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From Bedsores to Global Health Care: Insights from Nightingale’s Notes on Nursing

Ayello, Elizabeth A. PhD, MS, BSN, RN, CWON, ETN, MAPWCA, FAAN

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Advances in Skin & Wound Care: May 2020 - Volume 33 - Issue 5 - p 237-238
doi: 10.1097/01.ASW.0000658604.86284.f2
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Let whoever is in charge keep this simple question in her head, not how can I always do this right thing myself, but how can I provide for this right thing to be always done?1

A little over 100 years after the printing of Nightingale’s Notes on Nursing, it was required reading as part of the professional nursing course at the City University of New York where I was a nursing student. Nightingale’s timeless ideas and hints resonated with me and became a foundation upon which to build my professional nursing career. To re-read Notes on Nursing again, nearly five decades later, through the eyes of an experienced board-certified wound and ostomy nurse, educator, and researcher reminded me that Nightingale’s important principles still have relevance for today’s practice.

Let me share with you some of my insights as a global expert nurse in skin and wound care that nursing students or beginning nurses might want to consider as they begin their practice journey. Just as Nightingale illustrated her hints with clinical examples, I have included some exemplars from today’s nursing practice. Many of my clinical examples will be from my specialty practice.


The most important practical lesson that can be given to nurses is to teach them what to observe—how to observe—what symptoms indicate improvement—what the reverse—which are of importance—which are of none—which are evidence of neglect—and of what kind of neglect… But if you cannot get the habit of observation one way or the other, you had better give up the being a nurse, for it is not your calling, however kind and anxious you may be.1

Nurses are still the main professionals who are present and monitor patients in most care settings 24/7. Being able to see obvious changes in a patient as well as smaller, more subtle changes is critical and may make the difference between life and death for the patient. Today, there exists technology for physical assessment that Nightingale could only dream of: infrared thermometers to detect Charcot foot deformities and undiagnosed infection in the feet of people with diabetes, pulse oximeters to determine oxygen saturation level, sensors that can alert nurses to BP increases or lack of patient mobility (both of which are implicated in the development of pressure injuries), and communication techniques to assist the nurse in a holistic assessment of the patient.

However, just making the observation and understanding its importance is not enough; it must be communicated to other members of the healthcare team, especially physicians. Nightingale said, “In all diseases it is important, but in diseases which do not run a distinct and fixed course, it is not only important, it is essential that the facts the nurse alone can observe, should be accurately observed, and accurately reported to the doctor.”1 She was right; the importance of timely and thorough interprofessional communication, verbal and written, cannot be emphasized enough.


As a board-certified wound and ostomy nurse, I believe one particular quote is sometimes misunderstood: “If a patient is cold, if a patient, is feverish, if a patient is faint, if he is sick after taking food, if he has a bed-sore, it is generally the fault not of the disease, but of the nursing.”1 Notice that she wrote nursing, not nurse. Critically, Nightingale further explains that “by this I do not mean that the nurse is always to blame,” but rather proposes that the system the nurse is practicing within “often make[s] it impossible to nurse.”1 Thus, although some believe they are a nursing-sensitive indicator, bedsores (now called pressure injuries) are really a measure of a care system within which the entire interprofessional team works to preserve skin integrity. Nightingale’s principles to reduce bedsores required the nurse to look at the whole system of care practice. These principles are still relevant today, as the CMS’ hospital-acquired condition of pressure injury must be addressed.

My work of looking at pressure injuries as a systems problem rather than a nurse problem was used by the Institute for Healthcare Improvement in its work to reduce the incidence and prevalence of pressure injuries. Likewise, it was the basis of the highly successful New Jersey Hospital Association statewide collaborative that reduced pressure injuries by 68% across the 150 care partners (including hospitals, long-term-care facilities, and hospice). We must eliminate blame and focus on care processes across the system of care instead.


I am a clinical nurse specialist who for many years worked with surgical patients. Nightingale wrote about the importance of restoring and preserving health and that in particular “in surgical wards, one duty of every nurse certainly is prevention.”1 Although Nightingale believed that “the exact value of particular remedies and modes of treatment is by no means ascertained,”1 she did have some hints about specific practices to prevent bedsores. “It may be worth while to remark, that where there is any danger of bedsores a blanket should never be placed under the patient. It retains damp and acts like a poultice.”1 Today’s clinical practice guideline to prevent pressure injuries ( still cautions clinicians about limiting the amount and type of linen underneath the patient. It also strives to explain how the microclimate where the skin meets the surface the patient is sitting or lying on are believed to contribute to the development of pressure injuries.

Nightingale was a truly global citizen. Although prevention of pressure injuries is a major focus of care systems throughout the world, prevention of foot ulcers in persons with diabetes mellitus is also paramount. To that end, nurses need easy-to-use tools that decrease the risk of ulceration and even amputation to prevent negative outcomes for people at risk. One such tool, a 60-second screen for the high-risk diabetic foot,2,3 can be downloaded for free from The team that developed this and tested it globally has reduced amputations by 68%. Remember, prevention is better than treatment.


The importance of evidence-based practice and the need to determine the true cause of a healthcare problem are critical. As Nightingale said, “I have known cases of hospital pyaemia quite as severe in handsome private houses as in any of the worst hospital and from the same cause, viz., foul air. Yet nobody learnt the lessons. Nobody learnt anything at all from it. They went on thinking—thinking that the sufferer had scratched his thumb, or that it was singular that ‘all the servants’ had ‘whitlows’ or something was ‘much about this year; there is always sickness in our houses.’ This is a favourite mode of thought—leading not to inquire what is the uniform mode of thought—leading not to inquire what is the uniform cause of these general ‘whitlows’ but to stifle all inquiry.”1

Because of my expertise in skin and wound care, I was part of a team that developed the wound bed preparation model. The first part of this model requires the practitioner to identify the correct cause of the skin/wound problem. Without knowing the true cause, knowing how to prevent or implement the proper treatment plan of care can be impossible. Take for example leprosy (now known as Hansen disease), which has been written about since ancient times. Persons with leprosy can be disfigured, have skin lesions, and suffer from nervous system damage leading to neuropathy especially in their hands, arms, and feet. Because in early times its cause was thought to be a curse or a punishment from God, persons with leprosy were stigmatized, shunned, and forced to live isolated from others in leper colonies. The treatment was wrong because the cause was wrong. We now know that leprosy is caused by a bacterium, Mycobacterium leprae. Nightingale’s examples of this, including smallpox (“People are somewhat wiser now in their management of this disease”1), further underscore the importance of getting the cause right. Although we may not understand everything, we must never stop researching.


Holistic healthcare is what nurses do in a variety of care settings, “and what nursing has to do in either case, is to put the patient in the best condition for nature to act upon him.”1 Nightingale used her experiences in other regions of the world and brought the changes/reforms back to the local hospitals in England. She networked with people and was able, in part, to make change because of her relationships with people who gave her the opportunity to implement her vision.

Nightingale was also a prolific writer. She inspired me to begin writing articles and eventually books. Nurses need to share their wealth of knowledge, and it is my hope as a journal editor that all nurses will contribute to the literature. The educational programs that I teach have brought me around the world to resource-abundant and resource-challenged areas, but always the focus is on how to improve patient outcomes. The insights I learned from seeing healthcare systems and care practices outside the US and evaluating what could then be useful back home are invaluable. Through this concept of “disruptive innovation,” the delivery of care everywhere can be improved.

I wish to leave you with a final thought from Nightingale and then one of my own. “To our beginner good courage, to our dear old workers, peace, fresh courage too, perseverance: for to persevere at the end is as difficult & needs yet better energy than to begin new work.”4 To new nurses, welcome and enjoy the journey; to experienced nurses, thank you for your journey. I hope Nightingale is proud of us.


1. Nightingale F. Notes on Nursing: What It Is and What It Is Not. Comm Ed. Philadelphia, PA: Lippincott, Williams, & Wilkins; 1992.
2. Ostrow B, Woo KY, Sibbald RG. The Guyana diabetic foot project: reducing amputations and improving diabetes care in Guyana. South America. WCET J 2010;30(4):28–32.
3. Sibbald RG, Ayello EA, Alavi A, et al. Screening for the high-risk diabetic foot: a 60-second tool© 2012. Adv Skin Wound Care 2012;25(10):465–76, quiz 477-8.
4. Ulrich BT. Leadership and Management According to Florence Nightingale. Norwalk, CT: Appleton & Lange; 1992.
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