Brown, 2020; Royal College of Nursing, 2020). The focus of ethical concern belatedly attended to the devastating impact of COVD‐19 on many residential care homes for older persons (Oliver, 2020). There has also been much attention to the impact of COVID‐19 on nurses’ health and well‐being. At the time of writing, the International Council of Nurses [ICN] estimated that approximately 600 nurses have died from COVID‐19 (ICN, 2020).

Given the different eras, diverse range of contemporary issues and evolved status of nurses, it may seem futile to enquire what 21st‐century nurses might learn from the life and work of 19th‐century Florence Nightingale. I aim to show, drawing on insights from recent work on ‘slow ethics and the art of care’ (Gallagher, 2020), that contemporary nurses can indeed learn from the life and work of Nightingale. Her life and work shows the value of stories, sensitivity, solidarity, space, scholarship and sustainability.

Nightingale's story begins with her birth into privilege. She resisted enticements to become a genteel lady who took tea and embroidered and instead followed a calling to become a nurse, leading a small group of women to respond to the suffering of soldiers during the catastrophic Crimean war (Hamilton & North, 2015). Her commitment to improve the conditions of gravely ill and dying soldiers, to develop the evidence base underpinning care and her resilience are inspiring and paved the way for modern nursing. Florence Nightingale's story also details how she responded to risks of infection in the Crimea. This was witnessed and reported by a contemporary witness, Lord Sidney Godolphin Osbourne (1855, p.26) who wrote:

She has an utter disregard of contagion; I have known her spend hours over men dying of cholera or fever. The more awful to every sense any particular case, especially if it was that of a dying man, her slight form would be seen bending over him, administering to his ease in every way in her power, and seldom quitting his side till death released him.

Regarding Nightingale's demonstration of sensitivity, it was reported that she wrote letters to the families of soldiers who had died in her care. The letters were said to be carefully crafted, demonstrating her appreciation of their importance for families to know the circumstances of the soldier's death. It was said that she tended to minimise the soldier's suffering and emphasise his heroism (Hamilton & North, 2015, p. 46).

During the current pandemic, there are instances where families are unable to be present when loved ones are dying. Nurses have, then, an important role as conduits of love between patients and families when separated at the end of life. Nurses today may not write letters as did Nightingale, however, they can receive and share messages between patients and families by phone and other technology. They also provide comfort to families by reassuring that their loved one did not die alone and was comforted until the end.

Regarding the sustainability of nursing—and of environmental issues more generally—following the Crimean war, Nightingale initiated nurse training programmes and highlighted the importance of environmental factors in promoting or undermining health and well‐being. National nurses’ associations and the ICN now play a critical political role in advancing the interests and values of nursing and nurses and in lobbying for better conditions and respect for all care‐givers and for environmental issues.

It seems plausible that Nightingale's perspective on solidarity was limited by her time and experience of more global issues. However, she understood the importance of evidence and of compassionate care for all, and both have international significance. Given our increasing inter‐connectedness—albeit now with pandemic limitations—nurses are in a strong position to enact local and international solidarity and genuine political commitment. This is necessary to enable nurses, and other care‐givers, to do what they have always done: to aid recovery; to enable the best possible end of life experience when cure is not possible; to care always for care‐recipients, families and communities; and not to abandon those in need of care.

Engagement with scholarship on nursing history and ethics is helpful as it enables nurses to reflect on, and compare, past and present activities of Nightingale and other nurses of her era. Nursing and nurses have, of course, changed significantly since the time of Nightingale. Nurses are now generally well educated in the art and science of nursing, are accountable professionals, are independent and are still mostly women, many with family commitments and many travelling to work in other countries. Nurses are also likely to have a good grasp of the ethics of their practice and to have an awareness of the requirements of a professional code. An increasing number of nurses also practise as clinical ethicists and have post‐graduate qualifications in ethics. Hence, a fruitful discussion could be had with students regarding Nightingale's ‘disregard of contagion’. How might contemporary nurses respond to this?

Many of the ethical issues arising during this pandemic, as detailed above, will not be new to experienced nurses. For example, issues relating to the fair allocation of scarce resources are common in most health systems. Nurses are also no strangers to challenges and opportunities of respecting the wishes and dignity of care‐recipients, of the delivery of compassionate care, including at the end of life, and of working to minimise harm. What will be new to most nurses are the risks and constraints of a highly infectious and lethal virus. This virus jeopardises the lives of patients and care‐givers alike, makes all humans potential vectors and victims and seems to have a disproportionately negative impact on Black, Asian and minority ethnic communities. Many nurses and care‐givers are from these communities, and many have died from COVID‐19 infection.

Regarding the role of space in nursing in Nightingale's time and now it seems likely that, whereas reflective practice and moral spaces were not considered priorities in the 19th century, this does not mean that Nightingale and her peers were unreflective or lacking in the enactment of ethical values.

So, can we learn from Florence Nightingale? And where might this take us in terms of new directions for care ethics?

We can learn from Florence Nightingale as she role‐modelled many of the qualities most needed during this pandemic, for example resilience, compassionate care, courage and a commitment to lobby for, and bring about, change in the health conditions of marginalised populations. The example of Nightingale taking time to write letters to the families of soldiers who had died during the Crimean war resonates with circumstances nurses may find themselves in during this pandemic.

However, Florence Nightingale was a person of privilege with powerful networks of support. Nurses are a diverse group and, while many have the confidence and competence to speak out—and advocate for care‐recipients, families and communities and their own safety—others will find this challenging. A report relating to the predicament of Filipino nurses during the pandemic, for example, cited one nurse as saying, ‘It's not in our nature to complain’ (Vincent, 2020).

The position of nurses who are working away from their home countries may be precarious due to visa and immigration constraints. This will impact also on nurses’ families particularly if a migrant nurse becomes ill or dies. Their interests need to be protected. Thanks to work begun by Florence Nightingale and others, we have an increasing evidence base to guide nurses and other care‐givers as to the best means to remain well during the pandemic. Nurses—and other care‐givers—are precious and valuable as individuals and play a central role in compassionate and fair responses to all who need care in our varied health systems.

This view from ‘slow ethics’ attempts to bring together some strands of nursing history, care ethics scholarship and current pandemic care issues. The pandemic urges a bolstering of care ethical values and processes for these extraordinary times. Reflection on the legacy of Florence Nightingale regarding the future directions of the field is fourfold:

First, a renewed focus on solidarity and social justice—learning from, collaborating with, and supporting each other in our global community—is critical for an ethical pandemic response. The recent seminal State of the World's Nursing Report (WHO, 2020), a collaboration among the WHO, Nursing Now and the ICN, urged ‘a decade of action that begins with investing in nursing education, jobs and leadership’. Specific ethical guidance from centres of ethics excellence around the world is also invaluable in supporting nurses in doing the right thing in challenging times. There is work to be done to develop accessible normative accounts of solidarity and social justice which should form a central component of the curriculum for nurses and other professional. It needs to be borne in mind that the majority of care‐givers do not benefit from professional privileges and their contribution needs to be valued and their interests safeguarded.

Second, it is suggested that we have less preoccupation with moral distress and more focus on moral resilience. In recent decades, there has been abundant attention to the moral distress and stress of nurses and this has continued during the pandemic. Focusing on the moral and emotional frailty of nurses rather than on their resilience and coping is unlikely to support public trust, respect from other professions or inspiration for future recruits. A balance is to be struck here, with more focus on coping and creative responses to challenges and on stories of nurses overcoming the odds to provide the best possible care to patients and families.

Third, we need to continue to increase the visibility of creative compassionate care and prioritisation of non‐abandonment. At a time of significant global suffering, nurses and other care‐givers play a critical role in aiding recovery and, where this is not possible, in being with people who are dying. Care‐givers’ role in comforting families as conduits of love cannot be overstated: sharing final messages between patients and families and making conversations possible using technology when families are physically separated. The care ethics principle of non‐abandonment is to be remembered here, applying to responses to care‐recipients and families and also to the provision of resources so that care is safe and ethical for all.

And, finally, we need to learn and avoid post‐pandemic forgetfulness. International organisations, governments and care organisations need to show—over the long term—that they are not forgetful. The six elements of slow ethics—stories, solidarity, sustainability, space, scholarship and sensitivity—are elements that connect past and present and remind us of the fundamentals of care. These elements of nursing care are brought to the fore during this pandemic and enriched by reflecting on the contribution and legacy of Florence Nightingale. Politicians and the public need to demonstrate that they are genuine in their praise and honour promises to support, reward and respect nurses and other care‐givers. The future of this most critical work, that operationalises humanitarianism, depends on it.

Gallagher A. Learning from Florence Nightingale: A slow ethics approach to nursing during the pandemic. Nurs Inq. 2020;27:e12369 10.1111/nin.12369