Lynn McDonald, ed.,Collected Works of Florence Nightingale (2001-12, 16 vols), of which:
Lynn McDonald, ed.,Collected Works of Florence Nightingale (2001-12, 16 vols), of which:
2 volumes on civil nursing, 1 on health care 2 on military nursing, 1 on hospital reform, 1 on society and politics (statistics)
former Canadian MP, author, Non-smokers’ Health Act, 1988
Fame from the Crimean War 1854-56
Fame from the Crimean War 1854-56
Major founder of the modern profession of nursing
Social scientist, first woman Fellow of the Royal Statistical Society; pioneer of evidence-based health care
Pioneer environmental health theorist (from the lessons of the Crimean War)
Death rates per admissions, at London teaching hospitals were around 10%, when her nursing school opened in 1860
Death rates per admissions, at London teaching hospitals were around 10%, when her nursing school opened in 1860
In Crimean War hospitals at 40% in the worst months of the war (early 1855)
British Army death rate in Crimean War 22%
U.S. Army death rate in Vietnam 2.3%
Much of Nightingale’s time spent on cleaning up the hospitals (faeces on the floor) getting supplies in (food, bedding, clothing)
Much of Nightingale’s time spent on cleaning up the hospitals (faeces on the floor) getting supplies in (food, bedding, clothing)
Laundries established (laundresses quit from the smell)
But the significant change not until March 1855, with the Sanitary Commission
Nightingale saw the terrible conditions, and saw the changes made when the (civilian) experts were sent by government to the war hospitals: the Sanitary Commission (headed by Dr John Sutherland, with Robert Rawlinson, C.E.) and the Supply Commission, which improved nutrition, clothing and shelter
Nightingale saw the terrible conditions, and saw the changes made when the (civilian) experts were sent by government to the war hospitals: the Sanitary Commission (headed by Dr John Sutherland, with Robert Rawlinson, C.E.) and the Supply Commission, which improved nutrition, clothing and shelter
Massive clean-up, with “nuisance inspectors” from Liverpool, the city that pioneered public health measures
Massive clean-up, with “nuisance inspectors” from Liverpool, the city that pioneered public health measures
Removed dead horses from the water supply, improved ventilation, removed tons of “filth” (faeces) from the sewers and drains
The British Army made changes
The British Army made changes
French Army did not
The results in the statistics—overwhelming success for the British
1st winter dead total effectives percent
French 10,934 89,885 12%
British 10,989 47,749 23%
2nd winter
French 21,191 106,634 20%
British 606 27,384 2.2%
Source: Jean Charles Chenu, De la mortalité dans l’armée et des moyens d’économiser la vie humaine (Paris: Hachette 1870) 131
Nightingale and her team learned and applied the lessons of the war in radically reformed public administration, improved hospital design and the creation of a new profession, nursing
Nightingale and her team learned and applied the lessons of the war in radically reformed public administration, improved hospital design and the creation of a new profession, nursing
My view--based on primary sources
Other views still popular, both positive and negative
“Within several months of her arrival, she implemented hygiene practices--use of clean water, clean sheets and hand washing--that decreased the facility’s mortality rate to approximately that of London hospitals at that time.” Gawande, “Notes of a Surgeon: On Washing Hands,” New England Journal of Medicine 350 (2004)
“Within several months of her arrival, she implemented hygiene practices--use of clean water, clean sheets and hand washing--that decreased the facility’s mortality rate to approximately that of London hospitals at that time.” Gawande, “Notes of a Surgeon: On Washing Hands,” New England Journal of Medicine 350 (2004)
“She kept extensive and accurate records of military hospital conditions and mortality and differentiated deaths related to hospital conditions” (Munro, “The ‘Lady With the Lamp’ Illuminates Critical Care Today,” American Journal of Critical Care 19,4 (July 2010).
“She kept extensive and accurate records of military hospital conditions and mortality and differentiated deaths related to hospital conditions” (Munro, “The ‘Lady With the Lamp’ Illuminates Critical Care Today,” American Journal of Critical Care 19,4 (July 2010).
Nor did she invent “triage”
Hugh Small’s claim that the death rates highest at “her” hospital, and she to blame, that she was “criminally negligent”
Hugh Small’s claim that the death rates highest at “her” hospital, and she to blame, that she was “criminally negligent”
With not one table or figure to document this; yet this view taken up by nurses, many historians, the BBC, etc.--rough estimates, general and regimental hospitals compared
Mortality high everywhere, but the highest, when disaggregated data available, were at Koulali, nursed by the Irish Sisters of Mercy
Mortality high everywhere, but the highest, when disaggregated data available, were at Koulali, nursed by the Irish Sisters of Mercy
And this known since the war, in the official statistics collected by the War Office (which Small did not use)
Koulali had the worst sanitary conditions, noted by Dr Sutherland in the report of the Sanitary Commission
Koulali had the worst sanitary conditions, noted by Dr Sutherland in the report of the Sanitary Commission
Major clean up helped, but Koulali given back to the Turks
The decline in death rates NOT from nursing care—it required structural changes—sewers and drains
“Different treatments [have but a] small influence on the death rate”
“Different treatments [have but a] small influence on the death rate”
“Administration saves more hospital patients than the best medical science” (comments on Quetelet’s Physique sociale)
Sidney Herbert her collaborator on improving public administration
To compare results when “neglect of the laws of nature” and what may expect “from their observance”
To compare results when “neglect of the laws of nature” and what may expect “from their observance”
“Nature is the same everywhere, and never permits her laws to be disregarded with impunity” (“A Contribution to the Sanitary History of the British Army”)
“The law of life after operations has not yet been ascertained. And no hospital statistics have yet been kept so as to ascertain it.” (Nightingale letter 1861)
“The law of life after operations has not yet been ascertained. And no hospital statistics have yet been kept so as to ascertain it.” (Nightingale letter 1861)
Death rates post-surgery then around 50% (pre-Lister and anti-septic surgery)
Nightingale published on safety from 1858 papers to her full Notes on Hospitals, 1863
Four great defects of hospitals (from 1858)
Four great defects of hospitals (from 1858)
large numbers under one roof
deficiency of space
deficiency of ventilation
deficiency of light
Later editions of “Notes on Nursing” expanded to 16 causes
“Every nurse ought to be careful to wash her hands very frequently during the day. If her face, too, so much the better.” Florence Nightingale, “Personal Cleanliness,” Notes on Nursing, 1860.
“Every nurse ought to be careful to wash her hands very frequently during the day. If her face, too, so much the better.” Florence Nightingale, “Personal Cleanliness,” Notes on Nursing, 1860.
“Proper hand hygiene is the primary method for reducing infections,” A. Gawande, in “Notes of a Surgeon On Washing Hands,” New England Journal of Medicine, 2004.
Her most brilliant charts combine cross-sectional data (normal death rates and excessive death rates)
Her most brilliant charts combine cross-sectional data (normal death rates and excessive death rates)
With longitudinal (declining death rates over time as reforms brought in)
No other army learned the lessons of Crimea as the British
French Army: its next war, Italian Wars of Independence, 1859
At Solferino, the dead and dying left on the battlefield for days (Henri Dunant was there and went on to found the Red Cross)
Nightingale gave advice to the Northern Army (Harriet Martineau also acted for her)
Nightingale gave advice to the Northern Army (Harriet Martineau also acted for her)
Her Notes on Hospitals used by both armies
Nightingale concluded that, if the Americans (the North) had used her advice properly, their hospital death rates could have been 3%, instead of 10% (Wars and the War Office, vol 15:679)
French Army hospital death rates in the Franco-Prussian War were 12%, although France declared war.
French Army hospital death rates in the Franco-Prussian War were 12%, although France declared war.
Better than Prussian Army hospital death rates (they won the war) at 20%.
The British government acted on the comprehensive recommendations of the official royal commission (FN briefed witnesses as well as giving her own evidence)
The British government acted on the comprehensive recommendations of the official royal commission (FN briefed witnesses as well as giving her own evidence)
Sidney Herbert chaired the royal commission, then the 4 sub-commissions created to implement key recommendations
Barrack and Hospital Improvement Commission, later called the Army Sanitary Commission (John Sutherland)
Barrack and Hospital Improvement Commission, later called the Army Sanitary Commission (John Sutherland)
Army Medical School
Army Statistics Department
Army Cooking School
In China, reforms brought the army death rate down to 3% per year (like Crimea in the second winter, 2.2%).
In China, reforms brought the army death rate down to 3% per year (like Crimea in the second winter, 2.2%).
This in a “hostile” country, on “the opposite side of the world,” “notorious for its epidemic diseases” (15:347)
Netley Hospital and Herbert Hospital both overbuilt—beds provided for 10% of troops
Netley Hospital and Herbert Hospital both overbuilt—beds provided for 10% of troops
With the reforms, beds needed for only 5-6%.
‘”It is not our fault if the number of sick has fallen so much that they can’t fill their hospitals” (Nightingale letter 15:408)
“I know no class of murderers who have killed so many people as hospital architects. At this moment (1877) there are many diseases less fatal in their most wretched homes than in hospitals: i.e., hospitals secure a higher mortality.”
“I know no class of murderers who have killed so many people as hospital architects. At this moment (1877) there are many diseases less fatal in their most wretched homes than in hospitals: i.e., hospitals secure a higher mortality.”
FM advised on design: St Thomas’ London (civil), Herbert Hospital, Woolwich (army)
Solution in Nightingale’s day: the “pavilion” model, in effect each pavilion (28-30 beds) became a hospital on its own
In effect reducing the scope for cross-infection
(previous) Edinburgh Royal Infirmary
(previous) Edinburgh Royal Infirmary
Royal Victoria Hospital, Montreal
Johns Hopkins University Hospital, Baltimore
City Hospital, Berlin (Friedrichshain)
Hospital experts made the pilgrimage to London, when before Nightingale sent them to Paris
Hospital statistics key to saving lives:
Hospital statistics key to saving lives:
they enable tracking of epidemics,
judging success or failure of hospitals
(mortality rates, duration of stay)
“There are laws which regulate disease.” With “fixed data...the laws which regulate diseased action would become better known.”
Yet workhouse and hospital statistics were an “unworked mine”
Yet workhouse and hospital statistics were an “unworked mine”
While both types of institution were “created for the relief of human distress,” they did not know “whether they relieve it or not” (1858, at the National Association for the Promotion of Social Science)
Chapters in Notes on Nursing on ventilation, cleanliness, light, nutrition, patient comfort
Chapters in Notes on Nursing on ventilation, cleanliness, light, nutrition, patient comfort
From the causes of high death rates at the unsanitary Barrack Hospital, Scutari – environmental causes– overcrowding, lack of ventilation, faulty toilets, overflowing sewers, lousy food (scurvy frequent), polluted water, dirty bedding, vermin and faeces in clothes
Nightingale’s theory of health and nursing called “environmental”
Nightingale’s theory of health and nursing called “environmental”
From the lessons she learned in the Crimean War
Basic external factors MUST be dealt with first: clean air, water, floors, bedding, etc.
May need political change, legislation, more money, new building, different hospital site, better training, different personnel and mode of appointment, improved reporting prodcedures
May need political change, legislation, more money, new building, different hospital site, better training, different personnel and mode of appointment, improved reporting prodcedures
Must monitor, check results (causal links are complicated)
Still needed?
Still needed?
Hospital-acquired infections (AKA healthcare-associated infections) in U.K. estimates of 6% of hospital patients
U.S. estimates 1,200,000 patients, of whom some 100,000 die
Antibiotic resistant pathogens pose new threats – which may require revisiting old solutions (pre-antibiotics) MRSA, Ebola
Antibiotic resistant pathogens pose new threats – which may require revisiting old solutions (pre-antibiotics) MRSA, Ebola
Issues of priorities for spending and centrality of patient care – the same now as ever
6,000,000 cigarette smoking (increasing)
6,000,000 cigarette smoking (increasing)
2,200,000 alcohol-attributable
2,000,000 indoor air pollution
1,700,000 diarrheal
1,700,000 HIV/AIDS
1,300,000 outdoor air pollution
1,200,000 road injuries
660,000 malaria (decreasing)
300,000 maternal (decreasing)
Nightingale’s research methods and examples should be taught at the graduate level, in nursing and public health
Nightingale’s research methods and examples should be taught at the graduate level, in nursing and public health
Also her policy work, briefs on legislative changes needed, new programs
