In 1853, war had broken out in the Crimea between Russia and the Ottoman Empire and by 1854 Britain and France (and later Sardinia) felt compelled to join the conflict because of fears of Russian military expansion in the region.
Background
At the beginning of the Crimean War senior military officers displayed an appalling disregard for the lives of British soldiers. However, unlike previous wars, when the general public were kept in the dark and uninformed about casualties, this was to be the conflict in which war correspondents were allowed to be present. They sent back first-hand accounts of what was happening to their respective newspapers. Through their dispatches they were able to describe to the reading public the dreadful situation of the suffering of the sick and wounded soldiers.
William Howard Russell, who was the war correspondent for The Times newspaper, brought to the attention of the public the inadequate hospital provision for the soldiers, highlighting that ‘the sick have not a bed to lie on’ (Baly, 2002) These and similar dispatches enraged the public, who poured their vitriolic anger on the Minster for War, Sydney Herbert. On 15 October 1854, at the personal request of the War Minister, Florence Nightingale agreed to recruit a cadre of nurses for duty in the war zone. It is a testimony to her logistical skills that within a few days she had managed to enlist a group of 38 volunteers and set sail for Turkey on 21 October 1854.
Some weeks later on 4 November, Nightingale's contingent arrived at the former Ottoman barracks being used as the British Army hospital at Scutari, now in modern-day Istanbul. She had at her disposal some £30 000, in today's money worth over £4 million, from The Times newspaper monetary fund, which came from public donations and was intended to help sick and wounded soldiers. Nightingale and her nurses found that the hospital was wholly inadequate; there was little clean water available and the toilet arrangements were grossly inadequate for the thousands of casualties, many of whom were bed bound. Ten times more soldiers were dying of diseases such as typhus, typhoid, cholera, and dysentery than from battle wounds (Fee and Garofalo, 2010).
The disastrous Battle of Balaclava had been fought on 25 October just prior to the nurses' arrival at Scutari and the hospital was filled with wounded and dying soldiers. Initially, the army medical doctors ignored the nursing contingent and refused all offers of help. Nightingale showed great stoicism in the first few days after her arrival and directed her nurses to make mattresses and bandages. It was because she had access to The Times fund that she was able to buy equipment without going through the tortuous process of navigating the army quartermaster red tape.
Then just two days after the nurses' arrival at Scutari the gory Battle of Inkerman commenced and soon thousands of sick and wounded soldiers were being ferried across the Bosphorus to the British hospital. The doctors and orderlies were soon overwhelmed and in desperation formally requested the help of Nightingale and her nurses. It is said that at one stage there were some four miles of wounded and sick soldiers on mattresses being care for on the floor of the hospital.
With The Times fund at her disposal, the British army doctors soon realised that Nightingale was someone who had the power and the authority to bypass the inefficiencies of the system to buy provisions and equipment for managing these patients.
Discussion
To understand the complexity of the situation facing Nightingale at Scutari it is useful to examine her contribution to the war effort using the contemporary methodology designed by the Care Quality Commission (CQC) for inspecting acute care hospitals. The CQC evaluates hospital services under five discrete domains—safe, effective, caring, responsive and well led—and rates them as ‘outstanding’, ‘good’, ‘requires improvement’ and ‘inadequate’.
So was Nightingale's service delivery: 1) safe, 2) effective and responsive, 3) caring and 4) well led?
1. Safety domain
Rating = inadequate
Despite the almost religious zeal that Nightingale and her nurses applied to care, it should be appreciated that the Crimean War occurred some two decades before the modern concept of bacteriology and germ theory was discovered by scientists such as Louis Pasteur.
Mortality rates were horrendous, with a 20% death rate, but this was not down to the instruments of war, but rather infection. Although Nightingale was an advocate of handwashing, many of the doctors were not, and many people, including Nightingale herself, believed in the miasma theory of disease, which was based on the supposition that inhaling miasma, or bad air, exposed an individual to corrupting matter and spread disease. In her book, Notes on Nursing, Nightingale wrote:’Every nurse ought to be careful to wash her hands very frequently during the day. If her face too, so much the better.’
Despite her being a champion for handwashing, the death rate at the Scutari hospital was higher than at any other hospital in the east and is now attributed to woeful sanitary conditions and ineffective sewers, which led to outbreaks of infectious disease. However, Nightingale clearly understood contagion and the transparent relationship between the diseases killing her patients and the filth in which they lay, the air they breathed, the water they drank, and the food they ate (Gill and Gill, 2005).
2. Effective and responsive domains
Rating = requires improvement
In terms of responsiveness, Nightingale and her team were well aware of their population of patients. In terms of effectiveness, the most important aspects are concerned with patient outcomes underpinned by competent staff.
Nightingale had a contingent of only 38 nurses at Scutari; there were initially around 3200 patients, giving each nurse a workload of 84. Such a nurse-patient ratio today would be totally unacceptable and it is likely that a significant number of patients would not have received anything other than suboptimum care. Within a few months the number of patients had risen to over 5000, but the number of nurses remained unchanged (Williams, 2008). Furthermore, Nightingale was not pleased with the contribution of some of the nurses she had brought with her, describing them as ‘not fit to look after themselves’ and one of the nursing nuns developed mental health problems and had to be sent back to England (Baly, 2002).
An analysis of the available data from Scutari shows that the mortality rate actually became worse and it was not until the spring following Nightingale's arrival at Scutari that things improved. This was because the government sent a sanitary commission team to Scutari, which led to the cleaning up of the blocked sewers and removal of a decaying horse that was contaminating the fresh water supply. Within a few months, the mortality rate dropped from 42.7% to 2.2%. Nightingale is also thought to be one of the first to use clinical audit as a method of illuminating the success or otherwise of her sanitary interventions on survival rates at Scutari.
Patient outcomes were initially poor but they started to improve, helped not least by Nightingale's efforts to improve nutrition and hydration. This emphasis on good nutrition was enhanced when in 1855 the government seconded famous London chef Alexis Soyer to the Crimea where he worked closely with Nightingale to improve the hospital diet. She and Soyer remained friends until his death in 1858.
Although one of the modern aspects of CQC inspections focuses on the effectiveness of multidisciplinary teamwork, had CQC inspectors been at Scutari they would have found this wanting. This is because the doctors and their orderlies were not initially in favour of working with the nurses. The situation did improve eventually and one of the senior military doctors became a strong ally of Nightingale.
3. Caring domain
Rating = outstanding
There is no doubt that the nurses worked hard and were extremely caring to the men they looked after throughout the hospital. Nightingale herself worked tirelessly day and night, and Baly (2002) reports that she often spent 8 hours a day on her knees dressing wounds. It was at this stage that her reputation as the Lady of the Lamp was born as she conducted her night-time hospital rounds carrying a simple Turkish paper concertina lantern.
Soon the wounded men began to call her the angel of the Crimea and would kiss her shadow as she walked past the beds. Although she was revered for her caring by the patients within the hospital, this adoration soon spread to the British public at home following the publication of a pen and ink drawing of her carrying a lamp on her ward round in The Illustrated London News in 1855. The public were desperate for a hero to emerge from the Crimean campaign, which was tainted by sheer and reckless foolhardiness.
Frequent newspaper reports about the exploits of Nightingale and her nurses further reinforced her reputation as the angel of the Crimea. However, she contracted Crimean fever, which was endemic throughout the war. She became gravely ill and it is said that the soldiers of the Scutari hospital turned their faces to the wall and cried, praying for her recovery. She eventually did and returned home after the war in 1856 to sail into the pages of history and legend.
4. Well led domain
Rating = outstanding
Nightingale had vision and strategy for her work at Scutari and, although not in modern terms a clinical leader, she became a powerful and successful role model for the subsequent academic, political and managerial domains of professional nursing (Stanley and Sherratt, 2010). She was a stern taskmaster who had high expectations of herself and those who worked with her. When she met with the British ambassador responsible for equipping the hospital at Scutari, who came up with a range of feeble excuses for his dereliction of duty, she purportedly told him: ‘Mr Ambassador, I never give an excuse and I never take one!’ (Baly, 2002).
Importantly, she was a pioneer in the development of evidence-based practice and in many respects she laid the foundation stones of clinical governance.
Conclusion
Although Nightingale became a legend in her own time, she was not the only nursing figure to rise to prominence during the Crimean war. Contemporaneously, Mary Seacole worked tirelessly to deliver care to wounded soldiers, but after her death in 1881 she was to remain lost in the annals of nursing history for over a century. In the next article, I will explore the founding of the first School of Nursing after Nightingale's return from the Crimean War.