Revisiting Florence Nightingale: International Year of the Nurse and Midwife 2020

This year sees the bicentennial anniversary of the birth of Florence Nightingale and has been designated the International Year of the Nurse and Midwife by the World Health Organization (WHO) and the International Council of Nurses in support of the Burdett Trust’s Nursing Now campaign which culminates at the end of 2020. The campaign aims to increase the profile and influence of nurses globally, emphasising the central role they have in helping to deliver the sustainable development goal of universal health coverage globally.

Florence Nightingale was born in 1820, and during her 90-year lifetime, she made an outstanding contribution to nursing, public health and the design and management of hospitals. In two articles about Florence Nightingale, Bill Newsom suggested that three of her books, Notes on Hospitals (1859 and 1863), Notes on Nursing (1860) and Introductory Notes on Lying-in Institutions (1871), had an enduring influence on infection control (Newsom, 2003a, 2003b). More recently, the popular romantic perspective of Florence Nightingale as the “lady with the lamp” has come under critical scrutiny. She was by all accounts a difficult person to get along with, and her privileged upbringing lead to difficult relationships with medical staff and other nursing contingents in the Crimea (Small, 2017; Williams, 2008).

However, it is apparent from the many biographies that chart her life that Florence Nightingale possessed qualities and skills that remain highly relevant to nursing roles globally. Her observation and organisation skills; a commitment to the fundamental requirements of those with health needs; a recognition of the power of collecting, analysing and using data to illustrate the need for change; and her ability to engage politicians, scientific collaborators and the media to influence opinion and change are all qualities that are critical to infection prevention and control practitioners of today.

Importance of fundamental elements of care

In January 2019, the UK Government published “Contained and controlled: The UK’s 20-year vision for antimicrobial resistance” and a “5-year national action plan to combat antimicrobial resistance 2019–2024” (Department of Health, 2019a, 2019b). Both continued to advocate the centrality of infection prevention as a means of minimising antimicrobial resistance (AMR) and preserving our ability to treat infection with available antimicrobials. Infection-prevention interventions are largely focused on taking the opportunity to avert the transmission of an infectious agent from a reservoir to a susceptible host. The factors that lead to a person becoming a susceptible host are legion, but globally the socio-economic deprivation experienced by sectors of the population in low-, middle- and high-income countries is among the most frequent. In Europe, there is evidence that in the 10 years since the global financial crisis, health inequalities play a role in the transmission of infection and infectious disease (European Centre for Disease Prevention and Control, 2013) and were exacerbated by cuts in public spending on public health and healthcare provision. Wilson (2018) suggested that the marked regional variation in Escherichia coli bloodstream infections may be due to a range of socio-economic factors, including reductions in social-care spending.

Florence Nightingale was a follower of Edwin Chadwick, a pioneer of public-health legislation. Her experience as a volunteer at the Middlesex Hospital in London during the Cholera outbreak in 1854 convinced her that the medical interventions of the day hastened the death of patients. Nightingale’s assessment of the situation on her arrival at the army hospital in Scutari was influenced by her belief that good nursing was based on ensuring that patients were well fed, hydrated, clean, warm and comfortable; sharing wash cloths was discontinued, and the cleanliness of the environment was prioritised.

Over the past five years, nursing and infection-prevention practitioners have refocused on the importance of fundamental aspects of care such as early mobilisation (Stolbrink et al, 2014), adequate hydration (Wilson et al, 2018), nutrition (Fitzpatrick et al, 2019) and oral care (El-Rabbany et al, 2015) as being central to improving patient outcome and minimising the risk of healthcare-associated infection.

The “passionate statistician”

Florence Nightingale had the advantage of a liberal education that included mathematics, for which she showed a particular aptitude. Her use of data to drive sanitary reform in the army and later the wider public-health agenda (Kopf, 1916) resulted in her being elected as a Fellow of the Royal Statistical Society in 1858. Florence was influenced by the statistical methods and ideas of the Belgian astronomer, meteorologist and social statistician Adolphe Quetelet; throughout her early life and nursing experience in Europe and England, she collected reports, pamphlets and returns which she analysed and reported. On her return from the Crimea, Florence collaborated with William Farr, one of the foremost statisticians of the era, to analyse data provided by the army in addition to that she had collected herself. While she was aware of the high death rate at the hospital in Scutari, she had attributed it to poor nutrition, suboptimal treatment and delayed transfer to hospital from the battlefront. It was only when Farr helped her to analyse the data that she realised that more lives could have been saved if she had had a greater focus on basic sanitation. One of Nightingale’s first books, Notes on Matters Affecting Health, Efficiency, and Hospital Administration of the British Army (1858), used statistical methods to compare the death rates of the army in peacetime with the civilian rate. Together with Farr, she showed that mortality was due to hospital conditions and concluded that “our soldiers are enlisted to die in barracks”.

The National Action Plan (Department of Health, 2019b) includes the use of the WHO core components for effective infection prevention and control (IPC; Storr et al, 2017). Core component 4 focuses on healthcare-associated infections (HAI) surveillance and makes recommendations for local and national IPC surveillance. A strong recommendation (based on very low-quality evidence) indicates that local HAI and AMR surveillance and feedback to staff should be used to guide IPC interventions and detect outbreaks. Nationally, the recommendation is that national HAI surveillance programmes and feedback networks that can provide benchmarking should be established. The Public Health England Fingertips Database (Johnson et al, 2017) provides the above, but its use in driving improvement locally is yet to be evaluated. Driving improvement also requires robust design, observation and measurement skills to demonstrate and report the difference that improvement programmes have been effective. Mary Dixon-Woods (2019) comments on the lack of robust evaluation that underpins many of the improvement efforts that are undertaken in health care, and suggests that many quality-improvement initiatives are “pervaded by optimism bias. It is particularly affected by the ‘lovely baby’ syndrome, which happens when formal evaluation is eschewed because something looks so good that it is assumed it must work.”

This links back to Nightingale’s initial assumptions that delivering “clean care” (the lovely baby) would make a difference to the outcomes for soldiers nursed at Scutari when in fact they made very little difference, as she was later to realise through her analysis of the data.

Nightingale as an influencer

Florence Nightingale was an astute and perhaps manipulative influencer, having been born into a wealthy and well-connected family (Williams, 2008). The Nightingale family had three residences during the year, one in Derbyshire (Lea Hurst) where they spent the summer and early autumn, one in the New Forest (Embley) where they spent the winter, and from March to June, they were in London at the Burlington Hotel for the season. At Embley, their nearest neighbour was Lord Palmerston who held the offices of Foreign Secretary, Home Secretary and Prime Minister during his political career. Another close neighbour was Sidney Herbert who as Secretary at War was instrumental in sending Florence to the Crimea. Florence also became a media darling during and after her period at Scutari. She was a prolific writer of letters, and her sister Parthe ensured that Florence’s observations were publicised in The Times and elsewhere. Public opinion was significantly altered by Nightingale’s time in the Crimea and resulted in donations to fund the training of hospital nurses (Small, 2017).

Influencing the healthcare agenda is a political activity; Nightingale recognised this and used her connections to her advantage. Engaging with politicians and policymakers is essential if IPC practitioners are to drive change at a national and global level. The new UK AMR strategy (Department of Health, 2019a) continues to highlight the central importance of preventing infection. This provides a golden opportunity for practitioners to make clear the priorities for strengthening the evidence base for IPC and how the service is delivered across primary care, community and acute settings. This requires engagement with politicians and policymakers at a local and national level; building strong coalitions and collaborative partnerships with other professional societies creates a coherent and powerful voice for the issues that need to be addressed. These coalitions should be integrally involved in deciding on the optimal design of an IPC service and the knowledge and skills required in the workforce to prevent and address the socio-economic drivers of infection. The power of publication is obvious; Nightingale’s obsession with data and its dissemination to influence change is something that IPC practitioners should pursue. The Journal of Infection Prevention provides one outlet for sharing research findings and the outcome of improvement strategies with colleagues and those who make decisions about infection prevention policy. Finally, in the International Year of the Nurse and Midwife and 200th anniversary of Florence Nightingale’s birth, we should not be afraid to “speak truth to power” in the pursuit of high-quality and safe care.