The “Lady With the Lamp” Illuminates Critical Care Today

Throughout her life Nightingale questioned the way things were. Her choice of nursing as a life’s work challenged the preconceptions of Victorian society, in which nursing was not considered an appropriate role for “respectable” women. She provided a legacy for nurses to continue to expand their professional opportunities. Nursing has continued to develop this theme in the establishment of critical care nursing specialization and certification and advanced practice expertise, including the development of the acute care nurse practitioner role.

At the outset of the British involvement in the Crimean War in 1854, despite initial opposition from male military physicians, Nightingale led a group of 38 female nurses in caring for casualties in a military hospital in Scutari, Turkey. Under her direction a triage system for wounded soldiers was established.³ Although there was no critical care nursing specialty, she and her nurses dealt with high levels of acuity in soldiers with horrendous war wounds and contagious diseases in overcrowded conditions (3000 to 4000 patients in a facility designed for 1700).⁴ 

Her insistence that none of the patients should die alone presaged the hospice movement and current interest in end-of-life care for critically ill patients. The presence of well trained, competent nurses who were secure in their disciplinary perspective permitted the development of the interdisciplinary care model that has become an essential feature of critical care practice.

Nightingale focused on the patient experience. Her writings express her belief that no matter what the underlying disease process or medical therapies, nursing could contribute to the patient’s recovery by improving the patient’s physical environment, personal hygiene, and nutrition.

Germ theory was not widely accepted until late in her lifetime and she expressed doubts about its validity.¹ Still, even before she accepted the theory of germs,⁵ her emphasis on cleanliness as an essential aspect of healing is fully congruent with our current emphasis on reducing environmental risks associated with nosocomial infections.

Recent research in critical care focuses on many issues that would be near to Nightingale’s heart. Examples include studies of handwashing, oral care, patient positioning, early mobilization, noise levels in the intensive care unit, and prevention of pressure ulcers. Expanding knowledge of pathophysiologic processes and therapeutic interventions is important to critical care providers, but understanding and optimizing the experience for critically ill patients is crucial as well.

Nightingale directed her energies toward patient outcomes that mattered. She kept extensive and accurate records of military hospital conditions and mortality, and differentiated deaths related to hospital conditions (what we now call nosocomial conditions) from deaths due to trauma or other causes. She developed a Model Hospital Statistical Form to standardize reporting of data from multiple hospitals. When she arrived at the Barrack Hospital in the Scutari military hospital in Crimea, the mortality rate was 42.7%; after initiation of better sanitation and nursing care, the mortality rate dropped to 2.7%.⁴ 

As we track patient outcomes in our critical care units, identify hospital quality indicators, and test interventions to improve patient care, we build on Nightingale’s early patient outcome focus.

Nightingale was statistically sophisticated and valued an evidence base for care. She stated, “What you want are facts, not opinions.…”^1,(p5) Aravind and Chung,⁵ who called Nightingale “the visionary of evidence-based medicine,” noted that “well over a century before the term ‘evidence-based medicine’ was coined, Nightingale was using statistical evidence to achieve improvements in patient care and outcomes.”^5 (p408) At a time when hospital mortality rates were high, she used careful calculations to predict a decrease in the hospital mortality rate that would be associated with improvements in hospital sanitation, and her hypothesis was supported when such improvements were instituted in military and civilian hospitals and mortality did decrease.

Nightingale is credited with the creation of the “pie chart,” which is a widely recognized method for communication of data.^2,5 She became the first female Fellow of the Royal Statistical Society in 1858 and an honorary member of the American Statistical Association in 1874. Analyzing and displaying data from our practice is a skill that continues to provide a powerful message about what works and what doesn’t for critically ill patients today.

She was active in dissemination of knowledge. While Notes on Nursing¹ is her best-known work (and is still a good read!), she published more than 200 books, reports, and pamphlets.² Three data-rich publications substantially improved outcomes for multitudes of patients by providing direction that resulted in better institutional design, sanitation, and training of both physicians and nurses (in 1858, Matters Affecting the Health, Efficiency and Hospital Administration of the British Army; in 1859, Notes on Hospitals; and in 1863, Observations on the Sanitary State of the Army in India).⁴ Critical care practice improves through continued dissemination of research, which provides a foundation for evidence-based care. When we publish our observations and original research, we follow Nightingale’s example.

Nightingale was active in teaching and mentoring others. In addition to establishing the Nightingale Training School, which continues today as she established in 1860, she assisted with founding the Military College of Medicine and the Women’s Medical College. She wrote letters of encouragement and advice to former students. She understood, as we do today, that mentoring others is an important aspect of improving the workplace and a potent force for improving patient care.

Florence Nightingale would be right at home as a contemporary critical care nurse. Her passion for improving patient outcomes, her commitment to evidence-based care, and her unwavering belief in the power of the discipline of nursing to improve patient experiences are still found in the hearts and minds of critical care clinicians today. Critical care clinicians and researchers can continue to look to the “Lady With the Lamp” for inspiration.