Portal de Periódicos da CAPES

Nightingale's geography

2003; Wiley; Volume: 10; Issue: 4 Linguagem: Inglês

10.1046/j.1440-1800.2003.00184.x

1440-1800

Gavin J. Andrews,

Migration, Aging, and Tourism Studies

During the past decade, a number of researchers have become interested in the dynamic between nursing, space and place, their body of empirical and theoretical research representing the emergence of a 'geography of nursing' (Liaschenko 1994, 1996, 1997, 2001; McMahon 1994; Purkis 1996; Peter 2002; Andrews et al. 2003; Halford and Leonard 2003; Malone 2003). This attention has led to recent reflections on the potential for, and scope of, future research (Andrews 2002), and the theoretical and philosophical basis for the geography of nursing (Andrews 2003). While consideration of research in the present and future is important, in this commentary I briefly reflect on the past, on the origins of a geography of nursing which, I argue, can be traced as a strand of Florence Nightingale's work. Andrews (2003) suggested that contemporary geographies of nursing have demonstrated at least the potential to underpin a professionally focused, practice-based and qualitative health geography. In this context, Nightingale's reflections represent the earliest traceable heritage and foundations of such a project. A broader and associated aim of this commentary is to trace the geographical elements of early nursing and nursing research. In 1859, when Florence Nightingale published her now famous Notes on nursing: What it is and what it is not, few people, including her, would have recognized it as having a geographical theme. Not only was nursing research yet to be established, let alone develop social science perspectives, but the geography of the time was a very different discipline in comparison to its contemporary form. Nevertheless, as this paper will demonstrate, Nightingale's book contains many references to and consideration of space and place. In particular, it considers the importance of health care settings; of their microenvironmental conditions such as ventilation, warmth and light, and their microsocial conditions such as nurses' proximities to, and interactions with, their patients. Albeit lacking the analytical and theoretical rigor of contemporary research, these topics are investigated on spatial scales that would not seem unfamiliar to twenty-first century human geographers who, since the late 1980s, have become increasingly interested in microscales, in 'places and settings' in addition to 'spaces, distributions and distances' (predominant in the 1950s–1970s). In contrast, for the most part the nineteenth century geographers of Nightingale's era were concerned, with grander scales and the 'big' world issues of the time. An early 'regional geography' aimed to describe and map all human activity captured within areas, divisible by their natural features. Such perspectives supported European exploration and empire building at the time and were promoted by powerful geographical institutional forces such as the Royal Geographical Society in Britain (Andrews 2003). Only towards the twentieth century did regional geographical analysis begin to focus on smaller scales like the regions within countries. Still, Nightingale's reflections on the ward, house and bedside, were far from the concerns of geographers. In addition, important to note is that, the male geographers of the period would most likely have thought nursing to be far too small and unimportant a subject for their consideration. Indeed, human geography only developed recognizable subdisciplines based on their empirical foci (such as rurality, urbanicity, economics) much later, and a sustained interest in medical and health issues from the late 1960s (Andrews 2003). Although, in terms of scale and approach, regional geography and Nightingale's reflections on nursing were largely incompatible, there are two similarities. First, both are in some way connected to a military and Imperialist past. As is well documented, Florence Nightingale was trained in military medicine, one of her main achievements being that during the Crimean War, she kept detailed statistics on mortality amongst sick and wounded soldiers. Later, she used these to argue for the reform of both civilian and military hospitals. Second, and theoretically, by suggesting direct associations between illness and environment, Nightingale's work has at least a loose connection to the theory of environmental determinism which underpinned much regional geography. Later variations of the theory involved a particular reading and extension of Darwinian theory: that local environmental conditions determine the evolution of the character of people, their activities and spatial behaviour (Andrews 2003) (incidentally, Darwin's Origin of the species was published in the same year as Notes on nursing). The main objective of Notes on nursing was to bridge clinical knowledge between health care settings. The intended readership of the 1859 book was not only hospital nurses, but also women caring for sick relatives in their own homes. Nightingale was a leader and 'maker' of her time but equally a product of her time. From the outset, she used a powerful geographical metaphor consistent with the British imperial and explorationary spirit. She likened the immense problem of creating and maintaining a healthy world to conquering a mountain and suggested: If we take as a principle — all the climates of the earth are meant to be made habitable by man, by the efforts of man — the objection would be immediately raised — will the top of Mont Blanc ever be made habitable? Our answer would be, it will be many thousands of years before we have reached the bottom of Mont Blanc in making the earth healthy. Wait until we reach the bottom before we discuss the top. (Nightingale 1859, 5) Nightingale's introduction to Notes on nursing argued that human suffering may not always be associated with universal symptoms, but may often be brought about, or at least contributed to significantly, by a patient's immediate environmental conditions. She commented: In watching disease, both in private houses and in public hospitals, the thing which strikes the experienced observer most forcibly is this, that the symptoms or the sufferings generally considered to be inevitable and incident to the disease are very often not symptoms of the disease at all, but of something quite different — of the want of fresh air, or of light, or of warmth, or of quiet, or of cleanliness, or of punctuality and care in the administration of diet, of each or all or these. (1859, 5) Nightingale never went as far as to suggest that the patient's determined environment caused disease, whereas environmental determinism assumed that environment determined human behaviour. As well as this difference in causal status, the distinction between disease and behaviour is also noted, and a substantial difference in scale, with environmental determinism focused on the world's regions and Nightingale's observations on rooms and the bedside. However, a similarity is evident between environmental determinism and Notes on nursing in respect to how people are positioned as being somewhat subordinate to their immediate physical surroundings. Nightingale argued that the term 'nursing', should be broadened from its narrow definition, to be concerned with these important environmental factors. Specifically, she commented: 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. (1859, 6) Because, in some respects, Nightingale's observations were regarded as representing the current orthodoxy in nursing knowledge, after Notes on nursing, early nursing was increasingly based on a greater appreciation of a patient's environmental context and circumstances. Supporting her initial arguments, Nightingale briefly outlined the scope and extent of health problems facing British society. In doing so, she demonstrated an early awareness of the spatial variations in mortality and morbidity, and a general understanding of specific urban health issues, topics that were at the very core of her beliefs and motivations. Directly addressing the nation's mothers, she stated: You know that one in every seven infants in this civilized land of England perishes before it is one year old? That, in London, two in every five die before they are five years old? And that in other great cities of England, nearly one out of two? (1859, 6–7) Notably, spatial inequalities in health, and their reduction, were eventually to concern the subdiscipline of medical/health geography more than 100 years later, and to the present day (Andrews 2002). After her introductory comments, Nightingale considered specific features of the patient's immediate environment. She thought that if addressed, and enhanced individually, they would reduce illness and suffering. Nightingale started her exploration of the caring environment with the most basic of human needs, 'air'. Referring to ventilation, she suggested: The very first canon of nursing, the first and the last thing upon which a nurses attention must be fixed, the first essential to the patient, without which all the rest you can do for him is as nothing, with which I had almost said you may leave all the rest alone, is this: TO KEEP THE AIR HE BREATHES AS PURE AS THE EXTERNAL AIR, WITHOUT CHILLING HIM. (original emphasis) (1859, 8) Furthermore, she vigorously criticized the caring practices of other nurses, and a popular opinion in nursing that heat is always good for a patient while cool or fresh air is bad: To attempt to keep a ward warm at the expanse of making the sick repeatedly breathe their own hot, humid putrescing atmosphere is a certain way to delay recovery or to destroy life. (1859, 10) Nightingale then described specific tactics to improve a patient's access to fresh air: With a proper supply of windows, and a proper supply of fuel in open fire places, fresh air is comparatively easy to secure when your patient or patients are in bed. Never be afraid of opening windows then. People don't catch cold in bed … But a careless nurse … will stop up every cranny and keep a hot house heat … (1859, 9) For Nightingale, second only to air in the production and maintenance of a healthy environment, was light. She explained: Without going into any scientific exposition, we must admit that light has quite as real and tangible effects upon the human body.… Who has not observed the purifying effect of light, and especially of direct sunlight upon a room? (1859, 48) These two basics, air and light, formed the foundation of a healthy caring environment. In discussing living conditions, Nightingale focused on houses as specific health care settings. She listed five essential points for securing the health of houses: pure air, pure water, efficient drainage, cleanliness and light. Addressing one physical condition in homes at a time, she referred to the need for pure air, and made a political point by criticizing architects and planners for being concerned primarily with profit over public health in housing design. Regarding pure water and drainage, Nightingale's comments were less contentious and credited recent urban reforms and improvements to housing stock in London. However, her brief description of overall urban cleanliness painted a horrifying picture of London life with 'dung' heaps in the streets contributing to child epidemics and illness. Perhaps nostalgically, Nightingale has often been referred to as one of the first epidemiologists and commentators on public health. Although not formally measured, Nightingale certainly made some important references to the spatial determinants of disease, a key topic for health geography since the 1960s (Andrews 2002; Kearns and Moon 2002; MacIntyre et al. 2002). Laying an important basis for the 'rules' of personal care, the remainder of Notes on nursing is concerned with various features of what Nightingale termed the 'petty management of illness'—'how to manage that what you do in a place'. Again, a substantial proportion of her observations and recommendations were concerned with the patient's immediate physical environment and the management of it, while others were more behavioural in their nature and focused on nurses' caring actions. Her first set of observations and recommendations concerned noise, and bodily movement. For example, Nightingale advised, for the sake of patients, to avoid external and excessive noise, to whisper conversations in a patient's room and to be quiet when standing directly outside of it. She commented on everyday bodily movement around patients and on the downfalls of the period's latest female fashions and associated body rituals: Man is now a more handy and far less objectionable being in a sick room than a woman. Compelled by her dress, every woman now either shuffles or waddles — only a man can cross the floor of a sick room without shaking it! What is become of woman's light step? — the firm, light quick step we have been asking for? … The nurse who rustles is the horror of a patient, though perhaps he does not know why. The fidget of silk and of crinoline, the rattling of keys, the creaking of stays and of shoes, will do a patient more harm than all the medicines in the world will do him good. (1859, 27) She also warned against rapid body movements, such as hurrying and rushing: Do not meet or overtake a patient who is moving about in order to speak to him, or give him any message or letter. You might as well give him a box on the ear. (1859, 29) Nightingale regarded subtle body positioning within a room to be of paramount importance to the patient's welfare. She commented: Always sit down when a sick person is talking business to you … by continuing to stand you make him raise his eyes to see you … Always sit within the patient's view, so that when you speak to him, he has not painfully to turn his head round in order to look at you. (1859, 28) These words on the body and place are particularly powerful, because a scale focus on the body, health and place was arguably only achieved as a sustained interest in health geography in the past decade (Parr 2002). In this sense, although observational and focused specifically on caring procedures, her focus was ahead of its time. Continuing with the management of illness, Nightingale also considered the importance, and various features, of what she termed 'variety' in a patient's immediate physical environment. This was motivated by her concern over the monotony and boredom created by a patient's observation of the same surroundings over long durations, and its concurrent impact on their mental and physical health. She stated: To any but an old nurse, or an old patient, the degree would be quite inconceivable to which the nerves of the sick suffer from seeing the same walls, the same ceiling, the same surroundings, during a long confinements. (1859, 33) As remedies to boring surroundings, Nightingale suggested a number of human interventions including the provision of beautiful objects (what she termed 'fancies') and subtle spatial changes to a room, such as moving the position of the patient's bed. These were combined with therapeutic nature-orientated interventions such as allowing the patient to look out of a window regularly and the giving of flowers. In comparison to contemporary nursing research, little attention is given in Nightingale's work to a reciprocal nurse–patient relationship. Rather, the nurse is largely focused on doing what is considered to be best for patients. However, a few of Nightingale's patient management recommendations have spatial implications. For example, Nightingale talked about the benefits of oral communication of 'chattering hope and advices'. This communication can be likened to what, in the current geography of nursing, Malone (2003) terms 'narrative proximity', a form of mental nurse patient proximity which depends on physical proximity or what Purkis (1996) terms 'quality space', a socio-spatial relationship between nurses and patients involving intimacy, 'performance and ritual'. Hence, in these earliest beginnings of nursing research and reflection, a connection can be identified between the spatial, physical and the emotional in nursing practice. The geography of nursing is a recent trend in qualitative nursing research. Like other trends, it may eventually develop into a broader field of dedicated research inquiry or it may wither and become consigned to a footnote in the discipline's history books. Yet, like many other strands of nursing research and their theories, concepts and perspectives, the origins of a contemporary geography of nursing can be traced back to Nightingale. Indeed, one does not have to search hard to find her geographical references and foci. They may not have matched the grandiose scales and intentions of the predominant regional geography of the time, but in terms of scale and what is now considered to be human geography, they are at least recognizable. On a related note, evident though examination of Notes on nursing is that some origins of nursing practice and nursing research have geographical features when viewed through a contemporary geographical lens. Finally, the insights of Nightingale's work are important for the subdiscipline of health geography. First, there is a brief point about research perspectives and disciplinary history: As suggested earlier, notable is that in the subdiscipline, microscale perspectives on health, place and the body have only become a main focus of research in the past 10 years (Parr 2002), yet they were evident, albeit with a different subject focus, in Nightingale's work in the mid nineteenth century. Second, there is also a more substantive point about research perspectives in the present and future: During the past decade, health geography has gradually disengaged from its somewhat self-imposed role of meeting the needs of mainstream medicine and health services research (i.e. to map and model disease and disease services), moved from being a predominantly quantitative to a mixed qualitative and quantitative tradition, and reduced the scale of its research to include foci on places as well as spaces and distributions (Andrews 2002; Kearns and Moon 2002). In this debate, postmodern qualitative research on health, place and well-being, is often positioned, theoretically and methodologically, as the most progressive strand of research moving the subdiscipline forward and further away from the dominance and shadow of medicine (Kearns and Moon 2002). Meanwhile, by comparison, traditional quantitative research on disease and disease services is positioned as being rather theoretically static and even subservient to medicine. Regardless of the accuracy of this belief, a change to qualitative research on health and places does not necessarily have to imply a disengagement with research on patients, illness and medicine. Indeed, research has shown that the current geography of nursing demonstrates, at least, a potential way that health geography can engage with medicine in the form of qualitative research on professional practice issues. In other words, the geography of nursing has the potential to be developed into a qualitative, professionally focused and practice-based geography of health (Andrews 2002, 2003). The current geography of nursing has moved far beyond the observational approach and environmental concerns of Notes on nursing, conceptualizing the economic, social and cultural features of settings that impact upon patient care (Liaschenko 1994, Liaschenko 1996; Peter 2002). This scope is discussed in greater detail elsewhere (Andrews 2003). However, disciplinary heritage is always a relevant consideration, and hence, the origins of a geography of nursing are important. The current paper demonstrates that they can be traced to Nightingale's work. Both in Nightingale's era and the present, nursing research has the ability to be part of and central to medicine but at the same time stand back and at times be critical of its dominant perspectives and assumptions. As such, nursing perspectives may be useful to a health geography in transition. My brief observations here undoubtedly require more substantive and dedicated attention beyond this short article, but evidently there is a potential for nursing, nursing research and the history, present and future of health geography to be explored together.