Nightingale and Ethics: Five Books, Eight Principles

Abstract

Florence Nightingale is remembered as the “Lady with the Lamp”, and the pledge recited at nursing graduations carries her name. Yet she never wrote an ethics code: the Nightingale Pledge was composed in 1893 in Detroit by Lystra Gretter and a committee of the Farrand Training School for Nurses. Nightingale’s ethics has to be found elsewhere, inside her practical instructions on ward design, mortality tables, nurses’ wages and the way food is brought to a patient. This teaching module reads five of her primary texts published between 1858 and 1863, extracts 47 concrete practices, and classifies each under one of eight ethical principles by asking a single question: what does this practice protect the patient from? For every principle it offers a story from the books, the practices themselves, a contradiction in Nightingale’s own writing and its echo in nursing today. A short review of recent PubMed literature sets out both the defenders and the critics of her legacy.

Keywords: Florence Nightingale, nursing ethics, patient safety, history of nursing, professional ethics, teaching material

Open the interactive module: a rotating 3D model of the ward Nightingale proposed, an animation of the Scutari mortality data, an animation showing how a hospital can “improve” its death rate by discharging dying patients, and a clickable wheel of the eight principles.
Nightingale and Ethics: Interactive Module →

Purpose and Reading Guide

The material is designed for undergraduate nursing students and their teachers. It can be used as a single lecture, as a reading before a seminar, or as the basis for small-group discussion. Each principle can be read independently. Quotations are taken directly from Nightingale’s texts; unit conversions are approximate.

1. Where the Story Begins: Scutari, 1854

In November 1854 Nightingale arrived at the British military hospital in the Selimiye Barracks in Üsküdar (Scutari), Istanbul. By her own later testimony, 4,077 soldiers died there between November 1854 and March 1855, most of them from disease rather than wounds. In February 1855, about 42 of every 100 soldiers admitted died. She spent the rest of her life asking why. Every principle below grows out of that question.

2. The Five Books

• Subsidiary Notes as to the Introduction of Female Nursing into Military Hospitals in Peace and War (1858): a management text for the War Office covering wages, pensions, sleep and discipline.
• Notes on Nursing: What It Is, and What It Is Not (1859): her best-known book, written for anyone caring for the sick at home.
• “Taking Food” and “What Food”, printed inside Directions for Cooking by Troops in Camp and Hospital (Richmond, Virginia, 1861).
• Notes on Hospitals, 3rd edition (1863): ward design, hospital management and statistics.
• Sanitary Statistics of Native Colonial Schools and Hospitals (1863): her least-known report, on the health of Indigenous children in British colonial schools.

3. Method

The five texts were read in full and every concrete “do this, don’t do that” instruction was extracted. Each practice was placed under the principle it most directly protects. The first four principles are the classic principles of biomedical ethics (Beauchamp and Childress): non-maleficence, beneficence, respect for autonomy and justice. The remaining four are central to nursing ethics and the ICN Code of Ethics: veracity, confidentiality, fidelity and advocacy, and accountability. The classification is an interpretation; a single practice can touch more than one principle.

4. The Eight Principles

4.1. Non-maleficence: harm does not only come from hands

Story. In a small hospital in one of the healthiest counties in England, 24 patients admitted for trivial accidents and minor operations caught erysipelas within nine months, and eight died. None of them, Nightingale wrote, should have caught it at all. Hence the opening of Notes on Hospitals: “It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.”

Practices. At least 100 square feet of floor and about 1,600 cubic feet of air per bed; hospitals that cannot be made safe “should not be there at all”; never waking a sleeping patient; no whispering in the sickroom, which she called “absolutely cruel”; never serving milk that has begun to turn; no airless, badly sited school houses.

Contradiction and today. She rejected contagion as one of the “spectres” that had terrified all ages and blamed bad air and bad management instead. The theory was wrong, yet the cleaning and ventilation she demanded saved lives, and her framing turned infection from fate into a management responsibility. Healthcare-associated infection is now treated as preventable harm.

4.2. Beneficence: an environment that helps recovery

Story. Fever patients in wooden huts with no window and nothing to look at but the knots in the wood. Nightingale saw this suffering and felt it herself; when a nosegay of wild flowers was sent to her, her recovery, she wrote, 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.”

Practices. Window sills low enough for the patient to see out from bed; colour, flowers and variety; the human voice and stringed instruments rather than the piano-forte; a caged bird or a baby’s visit; food in small amounts at the patient’s own times; playgrounds, singing and school rooms in children’s hospitals.

Contradiction and today. When newspapers argued that 25,000 child deaths a year in London called for a children’s hospital, she disagreed: the cause was defective household hygiene, and the remedy was not a hospital. The resource question, prevention or more beds, has not changed.

4.3. Autonomy and respect: a person, not a case

Story. A patient bedridden for years hears the same advice from every visitor: another doctor, another town, another pill. Nightingale replies that the patient has probably heard it fifty times, and that “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.”

Practices. Sit down and show no hurry when a patient talks; never speak from behind or from the door; tell the patient when you will be back; do not unsettle decisions already made; encourage patients to care for their own pets; admit religious nurses only on condition of “abstinence from proselytism”.

Contradiction and today. In the cooking writings she insists that a patient “should never be asked if he will have any particular article of food”, and elsewhere that “the Medical Officer is sole master of diets”. This is benevolent paternalism. Shared decision-making is now the norm, but the burden of choice in intensive care, dementia and end-of-life care is a real problem too.

4.4. Justice and equity: death chooses an address

Story. In Natal, Indigenous children brought to mission school were dressed in flannel and jerseys. The rain that used to run off their skin now soaked the wool, the children were chilled, and lung disease followed. Across 9,938 children in colonial schools she estimated mortality at double that of English children of the same ages, and concluded that “It is a matter for state interference.”

Practices. Excess deaths traced to a district, a street, one side of it, one floor of one house; one English infant in seven dying before its first birthday; the unhealthiest hospitals in London, the healthiest in small towns; no separate status for wealthy volunteer “ladies”; regular wage rises and pensions for nurses; colonial authorities held responsible.

Contradiction and today. She condemned colonisers who were “not always the best of the British people”, yet called Indigenous peoples “uncivilized” and still sought to “civilize” them, and she barred applicants from reformatories. Health inequalities, culturally safe care and the gendering of nursing (Stewart, 2025) continue these debates.

4.5. Veracity: honest to the patient, honest to the numbers

Story. Nightingale first blamed the Scutari deaths on poor nutrition and shortage of supplies. The real cause was a broken sewer and no ventilation; after the Sanitary Commission’s repairs in March 1855, mortality fell from 42.7 per cent in February to 2.2 per cent in June. After the war she studied the data, changed her mind and marked the Commission’s arrival on her own diagrams.

Practices. No false hope; truth-telling as a skill (“It is a much more difficult thing to speak the truth than people commonly imagine”); saying “I do not know”; “Death rate not the only statistics wanted”; exposing hospitals that discharged dying patients to lower their own mortality; stating the limits of one’s data.

Contradiction and today. The same book reported London hospital mortality above 90 per cent, because William Farr had divided a year’s deaths by the inpatients present on a single day; calculated over all inpatients, the rate was about 10 per cent (Iezzoni, 1996). Denominators and risk adjustment remain the core questions of hospital league tables.

4.6. Confidentiality: found in only one of the five books

Story. Nightingale reports a question “of medical ethics”: what should a doctor do if he suspects his patient is being poisoned at home? Insist on a confidential nurse being placed with the patient, or give up the case. Such a nurse “should never answer questions about her sick except to those who have a right to ask them.”

Practices. The trustworthy, confidential nurse; information only for those with a right to ask; no discussion of the patient in the next room; no intrusive advice from visitors.

Contradiction and today. She guards patients’ secrets, yet describes soldiers with venereal disease as “patients from a vile cause” while noting that they are “frightened, if not ashamed”. Data-protection law treats health data as a special category, but non-judgemental care is an ethical duty no statute can enforce.

4.7. Fidelity and advocacy: a voice for those who cannot speak

Story. In May 1856 one of Nightingale’s nurses brought food and drink to Private John McCormick, aged 20, ill with fever. The ward attendant, W. J. Northcott, was locked in the garrison cells for it, although he had been on duty three-quarters of a mile away. Nightingale printed his statement, spelling intact.

Practices. Cut off a source of harm at once, even at the cost of “a curious mine of observation”; remember that “among children, there can be no public opinion”; place adults beside children, since the woman in the next bed often becomes “the child’s best protector”; work with real love for each child’s recovery; keep to medical orders; do not seek public applause.

Contradiction and today. She called doctors “our masters the medical men”, yet repeatedly sided with patients against doctors, the army and ministries. The Mid Staffordshire scandal and the 2013 Francis Report, with its duty of candour and Freedom to Speak Up Guardians, show what happens when staff stop raising concerns.

4.8. Accountability: being in charge means building the system

Story. On the trial trip of “the finest and strongest ship that ever was built”, a tap that should have been open was closed, a funnel-casing burst and several people died. The inquest returned “accidental death”; the jury, Nightingale wrote, “apparently considered the tap ‘in charge’”. Her question for every ward: “What is done when I am not there?”

Practices. Seeing that others do things right; recognising that “the fault lies in there being no organized system of attendance”; counting the deaths of 521 nursing staff in 15 London hospitals with Farr; uniform registration of surgical outcomes; 12 hours on duty, 8 hours of sleep and 4 hours free for night nurses; no secret reports on nursing staff.

Contradiction and today. She explained that a tired night watcher “will either go to sleep, or drink to keep awake”, yet prescribed “instant dismissal if found asleep”. Just culture now separates human error, at-risk behaviour and recklessness, and fatigue remains a recognised safety risk.

5. Overview: Which Principle, in Which Book?

Notes on Nursing is the only book that touches all eight principles; Notes on Hospitals covers six, Subsidiary Notes four, and the cooking writings and the colonial report three each. Confidentiality appears in just one book, suggesting it was still a sickroom matter rather than an institutional one. Justice is the most widely spread principle: at the heart of Nightingale’s ethics is the question of how risk is distributed across society.

6. What the Literature Says

Recent work indexed in PubMed both defends and questions the legacy. Alcantara et al. (2026) link Notes on Nursing to current patient-safety frameworks; Zrelak (2026) reframes her as an early applied statistician; McDonald (2014) argues that her insistence on respect for patients remains relevant; Gallagher (2020) draws a “slow ethics” approach from her work. Critics read her differently: Stewart (2025) shows how framing nursing around feminine traits marginalised male nurses; Martín-Moruno (2020) reads her compassion as a practice shaped by gender, class, religion and ethnicity; La Torre (2020) revisits her opposition to the state register of nurses; and the Mary Seacole debate (McDonald, 2013, 2014; Pitts, 2018) continues.

7. Discussion Questions

1. For which patients would you defend the “don’t ask, just bring” rule, and for which would you reject it?
2. One of your ward’s indicators has improved. How would you tell a real improvement from a number game?
3. Had you been the nurse on Private McCormick’s ward, would you have followed orders, or fed the patient?
4. If the colonial schools report were submitted to an ethics committee today, what would the committee ask?

References

Primary texts

Nightingale, F. (1858). Subsidiary notes as to the introduction of female nursing into military hospitals in peace and war. London: Harrison and Sons.

Nightingale, F. (1859). Notes on nursing: What it is, and what it is not. London: Harrison.

Nightingale, F. (1861). Taking food; What food. In Directions for cooking by troops in camp and hospital. Richmond, VA: J. W. Randolph.

Nightingale, F. (1863). Notes on hospitals (3rd ed.). London: Longman, Green, Longman, Roberts, and Green.

Nightingale, F. (1863). Sanitary statistics of native colonial schools and hospitals. London.

Secondary sources

Alcantara, E. L., et al. (2026). Florence Nightingale’s contemporary legacy for patient safety: Implications for nursing and public health. Nursing Inquiry, 33(4), e70149. https://doi.org/10.1111/nin.70149

Gallagher, A. (2020). Learning from Florence Nightingale: A slow ethics approach to nursing during the pandemic. Nursing Inquiry, 27(3), e12369. https://doi.org/10.1111/nin.12369

Iezzoni, L. I. (1996). 100 apples divided by 15 red herrings: A cautionary tale from the mid-19th century on comparing hospital mortality rates. Annals of Internal Medicine, 124(12), 1079–1085. https://doi.org/10.7326/0003-4819-124-12-199606150-00009

La Torre. (2020). An almost ignored Florence Nightingale battle: The opposition to the creation of the state professional register of nurses. Professioni Infermieristiche. https://doi.org/10.7429/pi.2020.732069

Martín-Moruno, D. (2020). A female genealogy of humanitarian action: Compassion as a practice in the work of Josephine Butler, Florence Nightingale and Sarah Monod. Medicine, Conflict and Survival, 36(1), 19–40. https://doi.org/10.1080/13623699.2020.1719582

McDonald, L. (2014). Florence Nightingale and Mary Seacole on nursing and health care. Journal of Advanced Nursing, 70(6), 1436–1444. https://doi.org/10.1111/jan.12291

McDonald, L. (2014). Florence Nightingale and Irish nursing. Journal of Clinical Nursing, 23(17–18), 2424–2433. https://doi.org/10.1111/jocn.12598

McDonald, L. (2014). Florence Nightingale and Mary Seacole: Which is the forgotten hero of health care and why? Scottish Medical Journal, 59(1), 67–70. https://doi.org/10.1177/0036933013518276

Pitts, D. (2018). Two narratives, one history: Mary Seacole and Florence Nightingale. Windows in Time, 26(1), 7–9.

Stewart. (2025). Policy, profession, and gender: How Nightingale’s reforms elevated nursing and marginalized male nurses. Policy, Politics & Nursing Practice. https://doi.org/10.1177/15271544251364249

Zrelak, P. A. (2026). Florence Nightingale as a pioneer of applied statistics: Data, visualization, and the foundations of modern healthcare quality improvement. Nursing Outlook. https://doi.org/10.1016/j.outlook.2026.102941

Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. (2013). London: The Stationery Office.

Prepared by Prof. Dr. Mehmet Nurullah Kurutkan, Düzce University, Faculty of Business, Department of Health Management.