Devils’ advocate: Florence Nightingale and OH

This year marks the centenary of Florence Nightingale’s death. She is arguably the most famous occupational health (OH) nurse in history. We too often forget that she is inexorably linked with caring for workers close to their workplace. The type of work may be different, but soldiers are employees and military personnel remain an important and large occupational group.

While Florence is perhaps most associated with infection control (which she originally associated with poor working conditions), her most important legacies relate to nursing research, statistical methods, evidence-based practice, and standards in nurse education.

One hundred years after her death, standard-setting in nursing continues. After a long wait, it was announced last year that the training of all future registered nurses would be to degree level. Degrees for entry-level nurses have not been universally welcomed.

It is not so long ago that a degree wasn’t necessary to practice medicine. A well-known back-up to the degree in medicine was the licenciateship of the Royal College of Physicians. Many outstanding medical students took the relevant exams but it was also a route well-loved by those who failed or were likely to fail their finals as a back door into medical practice. This non-graduate pathway was only abolished in 1999.

Those who consider that medicine has some sort of academic primacy over nursing must remember that nursing closed the non-graduate route only one decade after medicine.

It is time for nursing to raise the academic bar again. In the past decade, PubMed – the US National Institutes of Health (NIH) free digital archive of biomedical and life sciences journal literature – has listed almost seven million articles, and there will be plenty more in nurse-oriented citation databases. The expansion of nursing knowledge is accelerating – this is the same number as in the two-decade period before 2000. More importantly, it is the same number as PubMed lists for the entire period up until 1985. Nurses training today have more literature to consider from just the past decade than nurses trained before 1985 had all together.

For those who don’t remember, it was in about 1985 that Project 2000 was being piloted in centres such as Nottingham. This shifted training from nursing schools to universities and raised the academic bar. The advent of diploma-level nursing received the same mixed welcome as degree-level has today.

Project 2000 nurses faced adverse comments about lack of vocation, lack of practical skills, and lack of confidence. However, these nurses also brought new insights, new ideas, new challenges, and new articulate arguments based on the rapidly expanding body of nursing research. Early teething problems were addressed and nursing standards rose.

In 1991, I saw a newly qualified nurse tell a medical consultant that she would not use Eusol on a wound. She eloquently explained the reasons why, citing the persuasive evidence of harm and contrasting this with the benefits of more contemporary treatments. She won the argument to the benefit of the patient. She was a junior rank on her first ward and he was a very senior naval officer (the Royal Navy being one of the first adopters of Project 2000).

Entry at degree level for nursing is long overdue. Raising standards in training should ultimately lead to better informed nurses, and this to better patient care.

Careful observation, statistical analysis, epidemiology, data presentation, report writing, and strategic influencing are all important skills in OH.

A century after Florence Nightingale’s death, too few OHNs match her pioneering proficiency. The standard of nursing in OH needs to improve swiftly. This is an area of advanced practice, and training and development should reflect this.

Nurses need to understand the complexities of case law in employment, the process of systematic evidence collation and review, the statistical analysis of data, the application of psychological techniques, and much more. These equate to a post-graduate standard of education.

Too few OH nurses have a degree, let alone postgraduate qualifications. This is damaging OH nursing as there is a shortage of suitable practice teachers and capable academic leaders.

Experience is only a partial substitute for a degree, and is not an excuse. OHNs without a degree, and who are genuinely proficient, will find degree programmes straightforward. If they are not proficient, then this is all the more reason to do a degree.

Nurses who consider they are specialists in OH must have a degree. If those graduate nurses are planning to stay in OH, then it is time to advance practice and pursue a Masters.

Dr Richard Preece is a consultant occupational physician.


  • CNO/Unison BBC interview

  • Lord M Making a Difference: the implications for nurse education Nursing Times 2002; 98(20): 38

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