COLUMN. Henrik Sjövall now draws Florence Nightingale into the long-running debate on the cause of the shortage of nurses. Today’s recent nursing graduates namely have more similarities with the real Florence Nightingale than the standard image many have of her.
There is an infected debate on why we have a shortage of nurses in university healthcare. Everyone is blaming each other, many say that it is just a matter of salary, others say that the cut-backs at the wards have led to such sparse staffing that supervision does not work – “recent nursing graduates are forced to take a responsibility they are not trained for”. Other arguments circulating are that today’s educational program generates “essay writers who cannot handle a CVC (central venous catheter, Ed.)” or that the program created “unrealistic expectations of regular working hours” – in other words that the job would not involve work on weekends and evenings. The situation right now seems pretty locked.
As you may note from my earlier columns, I read quite a lot more than professional literature, and one book I recently got hold of, “Eminent Victorians” by Lytton Stratchey, turned out to contain a biography of Florence Nightingale which naturally drew my attention. Hearing the name Florence Nightingale gives an image of a lonely, tender, caring woman with a lamp who busies about and comforts dying soldiers.
The story Lytton Stratchey conveys is another one altogether.
Florence Nightingale did not thrive in the self-righteous Victorian middle-class environment and had no plans whatsoever of getting married with some loser and conforming. She wanted to do good and get medical training, but at that time, nothing existed that was worthy of the name. Her parents also objected and she was first forced to travel to Germany to get training and then traveled around Europe on her own trying to find what little additional knowledge was available. When the Crimean War began, she pushed through approval to travel there as a volunteer nurse practitioner – the Crimean War was namely a bloody affair that was not going so well for Good Old England. Once there, she was met by a magnificently mismanaged military medical care: dark, dirty rooms, disgusting food and a major lack of medical equipment including first-aid supplies. The first thing she did was open the windows and let in light and air. She made sure it was clean and improved the quality of the food. There was a shortage of first-aid supplies and other medical equipment, but she succeeded in finding out that it actually existed, but was locked away in warehouses in the port for “customs reasons”. Somehow, she managed to get access to those warehouses from the boss in charge and made sure the equipment ended up where it should be, at the military hospital.
In a relatively short time, the mortality rate began dropping dramatically, but she constantly had to fight the bureaucracy of the military medical system. Intellectually, she was very alert and tried to use objective reasoning as far as possible and was a pioneer in what we today call descriptive statistics, shedding light on the state of affairs with pedagogical illustrations. One of her aphorisms is:
“To understand God’s thoughts one must study statistics…. the measure of his purpose.” Remember this when you are struggling with your statistics courses!
It is said that “against stupidity the gods themselves contend in vain” so after having clashed horns with the military bureaucracy, she packed her bags and boarded a boat to London, went up to the Army Headquarters in Westminster and held the minister and general in charge accountable: “This is simply not working, do something!” They tried to dismiss her, but she did not give up and ultimately, a commission was appointed to reform military medical care, with her ideas as a road map. Her philosophy of care is said to still form the base of today’s British military medical organization.
Still today, the book is worth reading
As you can understand, this woman began to become a threat to the establishment. The Crimean War ended and the war hospitals were taken down, but what was to be done with Florence Nightingale? At this point, her name was very well respected and a large amount of money was successfully raised for a kind of foundation to improve the status and quality of the nursing profession. She used the money to start the world’s first nursing program worthy of the name, and conducted extensive lobbying to attract gifted young women (at that time) to the profession. Sadly, during her time in Crimea, she had acquired a chronic disease (an unusual kind of brucellosis?) and was bedridden for long periods of time. But there was nothing wrong with her intellectual ability. She wrote a classic book, Notes on Nursing (ref), that summarizes her principles for successful care: light, clean, plenty of fresh air, good food, honesty to the patients, respect their need for rest, talk about life out there not their sickness, do not tire them with a lot of well-meaning lies… Still today, the book is worth reading and generally follows what we now call person-centered care.
In her final years, she became a “legend in her own lifetime”. She did not have the strength for meetings, but now and then took a small trip with her wagon and waved kindly to people; many therefore remembered her as “the nice old smiling lady from the Crimean War”. She reached the age of 90, dying in 1910.
The kind lady with the lamp was all the more easy to sell
So what became of her lifework when it was remodeled by the filters of history? Her magnificent entrepreneurial characteristics were naturally impossible to sell in Victorian society – after all, she was a woman – but the kind lady with the lamp was all the more easy to sell. And that is how it turned out. In the obituary, her magnificent entrepreneurship was toned down. Instead, emphasis was on the lady with the lamp who walked around and comforted wounded soldiers and that is what we mean today by the metaphor of “Florence Nightingale”.
The winner writes the history books…
So what does this story have to do with today’s nurse debate? Well, you could actually say that the training the nurses get today, among other things, prepares them for this very entrepreneur role, namely to take responsibility for quality work in a changing healthcare landscape. They learn quality assurance of information, they learn intellectual structure, they learn to read and evaluate original scientific works. And because this by definition takes time away from the “how-it’s-usually-done” education, it is perceived by the healthcare services as if they are “poorly trained for practical healthcare work”. And this may indeed be true in some cases. The university’s answer to this is that the “how-it’s-usually-done” education should actually mainly be provided by the healthcare services themselves, not the university, namely during what we call placement. And the complaining healthcare services are themselves responsible for it! And if this does not work, it is very difficult for the university to take over the task; what we can do is describe and simulate various typical situations at clinical training centers or simulation centers – which we also do.
As I see it, there are today two completely different maps concerning the cause of the nurse shortage in university healthcare:
- According to representatives for health sciences, the nursing students feel that they are met by mistrust (“where are all of the nurses, we really don’t have time to take care of you too!”), that promised supervised hours do not materialize (“we simply don’t have time”) and right after graduation, they are assigned to qualified duties and often lone work. And to add insult to injury, in the background there is a threat of a “three-shift” and maybe even “compulsory” lone night work… Perhaps it is not so strange that they are skeptical?
- The healthcare services have a completely different view of the world: the recently graduated nurses are perceived as “too poorly trained”, they are perceived to “not know how it’s usually done”, they are perceived to “not be able to handle simple medication calculations”, they are perceived to be “too detailed in their documentation” and to “not properly master pathology”. Since they are also considered to have “entirely unrealistic requests for wages and working hours”, it is understandable that the dialog is difficult.
As is usually said in negotiation contexts: the parties are very far from each other…
It is rarely just one side’s fault when two quarrel, and there is an ounce of truth in most of those assertions, on both sides of the line. As you may note, today’s discussion almost has the nature of a play by Lars Norén where everyone is shouting at each other and nobody trusts anyone. If we are to move on, we have to sit down at the negotiation table and at least try to agree on a shared map! Some of the problems that exist can actually be solved on the short term, others demand more long-term measures. Money is needed, yes, but then it should also be used where it does the most good! The working hours have to be discussed, shortcomings in supervision on the part of the healthcare services have to be discussed, some kind of career path where experience is weighed in has to be discussed. The issues of quality also have to be discussed, as well as the attitude problems on both sides of the line.
And, to get back to Florence Nightingale, you ultimately have to decide if you are going to train for the “sweet lady with the lamp” or create conditions for the role that led to a modernization of British military medical care! You probably have an idea of what I think from my text.
You ultimately have to decide if you are going to train for the “sweet lady with the lamp” or create conditions for the role that led to a modernization of British military medical care
P.S.: I have personally taken the initiative to the kind of discussions I recommend here at the Department of Medicine at Sahlgrenska, and with this submission, I hope that more of you will take the same route. We simply have to try to resolve this issue absolutely crucial to healthcare together through respectful and constructive discussions.
Reading tips:
- Nightingale F., Notes on Nursing. Dover publications 1969.
- Moberg, Å. Hon var ingen Florence Nightingale – människan bakom myten. [She was no Florence Nightingale – the person behind the myth.] Natur och kultur 2007
