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Florence Nightingale gets no respect: as a

Qual. Saf. Health Care 2003;12;317

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317

HEROES AND MARTYRS OF QUALITY AND SAFETY

Qual Saf Health Care 2003;12:317

F
lorence Nightingale (1820–1910) can be seen looking control groups. Her genius led her not to pick similar control
demure on a British bank note—a most respectable place groups but to choose them purposely to be non-comparable in
to have one’s portrait displayed. She is known today as the that their differences were biased against her hypotheses. To
founder of modern nursing, but is ignored as a healthcare show how bad Scutari was at its worst, she found a sicker group
research methodologist of the highest skill. She was a of soldiers. To show how healthy Scutari and the soldiers in the
“passionate statistician”, responsible for the most remarkable Crimea became, she found a presumably healthier group.
hospital quality improvement project ever carried out and, as For the first comparison she chose soldiers too badly
shown by her careful quantitative documentation, of both the wounded on the battlefield to be put on the transport ships
process and outcomes of care. and who were cared for in the Crimea. These soldiers, too sick
The central event of her life was her care improvements at Scu- to move, had a mortality rate of 27 per 1000 compared with
tari Hospital in Turkey during the Crimean War of 1854–6. In this 427 deaths per 1000 at Scutari at the same time. To
unnecessary but popular war the British, with their French and demonstrate the results of the improvements, she compared
Turkish allies, fought the Russians to a standstill on the Crimean the mortality at Scutari with the best hospitals in London and
peninsula on the north shore of the Black Sea. The incompetence the military hospitals there where the mortality rate was
of the British generals is remembered today through the bravery higher than the 2.2% rate at Scutari. She went on to show that
and folly of the “The charge of the Light Brigade”. Leo Tolstoy the death rate of all British soldiers in England was higher
wrote of even worse muddle on the Russian side. than those in the Crimea by the end of the war and after her
British soldiers wounded on the Crimean battlefields were reforms. This observation became the basis for her call for
put on transport ships and taken across the Black Sea primarily health reforms for the entire British army. The inadequacy of
to Scutari Hospital near Constantinople/Istanbul. When they the army’s healthcare data analysis led Nightingale to call for
landed there they were still in the uniforms they wore on the “the absolute necessity of a statistical department”. Her
battlefield when they were wounded. In the hospital they faced reform efforts continued throughout her long life.
dirty beds, clogged latrines, bad food, filth, and death. Overcom-
There are many reasons for her success. She had the techni-
ing the hostility from the British military hierarchy, Nightingale
cal and professional knowledge, knew what she wanted to do,
and her 40 nurses cleaned up this pestilential mess.
and did it with a constancy of purpose lasting decades. This
In her detailed statistical report she said the causes of the
was the first war with fulltime newspaper reporters. Their
Scutari mortality were fivefold: frightful overcrowding, want
reports to the British public made Nightingale a heroine and
of ventilation, drainage, cleanliness, and hospital comforts.
helped raise essential funds for her use, independent of the
She quantified and measured these problems and remedies. To
military. When she returned to England, instead of accepting
measure overcrowding she documented the amount of space
public applause in London she went to visit Queen Victoria in
per patient in London hospitals at about 1600 square feet
Scotland. The power of these two women, the public media,
compared with 300–500 square feet at Scutari. Windows were
opened for the first time and drains were cleaned out. For determination, and appropriate statistics explain Nightin-
example, in the week of 14 April 1855, 215 handcarts of filth gale’s ultimate success over a rigid military bureaucracy.
were removed, the sewers were flushed 19 times and the car-
WHERE TO LEARN MORE
casses of two horses, a cow and four dogs were buried. The
Nightingale threatened to publicly distribute her 1858
soldiers brought their blankets from the Crimea “unavoidably
statistical report “Notes on Matters Affecting the Health, Efficiency
covered with vermin”. Nightingale counted the thousands of
and Hospital Administration of the British Army Founded Chiefly on
items of clothing washed. Hospital comforts included a lack of
the Experiences of the Late War” unless the government appointed
eating utensils which she supplied.
a Royal Commission empowered to make improvements. The
She recorded the outcomes of care. The death rate among
Commission was created and these Notes were never distrib-
the patients was worst in February 1855 at 42.7% of all
soldiers admitted. After her sanitary reforms, which started uted. Today it is a very rare and ignored book. A large part of it
on 17 March 1855, the death rate fell to 2.2% by June 1855. has been republished in “Florence Nightingale: Measuring Hospi-
She showed a causal link between the sanitary reforms and tal Care Outcomes” by the Joint Commission on Accreditation of
this dramatic fall in mortality. You would think that this Healthcare Organizations, Oakbrook Terrace, Illinois in 1999.
evidence would have been sufficient to convince everyone. Of In addition to several well known biographies by writers
course not. The Principal Medical Officer of the Army said it uninterested in statistics, see:
was due to the improved character of the cases coming from • Vicinus M, Nergard B, eds. Ever Yours, Florence Nightingale, Selected
the Crimean peninsula—in short, severity of illness could Letters. Cambridge, MA: Harvard University Press, 1990.
explain away these differences. To rebut this argument Night- • Goldie S, ed. “I Have Done My Duty”: Florence Nightingale in the Crimean
ingale showed that the deaths were due not to battlefield War 1854–1856. Iowa City: University of Iowa Press, 1987.
wounds, but from what today we would call infectious
diseases. She reported that the hospital’s unsanitary environ- .....................
ment led to the deaths of both wounded soldiers and healthy D Neuhauser, Professor of Management, The Charles Elton
unwounded orderlies working there. Blanchard School of Medicine, Case Western Reserve University,
In addition to these before and after outcome measures 10900 Euclid Avenue, Cleveland, OH 44106-4945, USA;
linked to process reforms, Nightingale found two concurrent [email protected]

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