Florence Nightingale: Visionary for the Role of Clinical Nurse Specialist

Jennifer H. Matthews, PhD, RN, A-CNS, FAAN; Phyllis B. Whitehead, PhD, APRN/CNS, ACHPN, RN-BC, FNAP; Cindy Ward, DNP, RN-BC, CMSRN, ACNS-BC; Marion Kyner, MSN, RN, CNS; Terri Crowder, DNP, RN, CNS, ACNS-BC, CCRN


Online J Issues Nurs. 2020;25(2) 

In This Article

Nightingale's Work

Nightingale's initial observations on the administration of nursing and healthcare organizations began in 1851, first at the Kaiserswerth Deaconess Home in Germany and in 1853 on fact-gathering tours of hospitals in France, Austria, and Italy (Steward & Austin, 1962). In Scutari, concurrent with changes in hygiene practice and nursing care of the wounded, Nightingale initiated seemingly disparate wide-ranging projects to improve patient centered care, competence of the staff, and the healthcare environment. She surveyed the organization's human resources, determined the members for the interdisciplinary teams, and assigned them accordingly to set projects in motion to support the wellbeing of the patients.

For Nightingale to accomplish project goals, she identified root causes of problems, gaps, and then engaged accountable stakeholders, onsite and in London. In Scutari, she encountered reluctant stakeholders (e.g., jealous medical officers, bureaucratic men) and none were eager to take orders from or be outperformed by a female. She swayed their opinions through expert care, outcomes, and professional demeanor, eventually overcoming their skepticism because she sustained her focus 'for the sake of the work' (Andrews, 1929, pp. 146–147). Nightingale intuitively and wisely influenced local stakeholders by building onsite multinational teams whose collaborations were essential. The myriad individuals on the teams included her nurses; military medical officers and wives of soldiers; diplomats and their wives; local men of business and laborers; and religious sisters and clergy.

Nightingale was fluent in French, Italian, German, and Turkish. Her language skills became the glue that enabled her to direct team members to understand project scopes and work together for the common good. In addition, her other resources, including unrestricted funds provided to her by the War Office and her personal money, offered the means to assist with her projects. In London, the influential stakeholders were officials at the War Office, Queen Victoria, and aristocratic friends; among those opposing her work were the Prime Minister and Secretary of State. Like Nightingale's practice, the CNS role is independent and broad, and influences informed decision-making across changing environments, needs of populations, needs of organizations, budgetary appropriations, and regulatory mandates. CNSs are flexible and creative, adjusting their roles as Nightingale did when she leveraged her project resources in the face of one crisis after another.

Immediate changes occurred within days of her November 4, 1854 arrival to Scutari and by January 1855, Nightingale issued more than 6500 bed shirts and equal amounts of eating utensils from her inventory (Andrews, 1929). Existing food preparation was inadequate and there was often no fuel for cooking fires. Poor quality food was boiled in 13 copper cauldrons located at the one end of the hospital ward at distances of three to four miles through the corridors from individual soldiers (Cook, 1913a). Food was served cold, nearly raw, or cooked for hours depending on the distance from the cauldrons. Orderlies set the food beside the soldiers, expecting soldiers to feed themselves despite incapacities and handicaps such as upper extremity amputations.

Nightingale established new routines, breaking with those which hampered efficiencies established by the military medical officers. She determined which military and medical rules were sensible, and honored and respected these. Within ten days, at her direction, the engineers created two extra dietary kitchens and established three supplementary boilers (Andrews, 1929) which were used to make broths and a nutritious arrowroot supplement. Rejecting government supplied food, she used her money to buy food from local suppliers in Turkey. Nightingale wanted meat de-boned and gristle removed before serving, a request that caused medical officers to complain about giving "too much indulgence" to soldiers; they overruled her for that moment (Andrews, 1929, p. 149). Using immediate funds and her newly devised requisition system, Nightingale shortened the 2,000-mile supply chain from England to buy many goods and staples from local vendors (Cook, 1913a).