Florence Nightingale was a founder of modern nursing. She did not only make a revolution in nursing, but also in the medical sphere, because she discovered new ethical and social standards that changed nursing, reduced mortality of patients, and inspired for the creation of the Nightingale Pledge. She had strong ethical principles, whereby her religious beliefs were united with medical practices. Florence Nightingale set an example of empathy in patient care and established a hard-working hospital administration. The Nightingale Pledge was a real manifest of the ethics and standards of nursing with historical development, cultural values, and both positive and negative ethical effects that were discussed during the last century.
The Nightingale Pledge was constituted by Lystra Gretter, a nursing trainer at the old Harper Hospital in Detroit, Michigan. It was an adaptation of the Hippocratic Oath taken by physicians and included some special interpretations according to the codex of nursing and the historical period as well. The Nightingale Pledge is a common set of nurses’ goals to do their duties following certain ethical principles. This oath was read before all graduates (in the same way as physicians read the Hippocratic Oath at the end of their education). Since Nightingale’s documentation of her ‘bedside’ experiences, nursing has progressed from a vocation to a professional career (Zborowsky, 2014, p. 20). The Nightingale Pledge created ideal high ethical standards and specific regulations for nurses who wanted to follow strong ethics in their professional activities. Despite this, the code has a long history of adaptation to life, because every time it was interpreted differently.
In 1926, “A Suggested Code” was conditionally adopted by ANA and published in the American Journal of Nursing (AJN) (Fowler, 2010). Despite of some idealization, it was a quite solid and serious document, which defined professional principles of nursing clearly. Nevertheless, the Code did not list practical recommendations and was not adopted by the nursing community. In 1940, the Code was adapted considering the type of relationships, such as nurse-to-profession or nurse-to-patient (Fowler, 2010). In 1968, there was the next significant revision of the Code. This version included the term “professional” in the title in order to be adopted by the nurses’ committee. In 1976, an important revision was registered, which concerned an accurate attitude to the patient considering his or her mentality, character, and beliefs. The most relevant amendment was in 1995, when the committee did not only decide to change interpretative declarations, but also the provisions substantially. It was the most permanent revision for the last twenty-six years. The ethical principles were changed according to feminism, public provisions, and social ethics. The committee increased an interest in the global health, particular in different diseases, traumas, and nurse participation in the health policy. According to Zborowsky (2014), nurses did not have the respective medical terms to explain their experience and patient cases in the past, so the next interpretations were an attempt to summarize what nurses actually studied during the last centuries.
The institutes trying to change or rewrite the pledge have problems with certain parts of it. According to one of the editions of Nurse Week published on October 8, 2001, graduates have changed some lines. For instance, the graduating class at the California State University, Los Angeles, changed the word “God” to “of all faiths”, avoiding explicit Christian monotheism in the declaration. In addition, the line “to aid the physician in his work” was also changed. Instead, other health care workers were meant under the physician, destroying the social hierarchy and offering equal treatment of everyone (Domrose, 2001).
Despite this, the first formulation of the pledge has an actual value and contains some important explanations. Following the pledge, a nurse must faithfully practice her professional skills and never diverge from the ethical values. For instance, the main principle of the pledge is as follows, “I solemnly pledge myself before God and in the presence of this assembly: to pass my life in purity and to practice my profession faithfully” (as cited in Domrose, 2001). However, nurses discussed the pledge and its principles, trying to rethink its basic provisions. They doubted if it was necessary at all, especially in that current theoretical form, which had been proposed to the nursing community. Thus, the controversy surrounding the pledge had to be resolved because it questioned the status of nurses and could completely discredit the latter and Florence Nightingale, who did so many well-thought-of things for nursing. Anyway, the pledge has undoubted significance, as many organizations have adapted its principles to their objectives and codes. Some believe that the pledge means to follow human rights and ethical standards. Therefore, it is important for all licensed nurses to follow the pledge in order to assure the public in the professionalism of their practices.
The purpose of the pledge is to give a base that will direct the nurse to achieving the highest ethical standards. At its heart, the Nightingale Pledge is a kind of adaptation of the Hippocratic Oath, mixed with the idea of God and other Christian principles as well. This oath was historically adapted to values of the medical practice, incorporating a strong moral basis. Many believe that the Hippocratic Oath is the only one to be taken by healthcare workers. However, the context of the pledge is also very important and has been revised many times for centuries. As a result, there are many versions of the oath, because the ancient holistic principle has not survived to these days in its original form. In addition, every organization has its own vision of ethics. Because of the obscurity of many words in the Nightingale Pledge, nurses understood the essence of the principles according to their historical period. For example, they did not understand the meaning of “purity” and interpreted this term in different ways. However, most of them were convinced that “keeping promises” was the main principle, because it was ethical for both the community and patients (Domrose, 2001, p. 15). Hence, most of nurses used the pledge in their own way. There were so many cases of different interpretations of the source that it caused a conflict. Such situation is typical of any source, which is interpreted by different people in different ways (for example, the Bible as well as a legal law have hundreds of interpretations). As a result of these arguments, many schools have been forced to change the graduation ceremony (Domrose, 2001, p. 15). It has caused a difficult ethical dilemma obliging nurses to decide whether to take the pledge or to refuse in order to rethink its ethical principles.
Many nurses doubt the qualifications of Florence Nightingale that made her deserving this honor. Thus, the pledge has also been discussed in the light of these arguments. Despite the fact that Florence Nightingale founded modern nursing, she had some questionable moral values. She did not allow young British nurse Mary Seacole to work in her hospital during the Crimean War because of her skin color. Such refusal indicates her certain prejudice to people, particularly with regard to race. As for women’s rights, there are also certain contradictions that feminists often debate. McDonald (2014) mentioned that there was another reason for Nightingale’s choice, and it was not only the racial one. Actually, Seacole supported herself with selling Jamaican preserves and pickles (p. 1438). Moreover, she had not worked as a hospital nurse before, after or during the Crimean War and never called herself a ‘nurse’ (MacDonald, 2014, p. 1439). The facts also show that nowhere was written about a “black British nurse”, because Seacole was adapted to British society. Therefore, Florence Nightingale had another reason for refusal, namely, the lack of medical experience. It indicates the Nightingale’s intention to form a really professional nursing team during the Crimean War.
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Florence Nightingale also carried out many social reforms correlated with the feminist outlook. These changes included improving health care on all levels of British society, helping to eliminate prostitution laws that were more severe for women and advocating for the participation of women in the labor force. These ideas were truly revolutionary for that time, and therefore, they were considered sufficiently aggressive. However, Florence Nightingale did not deviate from her ideas, which were often more feminist than Christian. However, Bonfiglio (2014) stated that, “The Lady-Lamp image represented a cultural ideal of femininity and an important trope for all English readers to think and feel collectively as a nation and beyond the nation” (p. 10). Indeed, Florence took care of the fate of women, and when she saw that a woman held a bad social position, it aggravated her humanistic feelings. Moreover, she was also a very demanding mentor. Lorentzon and Brown (2003) analyzed letters between Rachel Williams and Florence Nightingale that “demonstrate the mentoring function which Nightingale adopted in regard to her favorite former probationers” (p. 267).
Thus, the Nightingale Pledge has generated many disagreements and problems in the nursing community and society for its historical evolution. Although it has an undeniable influence on nursing, it still requires active debates. The issue should be comprehensively reviewed and resolved. The community has to find a solution in order to save the original content of the Nightingale Pledge, eliminating the most pressing ethical shortcomings and prejudices. At the same time, Florence Nightingale and her tropes complicate the understanding of the mid-Victorian culture, evolution of nursing, and the ethical manifesto in health care.