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Nurse-led interventions in the steps of Nightingale

International Nurses’ Day commemorates Florence Nightingale’s birthday and so it seems fitting to reflect on nurse-led interventions. Like many of the nurses who followed her, Nightingale was an innovator. Beyond establishing modern nursing, Nightingale was a pioneering statistician and public health advocate. Her contributions to public health, in particular, led to major sanitation and health care reforms achieved largely through her innovative use of applied statistics.

Interestingly, Nightingale developed the use of the ‘coxcomb’ graph, adapted from the pie chart, as a way to present statistical information in an engaging way. Her raison d’etre included being able to engage Queen Victoria with data in such a way so as to easily demonstrate the need for greater public health funding and policy reform. Needless to say, Nightingale succeeded! Below is a diagram from one of Nightingale’s reports on causes of mortality in the Crimean War.


Figure 1: Coxcomb graph of Crimean War mortality, Florence Nightingale. Credit: Public domain.

For further information concerning Florence Nightingale’s life and artefacts, visit the Florence Nightingale Museum website.

Nightingale’s complex legacy

There has been criticism of Nightingale’s contribution to the nursing profession; in particular, the subjugation of nursing to medicine, the imposition of the trappings of a quasi-religious order and the military like governance. Hence the saying, ‘Nursing was born in the monastery, and grew up in the military.’ These measures were justified for the personal, professional and moral protection of the women choosing to become nurses. It seems reasonable, given that prior to Nightingale and reformers like her, nurses were women drawn from among the disadvantaged and what they would have described at the time as the disreputable.

Nightingale’s innovations have not been without detractors. From the late 20th century, there have been critiques of the gender defined divisions between nursing (women’s work; body work) and medicine (men’s work; mind work), an example of the perceived perception of ‘nurse as handmaiden to the doctor’. Despite that social dynamic, a product of Victorian norms, it must be acknowledged that Nightingale forged the basis for a collaborative and dynamic profession that has evolved with our rapidly changing world. In particular, her innovation and drive for quality and safe patient care are at the centre of, not just nursing practice, but contemporary health care. A thought-provoking and weighty discussion of nursing’s history was written by Sioban Nelson and Suzanne Gordon which I recommend and can be found here.

Evolution of nurse-led interventions

Nursing has continued to evolve beyond the nineteenth 19th century. As health care delivery has increased in complexity, nursing has adapted. The apprenticeship-training model, implemented by visionaries like Nightingale, prevailed until the move into the tertiary sector in the 1980’s and 1990’s. Similarly, parallel factors of workforce shortages, increased patient acuity and greater emphasis on chronic and complex care led to the evolution of advanced practice roles where nurses practice in ways never imagined by its modern founder. Yet, nursing’s strength remains in its capacity to work collaboratively with its interdisciplinary health care partners.

In the past 30 years, there has been a growth in nurse-led initiatives. Nurse-led interventions range from primary to tertiary prevention programs conducted in out-patient clinics (including rehabilitation), general and specialist practice, and remote health care services. In remote settings particularly, necessity has given rise to the need for nurses to provide a broad range of clinical and public health services to communities with considerably poor access to comprehensive health care. In remote as well as regional and urban settings, nurse-led interventions have had success, particularly in the management of complex chronic health conditions. However, more research is required to establish a robust evidence base for these approaches. Yet, it is important to note that the majority of these interventions are multidisciplinary and collaborative.

A collaborative future

Reflecting on the legacy of Florence Nightingale, it is timely to think about the many challenges and changes health care has experienced in 155 years. From the nurse as handmaiden, to a partner in providing evidence-based care, nurses undoubtedly occupy a central place in health care, yet, never in isolation. Rather, the strength of nursing, medicine and allied health truly lies with being part of an extensive multidisciplinary team. As such, innovation through collaboration centred on the mutual goals of improved outcomes for patients, their families and communities, should drive our work. So, to all nurses, particularly those working in regional and rural settings, and to our medical and allied health colleagues, I say, ‘Happy International Nurses’ Day’.

Nurse-led interventions in the western region

The HeartsFirst project is an example of nurse-led primary prevention project focused on engaging at-risk patients living in rural south-west Victoria. A group of highly experienced practice nurses at three rural clinics have worked with 21 primary care patients. The patient cohort consists of adults over the age of 45 years who are at risk of cardiovascular disease.

The project, led by four nurse researchers (Dr John Rolley, Assoc Prof Andrea Driscoll, Dr Alison Beacham & Prof Elizabeth Halcomb) aims to establish the feasibility of a nurse-led program as a sustainable part of ‘usual practice’ in rural and regional general practice clinics. The program involves a six month commitment to a tailored, person-centred program that supports the person in the reduction of absolute risk by focusing on aspects of health behavior the individual can change. In addition to absolute risk and demographic and clinical characteristics, other factors such as depression and health literacy are assessed to investigate how these factors may influence program outcomes.

Throughout the program, the nurses work collaboratively with their medical and administrative colleagues to ensure the appropriateness of the program in relation to the practice. While many questions remain, observing the approach the nurses have taken to implementation has been inspiring. Data collection is in its final stages, however the success of the project will largely be due to the professionalism and dedication of these practice nurses.