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Florence Nightingale’s Notes on Nursing and the Determinants of Health

Kagan, Sarah H. PhD, RN

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doi: 10.1097/NCC.0000000000000199
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Nursing’s tradition of studying determinants of health stretches back centuries, drawing on Nightingale and others. Successful science, such as nursing practice, ties end points to determinants while analyzing processes by which those outcomes are reached. Ideally, inquiry defines opportunity for intervention to improve both process and outcome. That improvement, however, rests on knowledge of determinants. Is our current focus on an array of determinants for health and illness sufficient to meet challenges across the cancer trajectory?

In our aging societies, determinants prove ever more important for overall health and figure prominently in cancer. Uncontrolled environmental exposures, such as secondhand smoke and food insecurity, represent real risk for developing cancer and other chronic noncommunicable diseases. Housing insecurity and inadequate sanitation put patients in danger of treatment complications such as infection as care delivery moves increasingly to ambulatory settings. In this current global context, advancing our science and improving our practice warrant new emphasis on the determinants of health.

Exploration of the determinants of health in cancer nursing research varies across our history. Our scholarly focus on personal dimensions of health—such as health behaviors—is clear and pronounced. However, our study of social, economic, and environmental dimensions of health varies widely. Recent research, such as that reported by McEwan et al1 in their analysis of determinants of late diagnosis and treatment of breast cancer in Egypt, reveals the promise of more robust investigations that include social, economic, and environmental determinants.

For many, our first connection to the determinants of health comes with hearing about, discussing, or reading Nightingale’s Notes on Nursing.2 But, secondhand knowledge of Notes on Nursing does not do justice to Nightingale’s analysis of the forces we know now as the determinants of health. Reading the edition first published in America in 1860 is easy, thanks to the digital revolution. It is now available in full text online as part of A Celebration of Women Writers (

In Notes on Nursing, Nightingale details her understanding of health and the full range of what determines it. She treats engagingly with personal factors such as hygiene and nutrition, social forces such as the still common ritual of friends visiting the sick, economic considerations including the influence of social class on housing and health, and environmental concerns comprising the cleanliness of everything from bedding to walls and beyond. Nightingale’s perspective is very much of her time while being remarkably relevant for our time. For example, her discourse on social relationships is charmingly anachronistic. This quality is foretold in the chapter title “chattering hopes and advices [sic].” The analysis within is nonetheless valuable for today, offering guidance regarding relationships and visits that are supportive and those that are not. Nurses practicing today will recognize the visitors Nightingale describes and know well their impact on patients’ health and well-being.

Contemporary initiatives to understand and intervene in the determinants of health sometimes appear to have marginal value for cancer nursing science. Perhaps that limited value stems from promoting programs such as HealthyPeople2020 ( in terms of primary healthcare. This approach limits obvious applicability for cancer nursing researchers who may be more drawn to investigate phenomena defined at the secondary and tertiary levels of prevention. Reading Notes on Nursing illustrates utility in framing care for people diagnosed with cancer as well as those at risk of developing cancer using the determinants of health. Identifying determinants implicated better characterizes those determinants requiring further description, relationships with process and outcome, and finally where intervention may best be outlined.

As we ready ourselves for the New Year 2015, I encourage you to take time to enjoy reading Notes on Nursing and to contemplate where the determinants of health sit within your program of research. Attending to determinants with energy equal to that we give outcomes and process promises rich rewards of robust science and improved care.


1. McEwan J, Underwood C, Corbex M. “Injustice! That is the cause”: a qualitative study of the social, economic, and structural determinants of late diagnosis and treatment of breast cancer in Egypt. Cancer Nurs. 2014; 37 (6): 468–475.
2. Nightingale F. Notes on Nursing: What It Is and What It Is Not. New York, NY: D. Appleton and Company; 1860. Accessed July 10, 2014.
© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins