By Karen Taylor, Director, Centre for Health Solutions
Tuesday 12 May was International Nurses Day, celebrating the contribution nurses make to society. It was also the 200th anniversary of the birth of Florence Nightingale, best-known for her pioneering work in raising the standards of nursing and educating nurses on good hygiene practices.1 Today her influence has been recognised in the name given to the newly-created Nightingale Hospitals – established in major UK cities. However, my admiration of the Florence Nightingale legacy began in early 2000s when I began a series of investigations into hospital acquired infections (HAIs). This week’s blog explains how Florence Nightingale’s passion as a statistician and health reformer influenced my work and why this is still relevant today.
Florence Nightingale’s lasting legacy
While I had been aware of Florence Nightingale’s role in modernising and indeed transforming the world of nursing, it was during the early 2000s, in my role, as the Director of Value for Money (VFM) Audit at the National Audit Office (NAO), that I researched her work extensively, and in particular her insights into reducing the risk of HAIs. Specifically, this research also heightened my interest in Florence’s enduring legacy as a ‘Passionate Statistician’.
Between 1854 and 1856, Florence and her team of 34 nurses improved significantly the sanitary conditions at a British base hospital and reduced the death count by two-thirds. On her return she embarked on a painstakingly meticulous analysis of mortality data from the Crimean battle hospitals and identified the main underlying causes as poor sanitation. Using data visualisation (Nightingale Rose Diagram) she persuaded the then government to carry out fundamental health reforms. She then applied her rigorous methodology to civil hospitals in Britain, identifying and subsequently influencing hospitals’ approach to tackling overcrowding, poor ventilation and lack of cleanliness. This earned her the accolade of being ‘the first female health statistician’.2 Her nursing principles and practices have continued to have relevance to the nursing profession, albeit compliance has sometimes waned. Importantly, her fearless advocacy for patients was based on a compassionate, caring and intellectual strength that remain a critical part of nursing today.
How Florence Nightingales’ passion for statistics helped shape my work on HAIs
In 1999, while at the NAO, my team and I conducted a series of interviews with nurses and other staff across the NHS and identified concerns about standards of cleanliness, and more importantly an escalation in concerns about HAIs. We therefore designed our research to focus on NHS hospitals’ approach to the management and control of HAIs. Specifically, on identifying the extent and costs of HAIs and the effectiveness of prevention, detection and containment measures in acute hospitals in England.
The NAO report identified a lack of basic, comparable data about rates of HAIs but that the limited data that was available suggested that, at any one time, nine per cent of patients (around 300,000) had an HAI. It also showed that the effects varied from extended length of stay, to prolonged or permanent disability and, for at least 5,000 patients a year, death; and estimated that HAIs were costing the NHS at least £1 billion a year. A census of infection control teams (ICTs) suggested some 15 to 30 per cent could be prevented by better application of good practice. On publishing the report, the head of the NAO noted that ‘hand hygiene is possibly the most important factor in preventing HAIs infection but that compliance is poor’. Other key findings included:
- wide variations ICTs levels of influence and a growing mismatch between expectations and the staffing and other resources allocated to ICTs, including wide variations in the ratio of ICNs to beds
- some 80 per cent of hospitals did not have a hand hygiene policy, with inadequate hand washing facilities
- limited evidence of screening, with the cost of screening patients considered to be too expensive and the cost-benefits of staff screening even less certain
- most hospitals had reduced their numbers of isolation facilities over the previous five years.3
The Committee of Public Accounts (PAC) examined the NAO’s findings and concluded that ‘the Department and local hospitals had not given sufficient attention to the issue, and had only limited data and understanding on the extent and cost of the problem and that there should be a shift towards prevention at all levels, underpinned by a commitment and philosophy that prevention is everyone's business’.4 In response the Department introduced mandatory reporting of Methicillin Resistant Staphylococcus aureus (MRSA) bloodstream infections (given evidence of large increases in cases and related mortality). In 2003 the PAC asked the NAO to undertake a follow-up report.
The NAO’s follow-up report, published in 2004, identified progress in putting infection control systems and processes in place and strengthening ICTs, but wider factors were continuing to impede good infection control. There had been limited progress in improving information on the extent and costs of HAI and, despite year-on-year increases in the number of MRSA bloodstream infections, the management and control of HAIs was not a board level priority. The report identified the need to change staff behaviours but noted that this was constrained by the lack of data, and evidence on the impact of intervention strategies. Importantly, increased activity had resulted in higher levels of bed occupancy (some of the highest in Europe) undermining good infection control and bed management practices.5
It was at this point in the story that my interest in Florence Nightingale collided with my findings on the growing challenge of HAIs. Following permission from the Director of the Florence Nightingale Museum, I used one of the Museums photographs as the front cover of the second report. However, to alleviate the concerns of the Department’s Lead ICN, that this might suggest infection control was the sole responsibility of nurses, I included an explanation on her role as a ‘Passionate Statistician’.6
The Department subsequently introduced a 50 per cent MRSA reduction target and, in 2004, mandatory surveillance of Clostridium difficile (C. difficile). However, following significant increases in C. difficile infections, in October 2007, set a 30 per cent reduction target by 2010-11. The Department also published ‘Towards cleaner hospitals and lower rates of infection’ and established a Programme Board, led by the Chief Nursing Officer7, which I was invited to join!
A second critical PAC report concluded that ‘progress in implementing its predecessor’s recommendations was patchy, and that there was a distinct lack of urgency on several key issues such as ward cleanliness and compliance with good hand hygiene; and limited progress in improving isolation facilities or reducing bed occupancy rates. It is also not yet clear how infections not covered by the Department’s current mandatory surveillance programme will be measured and consequently managed’.8
The NAO’s third and final report in 2009, concluded that the introduction of infection reduction targets, close performance monitoring, support and guidance, had been effective in helping to improve cleanliness and compliance with infection prevention practices and achieve aggregate reductions in MRSA and C difficile. However the performance varied widely between hospitals and the lack of surveillance information on some ‘80 per cent of infections’ led it to conclude that there was enormous scope for hospitals to improve infection prevention and control further and make savings by tackling other HAIs.9
The subsequent PAC report acknowledged that ‘the Department's hands on approach to what seemed, in 2004, to be an intractable problem, had been successful in reducing MRSA bloodstream infections and C. difficile infections; that hospitals cleanliness had improved; however, progress had not, been matched on other HAIs with voluntary reporting suggesting that these infections may be increasing’. It also concluded that there was still ‘limited progress in improving information on, and understanding of, hospital antibiotic prescribing’.10
Implications for today’s nurses in fighting novel infections
Historically, nurses have always been at the forefront of fighting epidemics and are critically important in driving the required improvements in and compliance with infection control. Today, we see NHS staff facing arguably the greatest challenge they have ever experienced, the novel coronavirus infection. As part of the armour needed to fight this pandemic, there are lessons to be learned from countries that were at the epicentre of SARS in 2002-2003, the Swine Flu in 2009-2010 and Ebola in 2014-2016. But there are also lessons from the NHS’s experience in tackling HAIs during the 2000s. Indeed, in all cases, nurses played a critical role in helping to bring the outbreaks under control.
Today, there is unquestionably a heightened acknowledgement and appreciation of the role and sacrifices made by nurses and other staff in treating the outbreak. We also have the benefit of detailed data analysis that is widely available and shared relentlessly. There is however, the real risk to staff themselves of acquiring an infection and a lack of suitable treatments. This makes compliance with evidenced based infection control practice even more important. My hope is that Florence Nightingale’s legacy and the lessons above, will help our nurses and other staff in their battle to defeat the COVID-19 pandemic.