Is Florence Nightingale relevant to 21st century nursing

1. Relevant or redundant? The Impact of Florence Nightingale in the 21st century Professor Carol Haigh Manchester Metropolitan University Professor Debra Jackson University of Western Sydney

2. F.N – a brief History 1820 – born 1837 – God speaks to her for the first time 1844 – Became advocate for poor law reform 1845 – decides to become a nurse 1847 – had mental breakdown 1851 – rejected marriage proposal from Richard Monckton Milnes 1853 – dresses herself and does her own hair for the first time 1853- took the post of superintendent at the Institute for the Care of Sick Gentlewomen in Upper Harley Street, London, 1853 – God gets in touch again 1854 – left for Crimea with 38 other women 1854 – God speaks to her for the last time 1855 - establishment of the Nightingale Fund for the training of nurses 1856 – Crimean War ends 1857 – Intermittent mental collapse begins 1859 – Notes on Nursing published in the UK 1860 -Nightingale Training School at St. Thomas' Hospital opens on 9 July. 1865 -The first trained Nightingale nurses began work on 16 May at the Liverpool Workhouse Infirmary 1907 – awarded Order of Merit 1910 - dies

3. A search on Google Scholar using the Search term “Florence Nightingale” shows 33,700 hits “Florence Nightingale and Nurse Education” shows 21,500 hit “ Florence Nightingale in the 21st Century” shows 2, 860 hits across Nursing, medical, historical & philosophical journals

4. Nightingale’s relevance to Clinical Practice Nurses at the Zeehan hospital Tasmania, c 1900

5. Patients We say…. Florence said….. Really good nurses are often distressed because they cannot impress the doctor with the real danger of their patient and quite provoked because the patient will look either so much better or so much worse than he really is when the doctor is there. The distress is legitimate but it generally arises from the not having the power of laying clearly and before the doctor the facts from which she derives her opinion Nurses work the "front lines" of a practice. They are the first person to interact with a patient, and are responsible for discovering the source of a patients problem, assessing the situation, and finding a solution. Many times, for non life threatening sickness or easy to treat symptoms, a doctor will not even be required and a nurse can take care of the problem. (http://www.rncentral.com/nursing-library/the-difference-between)

6. Nurses Florence said….. We say….. "Research shows that effective workforce planning in nursing greatly influences the quality of patient care – directly effecting factors such as mortality," commented Walter Sermeus, Professor at the Katholieke Universiteit Leuven, Belgium and RN4CAST Project Co-ordinator. (HospitalHealthcare.com 2009) If a patient is cold, if a patient is feverish, if a patient is faint, if he is sick after taking food if he has a bed sore it is generally the fault not of the disease but of the nursing

7. Noise What we say….. What Florence said…. Of one thing you may be certain anything which wakes a patient suddenly out his sleep will invariably put him into a state of excitement do him more ……mischief than any continuous noise however loud Never to allow patient to be waked intentionally Unnecessary noise then is the most cruel absence of care which can be inflicted either on the sick or well The World Health Organization WHO has defined a level of 35 dB as the benchmark for the average constant background noise level in hospital wards. Night time peak values should not exceed 40 dB. However, numerous studies attest to typical peak values of 45 to 60 dB, and occasionally even higher than 80–90 dB, caused by the sound of alarm systems and numerous technical appliances. At 100 to 110 dB, the noise level in the operating theatre is proving to be particularly dangerous for clinical personnel where drills, saws and other items of equipment create a significant risk of noise-related hearing loss.

8. Infection What Florence said... It cannot be necessary to tell a nurse that she should be clean or that she should keep her patient clean seeing that the greater part of nursing consists in preserving cleanliness What we say... Basic hygiene should be considered at the same time as cleaning. This will include not only handwashing, which is recognized as often poorly performed but also hand habits It is also becoming apparent that the sites closer to the patient are more likely to furnish an infection risk than those situated further away

9. Nightingale’s relevance to Nurse Education Graduation Class 1899 – Nova Scotia

10. Nurse Registration Nightingale stridently opposed registration for nurses Believed that the attainment of moral qualities was the main purpose of nurse education Feared technical skill could surpass moral character Believed that nursing would loose its autonomy over who was able to register as a nurse -> possible deterioration of standards Feared nurses training schools would come under the control of doctors Did not approve of dependence registration would have on nurses’ ability to pass exams

11. Nightingale and exams Did not oppose exams as such, but believed they tested only memory they advantaged upper class over working class women could not test for personal and moral character … “Written exams could not test a nurse’s ability to apply her (sic) knowledge on the ward, her appreciation of the character of each individual case, or the individuality of each patient” (Helmstadter 2007:158)

12. “Nightingale believed only experts – people currently working and training the nurses and who knew them personally - should credential nurses. Thy should be certified individually rather than by a standardized examination” (Helmstadter 2007:162)

13. Hospital Matrons Positioned as the gate-keepers for judging moral qualities Thus the matrons should control who could enter nursing and complete training

14. Becoming a nurse… then and now Hospital-based Matrons had selection control of students Applicants required to attend interview, often with parents Matrons had control over hospital schools -> could influence decision making around education and the implementation of curricula Matrons were required to sign-off papers recommending registration University based Applicants accepted on the basis of internet-based application Face-to-face interview often not required Universities influence decision making around nurse education and the implementation of curricula University staff sign-off papers recommending registration

15. Universities now control who is admitted into preparatory courses leading to registration as a nurse pass rates, through policies and measures such as level of pass required, ability to resit if failed subject etc Focus upon the needs of the University rather than the demands/standards of the service

16. Florence Nightingale as a nursing icon

17. Was she as saintly as she liked to appear? Traded upon her social position to influence both the Prime Minister and the War secretary Squandered resources by dismissing good nurses who were already out in Scuatri Was a class snob displayed considerable resentment towards people, Crimean doctors in particular, who had dared to rise above their station noted for her exaggerated statements and vituperative asides in relation to the senior medical staff Lied about some of her colleagues promoted the damaging assertion that John Hall (Principal Medical Officer in the Crimea) had no adequate medical qualification, when in fact he was an FRCS, by examination, and had an MD from St Andrews

18. Shamelessly took credit for the work of others Nightingale publically stated that she regarded the establishment of a medical statistical branch as one of her most important proposals adopted by the Royal Commission in 1857 In fact been Andrew Smith (director general of the army medical department) proposed in 1855 that a board for medical statistics be established formally within his office, a function that it was already performing Took credit for the idea of the need for an army medical school This had been proposed some 50 years previously The death rate began to fall six months after she took charge but only after a sanitary commission was sent out by Lord Palmerston to improve ventilation and clean out the sewers. Nightingale had believed the mortality rates were due to poor nutrition and overworking of soldiers but unpublished letter shows it was not until 1857 that she realised the conditions within the hospitals themselves had caused such a huge number of deaths. Chose to open her training school at St Thomas’s to capitalise upon the work of Mrs Wardroper, the Matron, who had already initiated a programme of reform in 1855

19. Media Darling This was the first foreign war to be fully reported in the press Denounced by John Hall as “publicity seeking meddler”. Had her own Fan club Reclusive in the extreme – only 8 photographs of her survive Developed an inflated idea of her own importance “the War Office cannot turn me out because the country is with me.”

20. So……. Relevant Ideas about patient requirements (cleanliness, quiet etc) Link between clinical need and access to education Establishing a personal profile Redundant Opposed to registration Social class obsessions Bullying and manipulation Initiated the angel/whore stereotype Set dangerous parameters in the Dr/Nurse relationship that it took the profession decades to shed

21. A final Word….. “Perhaps the greatest good that has resulted from her noble life has been the setting in motion of a force which has led thousands of women to devote themselves to systematic care of the sick and wounded”. New York Times, August 15th 1910