War is a terrible, horrible thing. As a former military physician, I have been to war and have seen the mayhem inflicted by the mechanics and methodologies of modern warfare, alarming and sobering stuff, indeed. It ain’t pretty and it sticks with you, forever!
Having said this, it remains a fact that many great advances in health care have resulted from the experiences of doctors and nurses serving in war zones and treating medical, surgical and psychological casualties of both military and civilian victims – resulting from the destruction and chaos of conflict.
It should not surprise any of us involved in healthcare professions that amidst all this havoc, individuals with great compassion and even greater insight and awareness often arise. The collective adrenaline of our medical culture, functioning under duress, often fosters brilliance and innovation. Good stuff and good people percolate upwards.
Florence Nightingale was just such a person. She was not only a compassionate nurse, “the Lady with the Lamp”, but a brilliant observer and forceful, methodical implementer who brought the principles of sanitation, personal hygiene, nutritional adequacy and increased comfort to the victims of the Crimean War. Through the application of emerging statistical methods, she changed the world’s understanding of health and health care forevermore – Nobel Prize quality accomplishments, in my view.
The Story:
In the mid-1850s, the British, French, Turks (Ottoman Empire), Russians, and others got all mixed up in each other’s business over religion and imperial influence in the Middle East, with the inevitable outcomes associated with violence and conflict. Thousands of British soldiers were sent to Crimea (variously parts of both the Ukraine and/or Russia) on the coast of the Black Sea.
British military hospitals were poorly designed, understaffed, undersupplied, and overwhelmed by casualties. There was not even enough food for patients, and yet they were expected to heal somehow from their injuries. In fact, the importance of nutrition as part of health care was not given the recognition it deserved. Medical personnel were overworked and demoralized, and infectious diseases – poorly understood “epidemics” of fever, diarrhea, respiratory illnesses, and wound infections were rampant. Mortality was extremely high, not because of battlefield injuries per se, but rather due to the consequences of battlefield injuries combined with the primitive care being provided under horrendous circumstances.
Because of the abominable conditions in British field hospitals and the shortages of nurses, in particular (female nurses were notably undervalued and specifically not employed at the time), Florence Nightingale was directed by the Secretary of War to organize and take a contingent of nurses to the Crimea, thus laying the foundation for the greatest single improvement in patient safety in history, long before the IOM report1.
Florence Nightingale’s observations and her diligence did more to improve outcomes and reduce battlefield hospital mortality than all other medical and surgical interventions combined. She and her nursing teams promptly got to work addressing issues impeding the provision of safe and effective care. Simply by observing the appalling conditions and then taking action to better those conditions, she dramatically improved the quality of health care provided under austere conditions. This was well before the discovery that microorganisms were causes of infections or any scientific understanding of the mechanisms of infectious diseases resulting in death.
Hospital mortality declined by over 65 percent as a result of her leadership. Her efforts led to the formation of a UK government Sanitary Commission, which worked to improve sewage and waste disposal and to improve ventilation in the military hospitals. Not only did mortality decrease in British hospitals, but morale amongst medical staff improved dramatically, thus enhancing joy and meaning for the healthcare workforce.
On her return to England after the Crimean War, Nightingale wrote Notes on Matters Affecting the Health, Efficiency, and Hospital Administration of the British Army; Founded Chiefly on the Experience of the Late War, in which she proposed many improvements in management of military hospitals. In this report, Nightingale portrayed her now famous Rose Diagrams (i.e., wedge diagrams) as visual representations of the stepwise, statistical reductions in hospital mortality resulting from her interventions and those of the Sanitary Commission.
Florence Nightingale was patient safety’s first champion, a leader who displayed a truly patient-centered focus and the unique management qualities that exemplify the elements of “authentic leadership3” and she had never even heard of PDSA cycles!
Wonder why this has taken so long to be appreciated?
References:
• Institute of Medicine. To Err is Human: Building a Safer Health System, Washington, DC: National Academy of Science, 2000.
• Nightingale, F. Notes on Matters Affecting the Health, Efficiency, and Hospital Administration of the British Army. Founded Chiefly on the Experience of the Late War, London: Harrison and Sons, 1858.
• Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. Cambridge, MA: Institute for Healthcare Improvement; 2013. Available on www.ihi.org.