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Many doctors thought they couldn't be trained-that nursing care skills came only through experience. Many felt nursing was just fine as it was, and others feared that trained nurses would end up interfering with doctors, according to medical historians.

Nightingale did not envision nurses on par with doctors or practicing medicine in their own right. What she believed nurses could contribute was being the source of health promotion and prevention.

"Nursing was simply one part of a whole approach to public health care" imagined by Nightingale, said Lynn McDonald, Ph.D., a Canadian university professor of sociology and a prominent Nightingale researcher.

The educator

That led Nightingale to her best-selling Notes on Nursing in 1860, which, contrary to popular belief, was not a professional nursing textbook. Notes on Nursing was instead one of the first "how-to" health books for the general public. Besides hygiene and treatments for illness, the book included chapters on patients' mental needs for distraction (pets, flowers and window views) and conversation.

"Notes on Nursing was for the people nursing their families at home," said Marie-Beck. In her research on Nightingale history, Marie-Beck said she has found more than 400 references to the book in doctoral research materials.

Throughout the 1850s and 1860s, Nightingale was the most famous woman in England next to Queen Victoria. She wrote thousands of letters to members of Parliament, she oversaw and mentored the graduates of her training school and even caught the attention of the Union Army of the United States on recommendations for organizing its troops during the Civil War.

But according to Monteiro and other Nightingale scholars, her political influence waned in the 1870s, when many of her projects and ideas were starting to mature. Also, key colleagues had passed away (including her close friend and reformist ally, former war secretary Sidney Herbert). Some debate whether she was opposed to the suffragist movement. Monteiro and others believe she was not necessarily against the suffragists, but instead busy with her public health causes. There is also debate about how much she opposed the registration and licensing of nurses. "She didn't like the idea of unions, of tradesmen," in nursing, Monteiro said. "She wanted it to be a calling."

Nightingale also was definitively behind the times when the germ theory of disease began to gain acceptance in the 1870s.

Many prominent health experts of that era, including Nightingale, had trouble accepting the idea that diseases were the result of the arbitrary spread of tiny, bacterial agents. She didn't trust such a hypothetical assertion when her own experience convinced her that a unified infectious disease model of hygiene, clean atmosphere and even ethical behavior played a prominent role in illness prevention.

"She thought [germ theorists] had nothing to add to the argument," Martensen said. "In fact, they undermined her argument-it introduced an element of randomness. It didn't stress the relationship of moral space and social space and those elements of hygiene as much."

Germ theory proved to be the foundation of modern therapeutics and vaccines that ultimately contained perennial scourges like leprosy, tuberculosis and smallpox. But Nightingale was not entirely wrong in being slow to adopt it, scholars insist. Absent the miraculous cures that would not come for decades, her promotion of sanitary practices-cleanliness, proper nutrition, adequate ventilation and space-since the 1850s had done much to end the propagation of major diseases and cut hospital mortality rates.

"To give her credit, look at overall decline in mortality rates from infectious disease in her time," Martensen said. "The mortality rate of tuberculosis from 1830 to 1940 … in Europe and Germany went down 90 percent. That's before the advent of an effective antibiotic."

Nightingale's controversial views opposing the germ theory or women serving as physicians exemplifies why understanding the entirety of her life can be thorny, say researchers. It can be difficult to pin down the essential Nightingale from a woman who, over the course of 90 years, changed her mind and learned new ideas through experience and evolving thought. She made the historians' jobs particularly difficult by leaving behind a trail of 200 books and reports and more than 14,000 handwritten letters.

"It's like picking a scripture out of the Bible, out of context," said Linda Freeman, DSN, RN, a professor of nursing at the University of Louisville (Ky.). "You can quote her, and someone will have a quote [from Nightingale] in opposition to that."

"She was ahead of her time in some ways and behind the times in some other areas," Monteiro said.