Month: December 2014
Florence Nightingale was born in Florence, Italy, almost 200 years ago, when her wealthy parents were on a two year long honeymoon. At the time women were very seldom educated, but her father, feeling she was precocious, largely home schooled her in the rigorous classic style of the time: History, philosophy, literature, writing, mathematics, Latin, Greek, French, German and Italian. A Unitarian, at 16 she had an epiphany leading her to choose nursing as her life work, despite family objections. Nursing was seen as employment that needed neither study nor intelligence; some regarded military nurses as simply camp followers. She never married despite several apparently lasting and serious relationships.
In March, 1853, in an earlier Crimea, Russia invaded. Britain and France went to Turkey’s aid. British soldiers began falling ill with cholera and malaria, and malnutrition, among other things; within weeks an estimated 8,000 men were suffering from these two infectious diseases alone, in addition to war injuries. A public outcry ensued, and Nightingale, was commissioned to take a group of thirty-eight nurses to the war zone.
Her description of the ‘hospital’—a ‘filthy shut-in barracks without running water, hand washing, or sanitary food preparation, filled with parasite and vermin infested wounded’– was shocking. But within weeks the mortality there reportedly fell from more than 45% to 3%, not so much due to medical treatment, as to basic physical and environmental changes: to nursing care and administration.
Always a 24 hour a day stickler for detail, Nightingale became known as the Lady of the Lamp, because of her quiet nighttime rounds.
The Illustrated London News (24th February, 1855)
While the hyperbole of wartime may have inflated reports, there is no doubt that the facts Nightingale reported were essentially accurate.
In any event her Crimea effort was costly to Nightingale. She contracted Malta Fever (brucellosis), endemic there especially among goats, and had to return to England, where she suffered from it during the rest of her life. Yet she became a highly regarded statistician, remained an active advocate for women, and wrote extensively until her death at 90. Her accomplishments include:
1) Formalizing nursing education by establishing the first scientifically based nursing school—the Nightingale School of Nursing– in London,1860.
2) Promoting training for midwives and nurses in workhouse infirmaries.
3) Popularizing and promoting pie diagrams while analyzing the medical statistics of the Crimean war.
4) Developing a form of the pie chart now known as the polar area diagram, or circular histogram, to illustrate seasonal sources of patient mortality in the military field hospital she managed. She made extensive use of them to present reports on the nature and magnitude of the conditions of medical care in the Crimean War to Members of Parliament and civil servants who would have been unlikely to read or understand traditional statistical reports.
5) In 1859, Nightingale was elected the first female member of the Royal Statistical Society. She was first to effectively use pie histograms to make raw numbers more visibly understandable:
6) She was consulted by the North during the American Civil war, and also inducted into the American Statistical Society. (Her father was an abolitionist.)
7) She was the first woman awarded the Order of Merit in 1907. In 1908 she was awarded the Freedom of the City of London. She received the German order of the Cross of Merit and the French gold medal of Secours aux Blessés Militaires. On 10 May 1910 she was presented with the badge of honour of the Norwegian Red Cross Society.
As I walk today through an emergency room, or down a hospital hallway, or invade an ICU I am reminded of her book, ‘Notes On Nursing’ (1859). The noise, the blinking, clacking, and beeping cubicles, the voices sounding from the hallways, the intrusive gleaming glaring screens; the soulless, mindless TV, the overhead calls, and the invasive chaos of modern technology that continues day and night… It all leads me to me to suggest we need to consider Nightingale’s advise now. While,– at least in her early book– she holds to many misconceptions about infectious disease transmission of her time, that is not the essence of her message.
She stresses attention to the personal, and environmental, esthetic and physical conditions affecting a patient’s well being, health, and animus: fresh air, and circulation of air; safe water; a stable and comfortable room temperature; (consider the average ED where the temperature appears to be adjusted to the needs of frenetic professionals, rather than a nearly naked patient! Remember the warm blanket!)
Florence appeals for touching— frequent physical attention and contact, including warm soapy water bed bathing; for attention to the environment– airing and changing linens, fresh, clean, comfortable bed clothing; for good nutrition— healthy, appropriate, considerate serving of food and liquid; for thoughtful attention to the patient’s wishes, and personal comfort and preferences— minimizing all disturbance, especially from noise, (especially at night), including unsettling intrusions, business concerns, and visitors who may be unwittingly intrusive or thoughtless (She includes a list of visitor comments and questions that serve no purpose, but can be stressful or counterproductive.)
I was interested in tropical disease and started my internship at Gorgas Hospital in 1954 in the Panama Canal Zone. The sprawling hospital had been built by the French during their disastrous attempt to build the Canal. Some 40,000 people died during that effort, largely due to malaria, yellow fever, and diarrheal disease.
The old French Colonial hospital consisted of graceful white wooden one story buildings set among hillside gardens, connected by covered walkways. Wards and treatment areas, including surgery, were simply screened to remain open to the relatively cool westerly ocean breeze; yet there was a sense of grace, of quiet, of being nestled in the arms of nature; but only up to a point. During the entire year I never saw fly or a mosquito in the American Canal Zone, thanks mainly to the same sort or radical engineering that made the canal itself possible.
The day I began my medicine rotation the resident advised me to always speak with nurses before making a significant medical decision. That advice was among the best I ever was given. I recall it now, during this age of technologic marvels, to suggest we all listen to Florence Nightingale about order, cleanliness, quiet, environmental warmth, and the human touch. She calls for us to preserve these primal and essential aspects of medical care. She calls for us all to remember that an orderly safe environment, and healthful nutrition are essential health and to recovery from illness or injury. She calls for us all to be more empathetic and humane in our efforts to impose our concepts of ‘modern’ medicine on patients. Florence calls for us all to listen to the voice of old style nursing.