Nightingale and Ethics: Five Books, Eight Principles (Interactive Module)
Nightingale and Ethics
Five books, eight ethical principles: stories, contradictions and what remains for nursing today. This module reads Florence Nightingale not through the legend of the “Lady with the Lamp”, but through what she actually wrote.
November 1854, Scutari
Florence Nightingale arrives at the British military hospital in the Selimiye Barracks in Üsküdar (Scutari), Istanbul. That first winter, by her own later testimony, 4,077 soldiers die there between November 1854 and March 1855, most of them from disease rather than wounds. In February 1855, 42 of every 100 soldiers admitted die.
She spent the rest of her life on one question: why did these people die? Every principle in this module grows out of that question.
One myth first: the “Nightingale Pledge” recited at graduations was not written by her. It was composed in 1893 in Detroit by Lystra Gretter and a committee of the Farrand Training School for Nurses, as an adaptation of the Hippocratic Oath. Nightingale never wrote an ethics code. Her ethics lives inside her practical instructions.
The five books
- 1858Subsidiary Notes as to the Introduction of Female Nursing into Military Hospitals in Peace and War. A management text written for the War Office: wages, pensions, sleep, discipline.
- 1859Notes on Nursing: What It Is, and What It Is Not. Her best-known book, written for anyone caring for the sick at home.
- 1861“Taking Food” and “What Food”, printed inside Directions for Cooking by Troops in Camp and Hospital (Richmond, Virginia).
- 1863Notes on Hospitals, 3rd edition. Ward design, hospital management and statistics.
- 1863Sanitary Statistics of Native Colonial Schools and Hospitals. Her least-known report, on the health of Indigenous children in British colonial schools.
Eight principles, one question
We read the five texts cover to cover, extracted every concrete “do this, don’t do that” instruction, and placed each one under a principle by asking:
“What does this practice protect the patient from?”
The first four are the classic principles of biomedical ethics (Beauchamp and Childress). The last four are principles central to nursing ethics and the ICN Code of Ethics. Each principle below has a story from the books, the practices, a contradiction and its echo today.
Harm does not only come from hands
Nine months, 24 patients, 8 deaths
A small hospital in one of the healthiest counties in England. Patients come in for trivial accidents and minor operations. In nine months, 24 of them catch erysipelas in the hospital and 8 die. None of them, Nightingale writes, should have caught it at all.
“It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.”Notes on Hospitals, 1863, Preface
Crowded wards
At least 100 sq ft (about 9 m²) of floor and plenty of air for every bed.
The wrong place
Hospitals where even 2,000 cubic feet per patient is not safe “should not be there at all”.
Never wake the sleeper
Not waking a patient is “a sine qua non of all good nursing”.
Whispering
A whispered conversation in the patient’s room is “absolutely cruel”.
Sour milk
The most valuable food for the sick becomes the most injurious once it turns.
Airless schools
Badly built, badly sited, poorly ventilated school houses make children ill.
Drawn from the dimensions in Notes on Hospitals (1863). Blue particles show air entering one window and leaving through the opposite one.
She rejected contagion, calling it one of the “spectres which have terrified almost all ages and nations”, and blamed bad air and bad management instead.
The theory was wrong. The cleaning and ventilation she demanded still saved lives.
Healthcare-associated infection is now treated as preventable harm, not fate. COVID-19 brought hand hygiene and ventilation back to the centre of nursing (Martini et al. 2021; Peng 2020).
Ask your class: when an infection appears on your ward, is the first question “who?” or “how?”
An environment that helps recovery
A bunch of wild flowers
Fever patients lying in wooden huts, no window, nothing to look at but the knots in the wood. Nightingale says she saw this suffering and felt it herself when she was a fever patient. When a nosegay of wild flowers was sent to her, her recovery, in her words, became more rapid from that moment.
“People say the effect is only on the mind. It is no such thing. The effect is on the body, too.”Notes on Nursing, 1859, “Variety”
Seeing out
Window sills low enough that the patient can see out from bed.
Colour and variety
Beautiful objects and bright colour have “an actual physical effect”.
The right music
The human voice and stringed instruments help; the piano-forte does the reverse.
A bird and a baby
A caged bird may be “the only pleasure” of a long-term invalid; a baby’s visit refreshes the sick.
Little and often
If the stomach rejects a teacupful every three hours, try a spoonful every hour.
Play and school
Children’s hospitals need playgrounds, singing and school rooms.
Newspapers argued: “More than 25,000 children die every year in London under 10 years of age; therefore we want a Children’s Hospital.” Nightingale disagreed: the cause was defective household hygiene, and the remedy was not a hospital.
Most of the good we can do is won at home and in the neighbourhood. Prevention or new hospital beds? The resource question has not changed.
Ask your class: who defines what is “good” for the patient: the patient, the nurse or the state?
A person, not a case
Advice heard fifty times
A patient bedridden for years. Every visitor says the same thing: try another doctor, another town, another pill. Nightingale replies that the patient has probably heard this advice at least fifty times; had it been practicable, it would have been practised long ago. Patients gather their own information and make up their own minds.
“Irresolution is what all patients most dread. Rather than meet this in others, they will collect all their data, and make up their minds for themselves.”Notes on Nursing, 1859
Sit and listen
Sit down when a patient talks business; show no signs of hurry.
Face the patient
Never speak from behind, from the door or from a distance.
Say when you’ll be back
Tell the patient when you go and return, even for ten minutes.
Don’t unsettle decisions
Others changing their minds harms more than the hardest decision.
Let them do it
If a patient can feed and clean their pet, always encourage it.
No proselytism
Nursing sisters are welcome on condition of “abstinence from proselytism”.
“A patient should never be asked if he will have any particular article of food; let it be prepared, and brought to him.” And: “the Medical Officer is sole master of diets.”
We call this benevolent paternalism. Shared decision-making is now the norm, yet in intensive care, dementia and end-of-life care, the burden of choice is a real problem too.
Ask your class: where does sparing the patient end, and taking away their choice begin?
Death chooses an address
The rain and the woollen jersey
Natal, southern Africa. Indigenous children brought to mission school are dressed in flannel and jerseys so they look “civilized”. Before, the rain ran off their skin and they dried by the hut fire. Now the wet wool stays on them, they get chilled, and lung disease follows. Across 9,938 children in colonial schools, Nightingale estimated mortality at double that of English children of the same ages.
“It is a matter for state interference. It is impossible to stand by, while races are disappearing.”Sanitary Statistics of Native Colonial Schools and Hospitals, 1863
One side of the street
Excess deaths cluster in a district, a street, one side of it, one floor of one house.
One infant in seven
One in seven English infants died before their first birthday.
City and country
The unhealthiest hospitals were in London, the healthiest in small towns.
No privilege for “ladies”
Wealthy volunteers get no separate status: “Paid Nurses are always the most useful.”
Wages and pensions
A small yearly rise, and a pension after ten years of good service.
The state is responsible
Colonial authorities carry “a responsibility of the very gravest kind”.
She blames the colonisers: “the pioneers of British civilization are not always the best of the British people.” Yet she calls Indigenous peoples “uncivilized”, and her remedy is still to “civilize” them.
She also refused all applicants from reformatories: no second chances.
Health inequalities and social determinants of health. Culturally safe care: doing good without asking the community. Gender in the profession: defining nursing as “women’s work” marginalised male nurses (Stewart 2025).
Ask your class: when judging a historical figure, do we use her era’s values or ours?
Honest to the patient, honest to the numbers
The first diagnosis was wrong
Nightingale first blamed the Scutari deaths on poor nutrition and shortage of supplies. The real cause was a broken sewer under the building and no ventilation. After the Sanitary Commission repaired the drains and ventilation in March 1855, deaths fell sharply. After the war she looked at the data, changed her mind, and marked the Commission’s arrival on her famous diagrams herself.
Each dot is one of 100 soldiers admitted. February 1855: 42.7 per cent died. June 1855: 2.2 per cent.
Integrity is not never being wrong. It is changing your mind when the data say so, and saying so openly.
Figures from post-war analyses (BMJ Quality & Safety; National Army Museum). Dots are an approximate illustration.
No false hope
Stop “cheering” the sick by making light of their danger.
Truth is a skill
“It is a much more difficult thing to speak the truth than people commonly imagine.”
“I do not know”
Say plainly when you do not know.
One number is not enough
“Death rate not the only statistics wanted.”
Gaming the rate
Hospitals discharged dying patients to lower their own mortality.
Limits of data
“These death rates are of course only approximations to the truth.”
Illustrative numbers. The practice itself is described in Notes on Hospitals (1863): incurable cases “discharged from one hospital… and received into another hospital, to die there in a day or two after admission, thereby lowering the mortality rate of the first at the expense of the second.”
The same book that exposed number games reported London hospital mortality above 90%. William Farr had divided a year’s deaths by the inpatients present on a single day. Divided by all inpatients over the year, the rate was about 10%, and critics noted that case severity was ignored (Iezzoni 1996).
Denominators and risk adjustment in hospital league tables; 30-day post-discharge mortality; incident reporting systems that reward openness over hiding error.
Ask your class: is it ethical to use a misleading number for a good cause?
Found in only one of the five books
If the doctor suspects poisoning
Nightingale reports that it “has actually been made a question of medical ethics” what a doctor should do if he suspects his patient is being poisoned at home. Her answer is short: insist on a confidential nurse being placed with the patient, or give up the case.
“She must be no gossip, no vain talker; she should never answer questions about her sick except to those who have a right to ask them.”Notes on Nursing, 1859
The confidential nurse
Every nurse must be someone who can be trusted with a secret.
A right to ask
Information goes only to those who need to know.
The next room
The patient knows when he is being discussed next door, and strains to hear.
The nosy adviser
Too polite to ask about the patient’s state, yet not too polite to advise.
She guards the patient’s secrets, yet writes of soldiers with venereal disease as “patients from a vile cause”, while noting they are “frightened, if not ashamed, about themselves”.
Health data is a special category of personal data under data-protection law. But confidentiality is also about not judging and not stigmatising, which no statute can enforce.
Ask your class: how are diagnoses discussed at your nurses’ station?
Being the voice of those who cannot speak
Private McCormick’s meal
Scutari, May 1856. One of Nightingale’s nurses brings food and drink to Private John McCormick, aged 20, ill with fever. The ward attendant, W. J. Northcott, is locked in the garrison cells for it, although he was on duty three-quarters of a mile away and never saw the nurse, the food or the doctor who ordered his confinement. Nightingale prints his statement with his spelling intact.
When an act of kindness to a patient is treated as an offence, where does advocacy begin?
Patient first
Cut off the source of harm at once, even if “a curious mine of observation” is lost.
Children cannot complain
“Among children, there can be no public opinion. They cannot make their complaints.”
The woman in the next bed
On mixed wards she often becomes “the child’s best protector and nurse”.
Real love for the work
As if your own happiness were bound up in each child’s recovery.
Fidelity to the team
No food outside medical orders, however kind the intention.
Not for applause
Hospital work “never can be, a popular work”.
She calls doctors “our masters the medical men” and forbids stepping outside orders. Yet she sides with patients against doctors, the army and ministries, and sharply criticises religious nurses for whom it seemed “better for the children to die than to live”.
The Mid Staffordshire scandal in England and the 2013 Francis Report: patients left in soiled sheets, staff who stopped raising concerns, 290 recommendations, a statutory duty of candour and Freedom to Speak Up Guardians.
Ask your class: if a colleague were harming a patient, whom would you tell, and how?
Being in charge means building the system
Was the tap to blame?
“The finest and strongest ship that ever was built” on her trial trip. A tap that should have stayed open is closed; a funnel-casing bursts; several die and hundreds are endangered. The inquest returns “accidental death”. Nightingale: the jury “apparently considered the tap ‘in charge’”.
“What is done when I am not there?”Notes on Nursing, 1859, “Petty Management”
When I’m not there
Being in charge means seeing that everyone else does it right too.
The fault is in the system
“The fault lies in there being no organized system of attendance.”
Counting nurses’ deaths
Ages and deaths of 521 nursing staff in 15 London hospitals, tabulated with Farr.
A common form
Uniform registration of surgical operations and their outcomes.
12 + 8 + 4
Night nurses: 12 hours on duty, 8 hours sleep, 4 hours of their own.
No secret reports
Every report on the nursing staff shown to their superintendent: “a point of honour, not of grace”.
“If made to do night-duty after a laborious day, he will either go to sleep, or drink to keep awake, or he will get knocked up before his time.”
And in the same book: night nurses face “instant dismissal if found asleep”.
Just culture separates human error, at-risk behaviour and reckless conduct. Long shifts and fatigue remain patient-safety risks.
Ask your class: who is responsible for a medication error at the end of a 16-hour shift?
Which principle, in which book?
| Principle | Nursing | Hospitals | Subsidiary | Cooking | Colonial |
|---|---|---|---|---|---|
| 01 Non-maleficence | ● | ● | ● | ● | |
| 02 Beneficence | ● | ● | ● | ||
| 03 Autonomy | ● | ● | ● | ||
| 04 Justice | ● | ● | ● | ● | |
| 05 Veracity | ● | ● | ● | ||
| 06 Confidentiality | ● | ||||
| 07 Fidelity & advocacy | ● | ● | ● | ||
| 08 Accountability | ● | ● | ● | ||
| Principles covered | 8 | 6 | 4 | 3 | 3 |
● = at least one practice from that book was classified under that principle. 47 practices in total. The classification is an interpretation; a practice can touch more than one principle.
Three findings. Notes on Nursing is the only book that touches all eight principles. Confidentiality appears in just one book: it was a sickroom matter, not yet an institutional one. Justice is the most widely spread principle: at the heart of her ethics is how risk is distributed across society.
What the literature says
Defending the legacy
Notes on Nursing’s emphasis on hygiene, environment and systematic care aligns with today’s patient-safety frameworks.
doi:10.1111/nin.70149Reframes Nightingale as an early applied statistician whose data can be re-read with modern quality dashboards.
doi:10.1016/j.outlook.2026.102941Her insistence on respect for patients and high ethical standards remains relevant as specific practices change.
doi:10.1111/jocn.12598Proposes learning a “slow ethics” approach to nursing from Nightingale during the pandemic.
doi:10.1111/nin.12369Critiques and ongoing debates
Framing nursing around “feminine” traits raised its status but marginalised male nurses.
doi:10.1177/15271544251364249Reads her compassion as a practice shaped by gender, class, religion and ethnicity: “maternal imperialism”.
doi:10.1080/13623699.2020.1719582An almost ignored battle: her opposition to the state register of nurses, and her reasons.
doi:10.7429/pi.2020.732069The Mary Seacole debate: who was forgotten, and who was over-praised? Two narratives, one history.
doi:10.1111/jan.12291Four questions, no ready answers
- For which patients would you defend the “don’t ask, just bring” rule, and for which would you reject it?
- One of your ward’s indicators has improved. How would you tell a real improvement from a number game?
- Had you been the nurse on Private McCormick’s ward, would you have followed orders, or fed the patient?
- If the colonial schools report were submitted to an ethics committee today, what would the committee ask?
Sources
Primary texts by Florence Nightingale
- Subsidiary Notes as to the Introduction of Female Nursing into Military Hospitals in Peace and War. 1858.
- Notes on Nursing: What It Is, and What It Is Not. 1859.
- “Taking Food” and “What Food”. In: Directions for Cooking by Troops in Camp and Hospital. Richmond: J. W. Randolph; 1861.
- Notes on Hospitals. 3rd ed. London: Longman; 1863.
- Sanitary Statistics of Native Colonial Schools and Hospitals. 1863.
Secondary sources
- Iezzoni LI. 100 apples divided by 15 red herrings: a cautionary tale from the mid-19th century on comparing hospital mortality rates. Ann Intern Med. 1996;124(12):1079-85. doi
- McDonald L. Nightingale and use of statistics. Radical Statistics 128.
- McDonald L. The real goods and the oversell. Nightingale Society.
- National Army Museum. Florence Nightingale: The Lady with the Lamp.
- Vanderbilt University School of Nursing. Florence Nightingale Pledge.
- Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis Report). London: The Stationery Office; 2013.
- Alcantara EL et al. Nurs Inq. 2026;33(4):e70149. doi
- Zrelak PA. Nurs Outlook. 2026. doi
- Gallagher A. Nurs Inq. 2020;27(3):e12369. doi
- McDonald L. J Clin Nurs. 2014;23(17-18):2424-33. doi
- McDonald L. J Adv Nurs. 2014;70(6):1436-44. doi
- McDonald L. Scott Med J. 2014;59(1):67-70. doi
- Pitts D. Two narratives, one history: Mary Seacole and Florence Nightingale. Windows Time. 2018;26(1):7-9.
- Stewart. Policy Polit Nurs Pract. 2025. doi
- Martín-Moruno D. Med Confl Surviv. 2020;36(1):19-40. doi
- La Torre. Prof Inferm. 2020. doi
- Martini M et al. J Prev Med Hyg. 2021;62(3). doi
- Peng. Hu Li Za Zhi. 2020;67(3). doi
- Beck. Int Nurs Rev. 2024. doi
All quotations are taken from the five primary texts. Unit conversions are approximate. The Scutari mortality figures come from secondary sources and should be checked against the Collected Works of Florence Nightingale (ed. Lynn McDonald) before citation in published work. The ship in the “tap” story is not named by Nightingale; the details match the Great Eastern explosion of September 1859.
Prepared by Prof. Dr. Mehmet Nurullah Kurutkan, Düzce University, Faculty of Business, Department of Health Management.