Editor's note:  This article is published in anticipation of National Nurses Week, May 6-12, 2011, and National Hospital Week, May 8-14, 2011.

We remember Florence Nightingale as founder of the nursing profession (which she was), but most people are not aware of her other many contributions to the development of the hospital as we know it today. She was, in a very real sense, the first hospital administrator and architect of the modern hospital.

In a 22-month span between late 1854 and early 1856, Nightingale oversaw a revolutionary overhaul of the British military health care system. Great Britain, along with her allies France and Turkey, had gone to war with Russia for reasons long since forgotten by history.

Having not been in a shooting war in 40 years (not since Wellington defeated Napoleon at Waterloo), the British generals seemed to have forgotten that the one certain outcome of every war is casualties. When the Russian army surprised them by fighting back and their casualties began to mount, they didn't even have a place to put them all. So they petitioned the Turkish government to give them an abandoned army barracks in the city of Scutari in which to warehouse all of the sick, wounded and dying soldiers who had taken a bullet for their queen.

Even by the low standards of the day, conditions in the Scutari hospital (and the nearby general hospital) were horrendous. Soldiers were laid on bloody cots or straw with a bare 18 inches between them; they were infested with lice and vermin; the water was contaminated; the air was foul and the food was rancid; and physicians' treatment of choice was amputation (which almost always culminated in death by infection, largely because surgical rags went from one patient to the next without so much as being passed over a bucket of hot water). At the depths of the crisis, mortality rates approached 50 percent of everyone admitted.

Shortly after arriving at Scutari, Nightingale wrote home that "surely this is the Kingdom of Hell." One eyewitness observer, the Rev. Lord Sidney G. Osborne, called the Scutari hospital "a vast field of suffering and misery." Yet as Mark Bostridge wrote in his biography Florence Nightingale: The Making of an Icon: "By the end of the war, the Scutari hospitals had been transformed into efficiently-organized, smooth-running operations."

Health Care Transformed

Through her work to manage the Scutari hospital during those two years, and to reform the entire British health care system over the succeeding five decades, Nightingale did more than lay a foundation for the nursing profession, as remarkable an accomplishment as that was. She, more than any other person, oversaw the transformation of the "hospital" from a haphazardly managed building that originally had been designed for some other purpose (an army barracks building in the case of Scutari) into a facility specifically designed with the care of patients in mind. Her fingerprints are all over some of the most fundamental elements of today's health care system—things that we take for granted but that were revolutionary during her time.

Medical records. One of the first things Nightingale did upon arriving at Scutari was go around with a piece of chalk and number every patient cot. She then saw to it that detailed records were kept on every patient. She recorded physical symptoms, reactions to treatment, and (all too often) time and manner of death. She wrote to the families of dead soldiers, telling them of the circumstances under which their relatives died, typically with comforting words to the effect that they had died in peace.

In her classic work Notes on Nursing: What It Is, and What It Is Not, she said that the most important element of being a good nurse—more important than compassion or clinical skill—is the ability to acutely observe and record changes in a patient's condition. She certainly would have applauded the move toward electronic health records, though she also would have cautioned against the danger of managing machines instead of caring for people.

Medical triage. Nightingale certainly would have agreed with the comment by Mother Teresa that "we are all children of the same God," a point that was central to her unpublished book on religious theory and practice (see Florence Nightingale: The Making of a Radical Theologian, by Val Webb).

At a time when officers looked upon enlisted men as "the scum of the earth" (words the Duke of Wellington used to describe the men who brought him his victory over Napoleon), when the Anglican Church discriminated against Catholics, and when non-Christians were treated as something less than human, Nightingale insisted that medical care should be provided on the basis of the patient's clinical condition and not his religion, military rank or social standing—a radical idea in Victorian England. When she ran into considerable opposition from the class of officers and gentlemen, she stood her ground. Officers did not receive preferential treatment from Nightingale and her nurses.

Infection control. When Nightingale's nursing corps arrived at Scutari, she told them that the strongest among them would not be wanted at the bedside, but rather at the washtub. She used her considerable informal leadership abilities to insist that the orderlies, all men who at first looked down upon the ladies from London, routinely empty the chamber pots on patient wards. She made it her mission to clean up the deplorable sanitary conditions of the Scutari barrack hospital, going so far as to use her own money to hire a Turkish work crew to refurbish a burned-out wing of the building before it was used to accept new patients.

Although she herself did not accept germ theory until much later (at this stage she subscribed to the miasma theory, as did almost everyone else in medicine), in practice her methods set the stage for the laundry, housekeeping and maintenance functions in today's hospitals. Her subsequent work gave a major boost to the sanitation movement (she would have been absolutely horrified at the resistance hospitals still face in getting clinicians to wash their hands between patients). As Hugh Small shows in his book Florence Nightingale: Avenging Angel, her most important contribution to the precipitous decline of mortality rates at Scutari was due more to her insistence on cleanliness, which dramatically reduced infection rates, than it was to improved nursing care.

Hospital epidemiology. Following her return to London after the war, Nightingale was haunted by the specter of the outrageous death rate among British soldiers—the men she thought of as her children—at the Scutari barrack hospital. Completing the first-ever hospital epidemiological study—in the course of which she invented the famous cockscomb diagram, a precursor to the pie chart—Nightingale documented the dominant role that basic sanitation played in reducing mortality rates, thereby giving a major boost to the incipient sanitation movement. In recognition of her work, she was the first woman ever admitted as a fellow of the Royal Statistical Society.

Nutrition services. When Nightingale arrived at Scutari, soldiers were being fed whatever the officers refused to eat, which was thrown into a pot and boiled. She hired a French chef who traveled to Scutari to create nutritious recipes for the men; to prepare these recipes, he developed one of the most sophisticated hospital kitchens seen up to that time. Nightingale had an intuitive appreciation of the link between nutrition and healing (one of the 10 components of the Planetree model of patient-centered care).

Patient education and empowerment. British soldiers tended to drink away their pay as quickly as they earned it. When Nightingale determined to give them a library in which to spend their time, and to personally guarantee that their pay would be sent home to their families if they didn't first spend it on gin, the British generals mocked her naivete. But once again, she proved them wrong: Many soldiers did, in fact, replace drinking with trips to the library. Nightingale's library did not include health-related books, because at that time there were none, but her experiment at empowering patients to make productive use of their time was a precursor to the patient-centered care movement of today.

Hospital financial management. At Scutari, Nightingale transformed a haphazard and ineffective supply procurement process into a well-run and efficient materials management system. She calculated, then worked to reduce, cost per patient day, setting a precedent that has been followed by every hospital CFO ever since. She had an intuitive understanding that productivity and compassion are complementary, not opposing, qualities of an effective hospital. When confronted with a mandate to "do more with less," rather than complain about the lack of resources, she rolled up her sleeves and figured out how to use more effectively the resources she had, and how to act entrepreneurially to obtain the additional resources she needed.

Hospital architecture. The first structure built specifically to be a hospital (as opposed to another building being converted for the purpose) was London's Herbert Hospital, constructed in 1865 by the authority of Sidney Herbert, who was responsible for sending Florence Nightingale to the Crimea. Its design was based on Nightingale's concepts, and her philosophy of separate pavilions was a central element of hospital design for the next 150 years. Her book Notes on Hospitals was a vital resource for hospital architects for more than a century following its publication. When I was a junior administrator at the University of Iowa Hospitals and Clinics back in the 1970s, our last remaining open wards had 32 beds—the number that had been prescribed by Nightingale more than 100 years previously.

Patient-centered care. Nightingale would have been appalled to learn that today there is a movement for "patient-centered care." You can just imagine her reaction to hearing those three words: "Why do you need a movement? Isn't the patient in the center now? If not the patient, then who is in the center?"

Until the end of her life, Nightingale wrote an annual letter to the student nurses at the London school that to this day bears her name. Her language sounds quaint to today's ears, but the behavioral expectations she prescribed in those letters are essential qualities for any hospital that aspires to a patient-centered care culture. Nightingale never allowed any excuse or obstacle to stand between her and her patients. Her attitude was "Proceed until apprehended"—and she moved so fast that she usually outran those who would try to apprehend her.

Positive culture. In one of the letters she sent to nursing students at the Nightingale Training School, Nightingale wrote: "Trustworthy [is] never prying into one another's concerns, but ever acting behind another's back as one would to her face." In another letter she wrote: "… backbiting, petty scandal, misrepresentation, flirtation, injustice, bad temper, bad thoughts, jealousy, murmuring, complaining. Do we ever think that we bear the responsibility of all the harm we do in this way?" She never would have countenanced the gossip, complaining and other forms of toxic emotional negativity that are prevalent elements of the culture in many hospitals.

In the book The Florence Prescription: From Accountability to Ownership I put these words into the mouth of the Florence Nightingale character: "You can't be cynical and negative sitting in the cafeteria or break room and then somehow flip an inner switch and become genuinely caring and compassionate when you walk into a patient's room. And patients see right through the fraud." The cultural attitude of an organization is defined by what you expect and what you tolerate, and over time what you tolerate will dominate what you say you expect. Nightingale understood that the essential first step to cultivating a positive culture is reducing institutional tolerance for toxic emotional negativity (the way, not so long ago, we reduced our institutional tolerance for toxic cigarette smoke).

Advocacy for Soldiers and Veterans Health Care

Nightingale was history's first and most effective advocate for the health care rights of soldiers and veterans. She devoted herself indefatigably to reforming the British military health care system, and was an adviser to military hospitals during the American Civil War and the Franco-Prussian War.

The only known recording of her voice was one made late in her life by Thomas Edison; it was an appeal to the British people to support veterans of what was by then a long-ago war in a forsaken place. As Gillian Gil wrote in Nightingales: The Extraordinary Upbringing and Curious Life of Miss Florence Nightingale, "Observing with astonishment that this well-bred woman did not place the interests of her own class first, the ordinary English soldier began his long love affair with Florence Nightingale." After she died, her coffin was escorted by a corps of octogenarian veterans of the Crimean War, a war that most likely would have disappeared into the mists of history but for the work of Florence Nightingale.

The First Hospital Administrator


Other than her late-night rounds through the Scutari barrack hospital, where she often would stop to massage the feet of a dying soldier, "the lady with the lamp" gave relatively little direct nursing care. Her administrative responsibilities did not give her the time. It has been argued, with some merit, that Jamaican nurse Mary Seacole did more to advance clinical nursing care during the Crimean War than did Florence Nightingale. But that misses the point of her real contributions. While we remember Nightingale as the first nurse and as the lady with the lamp, her real legacy was created by her prodigious administrative skills and her vision for what hospitals and the nursing profession could, and should, be.

In the conclusion to his biography, Bostridge states: "One does not have to look far today to see that many of Florence Nightingale's greatest concerns remain ours too." Any hospital executive striving to improve clinical quality and patient satisfaction could do a lot worse than studying the way Florence Nightingale—in the face of strident opposition and severely limited resources—created a blueprint for the modern hospital.

Joe Tye, M.H.A., M.B.A., is the CEO of Values Coach Inc., a consulting and training firm in Solon, Iowa. He is also a member of Speakers Express.