Florence Nightingale died one hundred years ago in 2010. Hailed as one of the most important Victorians by Lytton Strachey in 1918 (Eminent Victorians (New York: G.P. Putnam’s Sons)), Nightingale remains a potent icon for the nursing profession. Until recently, her status as the inventor of modern nursing has rarely been challenged, and one would be hard-pressed to find a nurse or nursing student who does not know of Nightingale nor, in contrast, who understands the complex influence of Nightingale. While Nightingale definitely shaped modern nursing, hospitals, the field of statistics, military nursing and Victorian roles for women, her ideas on nursing, as Carol Helmstadter and Judith Godden point out in their book, Nursing Before Nightingale, were not always implemented as rapidly or as completely as the mythology suggests, nor were they the earliest foundation for reforming nursing care in hospitals.

Helmstadter and Godden examine pre Nightingale nurses from their perspective as internationally renowned Nightingale scholars and nurse historians who are familiar with and critical of the traditional and revisionist interpretations which they concisely examine, particularly in the preface. They use rich archival repositories of the twelve London teaching hospitals (rather than just the records of St Thomas’ Hospital, where the first Nightingale school was situated, or only of Nightingale herself) from 1819–99, employing a broader reading of the historical data than previous scholars. The authors set pre-Nightingale nursing (meaning before the Nightingale model became the dominant paradigm in nursing in the twentieth century) in the context of pre-industrial nineteenth-century England, its living conditions, hospitals and religious conflicts, and raise important questions about the Nightingale model: Was it inevitable, was it really implemented as formulated, why did it become the dominant model of nursing care reform and why was nursing reform such a formidable engine that culminated rather than began with Nightingale? To their credit, the authors answer these questions and more, and in the process give us a more fully nuanced version of the development of modern nursing than most other scholars. As the authors argue, modern nursing did not begin with Nightingale, although Nightingale is one reason modern nursing exists as it does.

Through the ten chapters of the book, Helmstadter and Godden provide exceptional evidence for pre-Nightingale origins of nursing reform, including the development of systems to teach nurses the clinical skills needed to operationalise new treatments physicians were using in the teaching hospitals, recruitment of a better class of women with higher moral standards, gaining public authority and responsibility for women, and better working conditions for nurses in the hospitals. London’s large teaching hospitals, although the place of much discovery and innovation, were warehouses of sick, poor and dying patients attended to by lower class women who had neither the skills nor the moral character to consistently tend to increasingly complex medical treatments, or the stamina to withstand the conditions of hard labor and miserable quarters found therein. Physicians began to demand attending nurses who could be relied upon to perform new techniques of wound care or monitoring of patients after surgery, as well as establishing order amidst the chaos of traditional hospital environments.

Helmstatder and Godden point to the religious sisterhoods instead of Nightingale as the earliest reformers. After Catholic emancipation in 1829, the Sisters of Mercy imposed order and strict expectations of behaviour on novice nurses while also providing instruction in nursing care. Their impact on nursing and hospital reform was not great, as anti-Catholic sentiment still ran high and the sisters could not nurse nor take their training system into the teaching hospitals. The Anglican sisters were not so limited and it is to them that Helmstadter and Godden assign primary responsibility for nursing reform. The Anglican sisters of St Johns House, primarily under superintendent Mary Jones (who later became a close friend of Nightingale), instituted a system of moral and clinical training interposed with systematic teaching, as well as close personal supervision, and saw nursing as a ‘specific body of knowledge’ (p. 189). The sisters themselves worked on the wards, teaching students and serving as role models. These important components not only supported physicians’ introductions of new types of medical treatment into nineteenth century hospitals, but also went far to improve the reputation of nurses in hospitals and improve patient care on the wards. The sisterhoods themselves fared less well as widespread public suspicions of them as fronts for papist tendencies made their existence difficult. Their insistence on women’s ability to hold authority and responsibility in the public sphere set up confrontations they did not win with male governing boards and finally forced them to withdraw from the hospitals by the end of the century.

Nightingale’s ideas for hospital nursing reform – the need for continuity of clinical instruction with school-based teaching, the secularisation of nursing vocation as embodied by the religious sisterhoods, the need to control school finances and school governance – forged by her experiences during the Crimean War, were important in concept but not applied in their entirety in the school established in 1860 at St Thomas’ Hospital, London. Because of entrenched hospital hierarchies and traditional governance structures that controlled nurses in the hospitals, Nightingale had little power to marry clinical experience with instruction and, in contrast to the Anglican sisters, could not gain permission for her school nurses to teach and practice on the wards.

Despite these obstacles and evidence that Nightingale’s ideals were rarely implemented, the Nightingale School was successful. It, rather than the nursing sisterhoods, became the public face of nursing reform for several reasons. The public’s admiration for Nightingale after her work in the Crimean War transferred to her nursing school and she carried none of the religious overtones that made the public suspicious of the sisters. Because of public generosity, the school maintained sound financial status and thus some independence. Nursing, indeed, became a vocation for many women who found personal (rather than religious) fulfillment in their work. Patient care improved, although the authors present little direct evidence of this, and physicians seemed more satisfied with the work of trained nurses, especially those who followed their orders without question.

Helmstadter and Godden’s book is a clear and concise analysis of nursing reform before Nightingale became the iconic figure of the nursing profession. The book contains enormous detail that may sometimes detract readers with little familiarity of London hospitals or the structure of hospital governance during the time period (although the authors include a very helpful glossary). In general, the authors successfully make their argument and introduce us to the reformers who came before or influenced Nightingale.

The dust jacket shows a slightly grainy photograph of a group of Guy’s Hospital nurses from 1860, before any reform initiatives were introduced at the hospital. The nurses are not in uniform but dressed in their black bonnets and street clothes, ready, as the authors suggest, to go out to the pub. These are lower class women, some who are slouching or sitting informally, legs on the sides of the chairs. They are clearly not ‘ladies’, and are staring directly into the camera. This photograph is a potent piece of the author’s argument for the urgency of reform. A contrasting photo located in the conclusion chapter, shows ‘the new trained nurse’ (p. 192), at St Bartholomew’s Hospital, c. 1890s. The nurses are wearing starched, clean uniforms and are straight of posture, glancing self-consciously away from the camera. These are the nurses after nurse training reform and, by choosing a photo that did not portray St. Thomas’ nurses, the authors bring their argument full circle – Nightingale was critical to reform but there were others who made her reforms possible.