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| 10 Leadership Lessons from Florence Nightingale |
Infection was rampant and rats ran wild. There was no ventilation or fresh water, the food was inedible, and there were virtually no drugs or medical supplies. Amputations were performed without anesthesia in full view of other patients, and most amputees quickly succumbed to gangrene. The orderlies were often drunk, and refused to empty chamber pots or go near the sickest patients. There was no money for even the most basic essentials. The chief medical officer made it clear that Nightingale was not welcome, and did everything he could to undermine her authority.
And we think we have a healthcare crisis!
Nightingale’s Legacy
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| Florence Nightingale in her role as history’s first professional hospital administrator – in the middle of the healthcare crisis that was the Scutari Barrack Hospital, Florence Nightingale laid the foundations for the hospital as we know it today (from a contemporary publication). |
In a 2-year period in the depths of this healthcare crisis Florence Nightingale established nursing as a respected profession and invented the hospital as we know it today. She developed the first modern hospital nursing, pharmacy, laundry, and nutrition services. Her meticulous recordkeeping was the forerunner of today’s medical records and epidemiology functions. She established the principle that triage should be based on medical need and not status, rank or religion. And while she was obviously a compassionate caregiver, she was also a tough-minded manager who calculated and then reduced cost per patient day. As Mark Bostridge wrote in his recent 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.”Florence Nightingale in her role as history’s first professional hospital administrator – in the middle of the healthcare crisis that was the Scutari Barrack Hospital, Florence Nightingale laid the foundations for the hospital as we know it today (from a contemporary publication).
Nightingale was the first woman admitted as a Fellow of the Royal Statistical Society; she was a scholar of religion whose (unpublished) book impressed even the great philosopher John Stuart Mill; she was history’s first and most effective advocate for the healthcare rights of soldiers and veterans; and of course she was the guiding light for the first professional school of nursing (her letters to Nightingale nursing school graduates are still well worth reading). Her book Notes on Nursing was the first manifesto for patient-centered care, and her book Notes on Hospitals influenced hospital design well into this century. Her collection of letters is the largest in the British Library – Winston Churchill’s is second – and these are not tweets and emails but in many cases brilliant and thoughtful treatises worthy of the highest literary acclaim.
This article outlines 10 lessons from the work of Florence Nightingale – lessons that she herself would more likely have described as calls to action.
Lesson 1 – Attitude: Attitude: Nightingale would have agreed with the statement that attitude is everything. She had an intuitive understanding that emotions are contagious, and would never have tolerated the gossip, complaining, and other forms of toxic emotional negativity that are prevalent in many hospital break rooms (and too often in public places). Toxic emotional negativity is the emotional and spiritual equivalent of cigarette smoke, and in its own way just as harmful. To promote a more positive and productive workplace culture, we must raise our attitudinal expectations and lower our tolerance for deviation from those expectations. Even in the horrendous circumstances that prevailed at Scutari, Nightingale insisted that people be treated with dignity.
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| Results of 12 Culture Assessment Surveys conducted by Values Coach for healthcare clients. |
According to research by Dr. Renee Thompson, 60% of all new nurses quit their first job within 1 year – most due to workplace bullying. The chart below shows results from one of the questions in the Culture Assessment Survey that we administer to our healthcare clients. I’ve collated responses from the past twelve surveys, including nine hospitals and three professional healthcare organizations. Out of nearly 5,000 responses, more people disagree with this statement than agree with it, and less than 6% strongly agree.
In one of the annual letters Nightingale wrote to graduates of the Nightingale School of Nursing she said: “Backbiting, [gossiping], bad temper, bad thoughts, jealousy, complaining. Do we ever think that we bear responsibility for all the harm we do in this way?” She would have been appalled to see results such as these, or to hear references to that hideous metaphor “nurses eat their young,” knowing how destructive toxic emotional negativity is to an organization. She would have agreed with the advice Michael Lee Stallard gives in his book Connection Culture: “Be intentional about developing the habits of attitude, language, and behavior that connect, and work to develop a connection culture in your organization.”
Lesson 2 – Commitment: Nightingale had a mission, not a job. She did not inquire about pay and benefits before leading her team of young nurses off to the Crimea, and she endured working conditions that would be considered intolerable in today’s world. Yet she never experienced “burnout,” and through devotion to her calling she changed the world of healthcare forever. Florence could easily have settled into a life of ease at her family’s country mansion; instead she chose a path of arduous commitment to caring for others. Her legacy reminds us that caring for the sick is more than just a business – it’s a mission, and that being a caregiver is more than just a job – it should be a calling. The first duty of healthcare leadership is inspiring this commitment, beginning with our own examples.
Lesson 3 – Courage: Florence was courageous and she was unstoppable. She did not allow opposition from the British aristocracy or the antiquated views of imperious physicians and military leaders to prevent her from doing her work. When she ran into a brick wall, she found a way around or over. Our challenges today are different than those faced by Nightingale more than one hundred years ago, but the need for courage and perseverance is just as vital now as it was then.
Lesson 4 – Discipline: Nightingale was a disciplined pioneer of evidence-based practice. Less well-known than her contributions to hospital and nursing practice was her pioneering work in medical statistics; her painstaking efforts to chart infection and death rates among soldiers at Scutari gave weight to her demands for improved sanitary conditions first at military hospitals, and later in civilian institutions. She demonstrated that if you want to be effective, it’s not enough to know that you’re right – you must be able to demonstrate that you’re right with the facts.
Lesson 5 – Empathy: Long before Daniel Goleman coined the phrase “social radar” in his book Emotional Intelligence, Nightingale appreciated that awareness and empathy are central to quality patient care, effective leadership, and to creating what Stallard calls a Connection Culture. At the Scutari Barrack Hospital Nightingale established the first patient library in hopes of giving the soldiers under her care something to do other than drink. While she was at first ridiculed by the military brass who insisted that the men their hero Wellington had referred to as “the scum of the earth” were incorrigible, they were astonished when in fact this act of empathy in action achieved the desired result.
Lesson 6 – Loyalty: Nightingale was a team-builder who cared passionately about the nurses under her wing and the soldiers under her care. She was a demanding leader, but also showed uncompromising commitment to the people she led. Upon her return to England from Scutari she personally endeavored to make sure that every nurse who had served with her there would find employment upon their return home. Her legendary loyalty to the soldiers she served was reflected in the fact that when she was buried, her coffin was escorted by octogenarian veterans of the Crimean War honored their debt to the lady with the lamp.
Lesson 7 – Humor: Nightingale’s contemporaries reported that she had a wonderful sense of humor and was often able to defuse tense situations with the light touch of laughter. I think she’d say that if she could laugh in the hell-on-earth environment of the Scutari Barrack Hospital, then no matter what the world throws at us, we can’t forget the restorative and healing power of laughter.
Lesson 8 – Contrarian Toughness: The first words I heard upon entering graduate school in hospital administration were “healthcare crisis,” and I’ve been hearing them ever since. We’re going to be hearing those two words for a long time to come. What would Nightingale tell us about dealing with this perennial crisis? Sara Rutledge, a nurse who’s a character in my book The Florence Prescription: From Accountability to Ownership, put it this way: “We need to see opportunities where others see barriers. We need to be cheerleaders when others are moaning doom-and-gloom. We need to face problems with contrarian toughness because it’s in how we solve those problems that we differentiate ourselves from everyone else.”
Lesson 9 – Initiative: Nightingale attributed her success to the fact that she “never gave or took any excuse.” When told there was no money to repair a burned-out wing of the Scutari Barrack Hospital that was scheduled to receive hundreds of new casualties, she hired a Turkish work crew and before anyone could stop her, had the wing refurbished. The acid test of an “empowering” workplace is whether people – regardless of job title – can take the initiative to do the right thing for patients and coworkers without seeking permission or worrying about recrimination. Although she herself never used the words, “Proceed Until Apprehended” (which I consider to be the most important three words in my book The FlorencePrescription) would have been a pretty good description of Nightingale’s approach to getting things done.
Lesson 10 – Aspiration: Nightingale never rested on her laurels, but rather continuously raised the bar. After proving that a more professional approach to nursing care would improve clinical outcomes, she helped found the first visiting nurses association, chartered the first modern school of professional nursing, and through her writing helped establish professional standards for hospital management. She remained active virtually until the end of her life at the age of 90.
The Florence Challenge
My book The Florence Prescription: From Accountability to Ownership was largely inspired by the legacy of Florence Nightingale. With more than 300,000 copies in circulation, the book serves as a manifesto for a culture of ownership that is emotionally positive, self empowered, and fully engaged. As you can see, when someone signs the Certificate of Commitment Florence is looking on. I know she would approve.
A concluding thought: Charles Dickens was a contemporary of Florence Nightingale. The opening line he penned for his classic novel A Tale of Two Cities certainly applies to healthcare today – it is the best of times, it is the worst of times. Were she alive in our era, Nightingale no doubt would have focused on the best-of-times side of the ledger, and implored us to remember that taking care of the sick and injured is a mission, not just a business; that being a healthcare professional is a calling, not just a job. We might not be able to immediately change the external environment, but we can start right now promoting a culture of ownership within our organizations. As Nightingale said, we should “never lose an opportunity of… a practical beginning, however small, for it is wonderful how often the mustard-seed germinates and roots itself.”
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