12 May, 2021
International Nurses Day is celebrated every year on May 12th: a date chosen in honor of the birth of Florence Nightingale, recognized as the founder of the modern nursing profession and one of the most influential British women of the Victorian Age.
The founder of San Raffaele loved to say that nurses are the "connective tissue" of the hospital. In fact, nursing is the largest healthcare profession in the world (440,000 in Italy alone), and also the most present and transversal in all medical specialties and health services.
What was the role of nurses in the Covid-19 pandemic and beyond? What does "taking care" mean? What does a student potentially interested in a nursing vocation need to know?
On the day dedicated to them, we report a reflection by Prof. Duilio Manara, associate professor of nursing, and by Drs Giulia Villa, nursing researcher, and Noemi Giannetta, research fellow in nursing.
Nightingale's name, Florence, comes from the city of Florence, where she was born on May 12, 1820 while her parents were traveling in Italy. Born into a very wealthy family, she dedicated herself to the care of the injured and the infirm. She was a great medical care reformer of the time: she wrote books to set up a nursing education based on science and moral rigor, and founded a prestigious Nursing School at St. Thomas Hospital in London. She also developed innovative statistical methods in order to demonstrate the effectiveness of the work of her nurses.
Florence Nightingale by Henry Hering, copied by Elliott & Fry, half-plate glass copy negative, 1950s (late 1856-1857); NPG x82368. Photo credit: National Portrait Gallery St Martin's Place London WC2H OHE
During the Crimean war (1853-1856), she left with 38 nurses for Scutari (Albania) and she herself went down in history as the "Lady with the Lamp", for her constant presence alongside the sick and wounded. She saved literally thousands of lives through assistance that included great attention to the care environment (cleanliness, light, clean air, pure water, silence, heat, diet) and the constant vigilance of the nurses next to the patients' beds.
Upon her return, she was celebrated as a heroine and Queen Victoria asked her to collaborate with the Royal Commission for Army Health. She was the first woman to be appointed a member of theRoyal Statistical Society and had a great influence on the health care reforms of the nineteenth century.
Finally, it was Nightingale who gave the English nurses the appellation of "nurse" (from the verb nursing, "to bring to the breast"), thereby indicating the profoundly healing spirit that was to characterize this new profession, distinguishing it from medical care.
Before Nightingale, nurses were considered domestic staff in the censuses. In the first census of the twentieth century, however, the English nurses were counted as "medical personnel". The "Nightingale model" spread rapidly, and since then the nursing profession has been regarded as one of the most recognized and valued healthcare professions in the world.
Florence Nightingale memorial statue at Waterloo Square, Westminster, London. Photo credit: Wikimedia Commons
Never before has there been talk of nurses as in the last year, but nurses have always existed. What has changed is that their contribution is now visible to many.
Nurses can make a difference. This is clear today and has been demonstrated, not only on this occasion, but throughout recent history.
For years, nursing has been an academic discipline with a dedicated course of study and career. Many studies have shown the impact of this discipline on the health of people and their loved ones [1-3]. We have seen how good quality nursing care, understood as a high level of training, high skills and the right proportion between the number of nurses and patients taken in care, affects some important health outcomes [1, 4-7].
Photo credit: Gruppo San Donato
The main ones concern the reduction of complications [1-4] such as infections, falls, pressure injuries. Nursing assistance improves adherence to drug therapy [3,6], self-care skills and correct health behaviors of the person making them independent and able to manage their condition, especially in the case of chronic diseases.
The nurse also intervenes with the patient's family members supporting them and, if necessary, by educating them in order to support their loved one in case of little autonomy [3, 6, 8]. Among other things, the nurse influences the length of hospitalization and the timeliness of treatment in case of urgency, consequently decreasing mortality [3, 9-10].
In these months in which the pandemic has overwhelmed us, all this has become evident not only to the scientific community but also to the general population. The work of nurses has not changed, the pandemic has made it evident. In some less fortunate cases, nurses have made a difference in the accompaniment at the end of life and in the long-distance relationship with family members: the ability to work in teams has emerged, considering heterogeneous work groups, formed from scratch with levels of different competences.
There are numerous studies related to the pandemic experience that have made clear the ability of nurses to deal with stress and moral distress [11-14]. Extraordinary results are emerging: ability to adapt to very different and unstable contexts, ability to work in a team, resilience, positive outcomes on the patient.
During the pandemic, nurses did not do different things than before, the difference is that others have noticed.
Photo credit: Gruppo San Donato
Paraphrasing what Florence Nightingale wrote, nursing is a well-balanced blend of sentiment and science, a noble art whose birth is to be placed in the mists of time, probably together with the creation of man. "Taking care" understood as a structurally relational attitude, which brings the self out of oneself, out of self-referentiality to open up to the other, is in fact something deeply inherent in man.
This is where the need to which nursing care responds arises. Placed in connection with this typically human need for proximity, the role of the nurse ceases to be just a profession and becomes a "vocation" that treats the patient not simply as a clinical case, but which looks at the person in a holistic way and respects them, their will, preferences, takes into consideration the affections and relationships, offering answers to their needs, manifest or unexpressed.
The nursing profession has accompanied a radical transformation of society and sociality, as well as of its management and government dynamics, from the Crimean war to the Covid-19 pandemic.
In those days and, more than ever, in these days, science and technology have walked together, and technology has shown itself in particular to be an essential means of maintaining the interpersonal relationship that is established in the therapeutic act intact, in full compliance with those premises that inspire the nursing practice familiar with the fragility and vulnerability of the human being.
Having to write words that are of inspiration for those who choose or will choose this profession and having to do it as a nurse, perhaps it is necessary to mix the awareness of the epochal scale of the challenges of our time with the indignation for an only occasional version of the emotion towards our 'heroisms' , who made (extra)ordinary the gestures of these pandemic days .
Courage is needed so that the recognition and progress of the nursing profession can be valued in its ordinary dimension and not (only) in the extraordinary one. This courage passes first of all to the enhancement of training and research courses, because there is no possible science that can survive without being fertilized by research.
Photo credit: Gruppo San Donato
And this is all the more true for the world of nursing which cannot be exhausted in the field of practice if it does not want to become the sterile (and moreover useless, sometimes inaccurate and approximate, therefore dangerous) application of procedures.
In this sense, research is a fundamental link that binds theoretical knowledge and practical wisdom, a link in whose circularity nursing science can produce useful results for practical action and practice can respond to scientifically validated ideal criteria.
Therefore, to you, current and potential students of nursing science, the wish to always have the courage to be aware that what is at stake is not the heroism of extraordinary days, but the daily choice of professionalism and specialization, which makes us operators and researchers together.
 International Council of Nurses, Nursing Sensitive Outcomes Indicators, Geneve, CH, 2006.
 Irvine DM, Sidani S, McGillis Hall L, Linking outcomes to nurses’ role in healthcare, 1998, Nursing Economics, 16(2), p. 58-64.
 Aiken, L.H. et al (2017) Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care. BMJ Quality & Safety, 26(7): 559-568
 Ausserhofer, D. et al (2014) Prevalence, patterns and predictors of nursing care left undone in European hospitals: results from the multicountry cross-sectional RN4CAST study. BMJ Quality & Safety, 23(2): 126-135
 Liao LM, Sun XY; Yu H, Li JW, The association of nurse educational preparation and patient outcomes: Systematic review and meta-analysis, Nurse Education Today, 2016; 42 9-16.
 Needleman J, et al. Nurse-staffing levels and the quality of care in hospitals, N Engl J Med, n. 22, 2002, pp. 1715-1722
 Sasso, Loredana & Bagnasco, Annamaria & Watson, Roger. (2016). Competence-sensitive outcomes. Journal of Advanced Nursing. 73. n/a-n/a. 10.1111/jan.12941.
 Ball, J.E. et al (2018) Post-operative mortality, missed care and nurse staffing in nine countries: A cross-sectional study. International Journal of Nursing Study, 78: 10-15
 Aiken LH et al (2014) Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. The Lancet (North American Edition), 5/24/2014; 383(9931): 1824-1830
 Turale S, Meechamnan C, Kunaviktikul W. Challenging times: ethics, nursing and the COVID-19 pandemic. Int Nurs Rev. 2020 Jun;67(2):164-167. doi: 10.1111/inr.12598. PMID: 32578249; PMCID: PMC7361611.
 Morley G et al Covid-19: Ethical Challenges for Nurses. Hastings Cent Rep. 2020 May;50(3):35-39. doi: 10.1002/hast.1110. Epub 2020 May 14. PMID: 32410225; PMCID: PMC7272859.
 Morley G et al Addressing caregiver moral distress during the COVID-19 pandemic. Cleve Clin J Med. 2020 Jun 9. doi: 10.3949/ccjm.87a.ccc047. Epub ahead of print. PMID: 32518134.
 Sriharan A et al COVID-19-Related Occupational Burnout and Moral Distress among Nurses: A Rapid Scoping Review. Nurs Leadersh (Tor Ont). 2021 Mar;34(1):7-19. doi: 10.12927/cjnl.2021.26459. PMID: 33837685.
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