In this draft case, hypothyroidism is critically analyzed using global best practices and with focus on altered physiology and path physiology. Mrs. Smith (name changed for the reason of confidentiality), a 60-year old, female patient, was presented with chief complaints of cold intolerance, weight-gain despite decreased appetite, bradycardia, constipation, fatigue, lethargy and puffiness of eyes. At the time of admission of the patient the following parameters were recorded:

Vital signs                                                            Lab Test

BP –      130/90                                                      Hb –          13.8 gm/dl [12-16 gm/dl]

Pulse – 50/min                                                      TLC –       11,000 [4,000 – 11,000/ul]

RR –     20/min                                                       Platelets –   2.45 lacs [1.50 – 4.0 lacs]

Spo2 –   95%


Renal Function Test                                         Thyroid Test  

B. urea        – 2.5[10-40mg/dl]                          TSH –        7 µIU /mL   [0.25-5.0µIU/mL]

B. creatinines – 1.2 [0.5-1.4mg/dl]                  T3     –       0.80nmol/L [0.92-2.33nmol/L], T4 – 40nmol/L [60-120nmol/L]


Critical Analysis:
Mrs. Smith came to the hospital with signs and symptoms of hypothyroidism (Black & Hawks, 2005). Hypothyroidism is a hormonal disorder which affects the neuroendocrine control of the body. Hypothyroidism is a clinical syndrome resulting from the deficiency of the thyroid hormones: T3 (tri-iodothyronine) and T4 (thyroxin). This disorder can range from sub-clinical hypothyroidism with no obvious symptoms, to severe hypothyroidism with overt symptoms (Smeltzer et al, 2004).

In hypothyroidism there is decrease in production ofT3 and T4 by the thyroid gland. From the above diagrammatic representation, it can be clearly made out that when there is decreased production of T3 and T4, there occurs a negative feedback cycle directed at the hypothalamus. Usually, when the hypothalamus does not have a negative feedback, it starts increasing the production of TRH (Thyrotropin-Releasing Hormone) which acts on the pituitary gland to increase the production of TSH (Thyroid-Stimulating Hormone). In hypothyroidism, in spite of raised TSH levels, T3 and T4 levels are low because the thyroid gland is unable to produce them in sufficient quantities (Tripathi, 2003) (Kasper et al, 2001).

Mrs. Smith had puffiness of both eyes when she came to the hospital. She also had non-pitting edema. Non-pitting edema occurs due to increased quantities of hyaluronic acid and chondroit in sulfate binding with the protein occurring in the interstitial space, causing the total quantity of interstitial fluid to increase. Since this interstitial fluid is of a gel nature, it is immobile, and consequently the edema in hypothyroidism is the non-pitting type (Guyton and Hall, 2006).

Normally, thyroid hormones increase active transport of ions through the cell membranes. One of the enzymes that increase its activity in response to thyroid hormones is Na+-K+-ATpase which increases the rate of transport of sodium and potassium ions through the cell membrane of tissues. This process uses energy and increases the amount of heat produced in the body. It has been suggested that this is one of the mechanisms by which thyroid hormones increases the body’s metabolic rate (Guyton and Hall, 2006). Since there was a deficiency of thyroid hormones in Mrs. Smith’s body, the activity of Na+-K+-ATpase enzymes decreases, leading to a decrease in the metabolic rate. The mitochondria inside the muscle fibers requires three chemicals – glucose, Vitamin –B, and the thyroid hormone T3 – to generate ATP (Adenosine Triphosphate) (Kasper et al, 2005). In Mrs. Smith’s body there is a decrease in T3, so ATP is depressed, leadingto energy within the cell for metabolism decreasing, resulting in decreased metabolism. The decrease in metabolism leads to dysfunction in Mrs. Smith’s body, like fatigue, which is due to the decrease in ATP levels and muscles not getting therequisite energy for relaxation. Cold intolerance is also due to the same process,as the decrease in ATP levelsresultsless heat being produced, leading to a fall in Mrs. Smith’s body temperature falls.Thedecreasein appetite, due to a decrease in the motility of the intestinal tract, is once again again attributable to a reducedbasal metabolic rate (Richard, 2005).

Mrs. Smith’s heart rate was 50 bpm (beats per minute). A heart rate of less than 60 bpm is regarded as bradycardia (Steadmen, 2000). Normally, T3 increases beta receptors in the blood. In Mrs. Smith’s body the decrease in T3 enzymes means less production of beta receptors, which leads to a fall in the heart rate, because beta receptors control the heart rate (Goldman and Ausiello, 2008).

Mrs. Smith also experienced weight gain despite the loss of appetite.This is due to the decreased secretion of thyroid hormones. The normal effect of thyroid on metabolic products is explained in flowchart 1 (Guyton and Hall, 2006), and how hypothyroidism leads to weight gain is explained in flowchart 2(Goodman and Gilman’s, 2002).

Constipation is another symptom which occurs due to decreased metabolism.Decrease in metabolism alters the function of the small intestine, whichmeans that the peristaltic waves of the small intestine are reduced, which give rise to constipation (Kumar & Clark, 2006).

Mrs. Smith was started on treatment with Levothyroxine sodium. Levothyroxine sodium acts, similar to endogenous thyroxine, to stimulate metabolism and reverse the metabolic rate.It also increases the rate of energy exchange and increases the maturation rate of the epiphyses. Levothyroxine sodium is absorbed rapidly from the gastrointestinal tract after oral administration. The aim of the treatment is to normalize increased thyrotrophic levels (TSH) (Katzung,2001)

To summaries, the above information will assist nurses to recognize early signs and symptoms of hypothyroidism,and recognize its effect on the regulation of body functions. This will help nurses intervene early and educate patients in self-care.

Meeting Patient Expectations: Determinants and a Nurse’s Role

Each human being is unique and no two individuals are the same in their demeanor. This unproven fact becomes most evident when an individual becomes ill. In this current era of consumerism, people are highly conscious and knowledgeable about services they can expect from a merchant, and there are a number of public initiatives to make them understand what to expect, in a service or a product. Meeting such expectations, on the part of the merchant, results in customer satisfaction, which is the highest goal of a service or a product. This satisfaction could be brand-driven, technology-driven or due to the influence of other factors.

In healthcare too, patient satisfaction or meeting a patient’s expectations, is one of the major goals of any healthcare provider, and this is determined by the patient’s experiences during the duration of the patient’s interaction with the healthcare provider. The most challenging job for a healthcare provider is to attain patient satisfaction. This article sets out to discuss the determinants of customer satisfaction in a healthcare setting.

There is no mutually agreed definition of what is patient satisfaction. The University of New South Wales, Australia, (2009) worked out a definition to conduct research on ‘Complaints and patient satisfaction: a comprehensive review of the literature’. According to this definition, patient satisfaction is defined as the degree to which the patient’s desired expectations, goals and or preferences are met by the healthcare provider and/or service.

Determinants of patient satisfaction

A number of studies have been conducted on the topic of ‘how to make the patient really satisfied or what makes the hospital stay for a patient a better experience’. A survey was conducted by Brown, Sandoval, Levinton, and Blackstien-Hirsch (2005) to unveil the most efficient ways of improving satisfaction in emergency departments. A questionnaire on patient satisfaction, mailed to 20,500 patients who visited 123 Emergency Departments (EDs), was used to develop ordinal logistic regression models for overall quality of care, overall medical treatment, willingness to recommend the ED to others, and willingness to return to the same ED. The survey found out that the four main predictors are “perceived waiting time to receive treatment,” “courtesy of the nursing staff,” “courtesy of the physicians,” and “thoroughness of the physicians.”

Another retrospective study was conducted in France by Boyer, Antoniotti, Sapin, Doddoli, Thomas, Raccah, and Auquier, (2003), with the objective of looking for the relationship between a patient’s satisfaction and the quality of care, in two diseases (diabetes, lung cancer), and which was evaluated by the French-validated Questionnaire of Satisfaction of Hospitalized patients (QSH).  Quality of care is measured by some objective indicators, in accordance with recognized guidelines. The results surprisingly found that there is a negative correlation between accreditation and patient satisfaction (r = – 0.23; p < 0.05) and that the least-satisfied patients are not those who have the worst quality of care. Furthermore, a link has been highlighted between the “specific” quality of care and the satisfaction with nurses, but not with the doctors (p > 0.05).

Based on the literature, the determinants in most of the studies considered few or all from the following: “thoroughness of the physicians”, “perceived waiting time to receive treatment”, “technology used in care”, “accreditation by the international bodies”, “key attributes of staff behavior”, “handling complaints by the nurses”, “courtesy of the nursing staff”, and “courtesy of the physicians”. Researchers have found it very difficult to measure patient satisfaction.

What factor highly contributes to patient satisfaction?  Nursing care!

Many a times, how a patient feels in hospital is not merely based on the quality or complexity of treatment even though this decides patient outcome, as quality of care is a nebulous concept for the patient, and varies from person to person. However, some of studies have shown up nursing service as the strongest determinant of patient satisfaction. Al-Mailam (2005) conducted a study in Kuwait to determine the extent of patient satisfaction with the care provided at the hospital, at all levels, and to correlate patients’ satisfaction with nursing care in particular, with their overall satisfaction. 420 patients participated in the survey. The results found out that the extent of overall patient satisfaction with the quality of care provided at the hospital was found to be quite high (Excellent, 74.7%; Very good, 23.7%). Individually, nursing care received the maximum patient satisfaction ratings (Excellent, 91.9%; Very good, 3.9%). A positive correlation (r = 0.31, P = .01) was noted between the patients’ perception of nursing care and their overall satisfaction with the medical care provided at the hospital. Significant positive correlation (r = 0.36, P = .01) was also found between overall patient satisfaction and their reported intentions of returning and recommending the hospital to others. The study concluded that overall patient satisfaction is linked with quality nursing care, which, in turn, depends on the quality of leadership practiced at the institution.

Similarly, another study has been conducted in US by Otani and Kurz (2004), with the primary objective of finding out which attributes play a more important role in increasing patient satisfaction and behavioral intentions to return to and recommend the hospital; using a comprehensive set of healthcare attributes. This study found that among six attributes, nursing care showed the largest parameter estimate for the patient satisfaction and behavioral intentions models. Thus, simply improving the nursing care attribute seems to be the most effective action to enhance patient satisfaction and behavioral intentions.

By understanding and acknowledging the fact that empowering nursing will benefit hospitals and raise the level of satisfaction of patients, healthcare facilities worldwide have started to implement nursing-focused policies and to provide a pivotal role for nurses. Studies have also reinforced the importance of having nurses sit in on all interviews for potential new employees, as well as sit on policy and procedures committees, and contribute to complaint management system designs (Cohen, Delaney and Boston 1994, “Patient complaints: guidance for nurses.” Nursing Standard, 1992).

All these revelations highlight the importance of nursing as a key player in patient satisfaction and recommend the widening scope of operation and the role of nurses in healthcare institutions. This is a good indication of the growth opportunity for nurses, but at the same time it stresses on the importance of an individual nurse’s competency and all-round skills,  over and above bedside procedures.

Challenges in meeting patient expectation

According to the National Advisory Council on Nurse Education and Practices 2010 report, to the U.S. Department of Health and Human Services, the medical knowledge-base that had previously been doubling every five to eight years is expected to begin doubling every year. Nurses simply will not be able to keep up with this freshly generated information without an advanced education and a system supporting life-long learning. Meeting patient expectations is considered the biggest challenge of nurses in future.  At time when medical knowledge, technology and patient expectations are changing fast, continuing education and learning, and practicing life-long self-learning skills are the only one way to achieve the level of an ideal nurse; one who is skilled enough to guarantee patient satisfaction in the modern era.

Nursing As An Attractive Career Option For Men

Nursing, in modern times, has not been perceived as a profession to be pursued by men; as a vocation, perhaps, through a religious order. You may find it surprising, though, that until the late 1800s nursing was a service primarily rendered by men.

It wasn’t until Florence Nightingale started advocating professional nursing care at the frontline, during the Crimean War (1853 – 1856), did women nurses start making their presence felt on battlefields, in Europe. In the USA, men were still performing a majority of the nursing duties during the American Civil War (1862 – 1865). It was during World War I (1914 – 1918), and the demand for able-bodied men, that governments started mandating “only women” for nursing services.

This mandate became so well entrenched that, even as late as 1980 men were not allowed admission into a majority of the nursing colleges in the USA. Today, although there aren’t any restrictions to men entering the nursing profession, the percentage of men in nursing is still very small (9 – 10%); thanks to the historical legacy, and to (Western) societal perceptions formed during this period when most of nursing was out of bounds to men.

With the projected acute shortage of nurses in the developed world, nursing is now, more than ever, an extremely attractive career option for men; coming at a time when traditional sources of blue-collar male employment, such as manufacturing and construction, are drying up on account of increased productivity or greater mechanization. Overcoming this shortage will require potential employers to increase wages significantly higher than the inflation rate, as mentioned in a previous blog.

So, the demand and the wages render nursing an attractive career for men (and women too), but what are the issues to keep in mind while opting for a career in nursing?


  • The first is, of course, the perception that nursing is a woman’s job. Going against this stereotype will require a good deal of character and resolution, especially when explaining the choice to one’s near and dear, and to friends. Overcoming this perceptual obstacle is half the battle won.
  • There are few male role models in nursing, for men choosing to join the profession, given the near-historical absence of men from this profession. So, advice, from a male perspective, on handling academic and professional pressure, specializations to opt for, etc. is hard to come by.
  • Choosing the right specialization is important. Women-specific specializations, e.g. Obstetrics & Gynecology, can be avoided, and during one’s career there may be situations when female patients may be more comfortable being taken care of by a female nurse. That said, male nurses tend to like specializations such as Anesthesia, Emergency & Trauma, Critical Care, Flight nursing, Oncology, Orthopedics, Psychiatry, Education, and Nursing management, to name a few.
  • Discrimination against male nurses, in the workplace, may be gradually fading but a male nurse should be prepared for it. Such discrimination may manifest itself solely on account of gender, or on account of relationship with the physician, or even on account of communication issues with female counterparts. In many cases discrimination is perceived and not practised, because the male nurse is operating in an unfamiliar situation where he is a (gender) minority.

It’s not all caution and taking care, though. There are a few advantages to being a male nurse: especially around patients who are violent or aggressive, or when physical strength is required (to lift or support a patient). And, strangely enough, at least in the USA, although men represent less than a tenth of the nursing population, they earn more their women counterparts in the same roles. This anomaly has been explained through the fact that male nurses tend to be better qualified than their female counterparts, for the same roles.

When it comes down to making a decision, it should be noted that nursing is a professional vocation, and any man opting for it as a career will first need to decide on whether he is going to find satisfaction and contentment in caring for an unwell fellow human being. If the answer is yes, then the issues outlined above will easily be resolved. If not, the career may not turn out to be as attractive as the salary promises.

Bringing Information Technology to Indian Nursing – Global Best Practices

ImageNursing is changing worldwide, as technology becomes more sophisticated and percolates into more practices within the nursing discipline. Having said that, there is an imperative need to introduce information technology in the Indian nursing system. At present, Indian nurses are unable to cope with work pressure due to the quantum of data generated in each of the cases they handle. This volume of data manifests itself in heavy paperwork, which nurses, attached to hospitals, are mandated to complete, to the detriment of their core nursing functions (Ball et al, 2000). In addition, Ball et al (2000) state that cost-cutting, at healthcare institutions, and consumerism have also created more pressure on nurses today.

Malpractice crises have forced nurses to focus more on complete and detailed nursing documentation. It is here that the adoption of information technology will significantly ease a nurse’s workload. Digital documentation and instant access to up-to-date information on a patient’s history, test results, and physician notes saves energy (that is otherwise spent duplicating documentation)and time (that is otherwise spent chasing down relevant documents in other departments). Not with standing the demonstrated benefits, rolling out an information technology platform is not easy and requires determination and perseverance from the implementers. The problem with introducing information technology is that, like in other fields, many nurses are resistant to any change in the existing system: especially, older generation nurses. Change, even if beneficial, is not always welcomed by the beneficiaries of such change.

Advances in biomedical technology and the use of sophisticated electronic equipment is already creating stress among nurses. Further compounding the stress, Ball et al (2000) argue that it is unfortunate that beneficiary nurses are not adequately involved in the selection and implementation of the information technology platform. Consequently, core nursing functions suffer too. The solution is to roll out information technology platforms in the nursing field, with the co-option and co-operation of the nursing staff. Indian nurses have to learn practices such as electronic recording and become more technologically savvy, so that their productivity can be improved and quality standards in delivering nursing care improved.

Marquis and Huston (2006) state that there are three reasons for change: firstly, to solve a problem or issue; secondly, to improve quality; and, thirdly, to decrease unnecessary workload for the particular working group. In the case of implementing information technology in nursing care, in India, all the three criteria are fulfilled: the problem of poor quality nursing care; addressing this problem using IT platforms; and in doing so, improve the efficiency and effectiveness of the nursing staff through the reduction in unnecessary paperwork.

Many developed countries such as Canada, UK, and USA have already implemented information technology in nursing field. Even in India, several corporate hospitals have started to utilize information technology. Having said that, there is still huge scope for Indian nurses to further benefit from information technology, in ways  which will reduce their workload even more. Needless to say, there will be, initially, stress and resistance to change; but as times rolls on, nurses will gain familiarity of any such new IT systems. IT is one global best practice that needs to be adopted by Indian nursing forthwith.

The Need for Change in the Indian Healthcare System with Respect to Infection Control

Does the Indian healthcare system provide a comprehensive range of health services? Is the healthcare system entirely independent? Does the system operate under different management, rules and political authority? If yes is your answer to these queries, then one has to wonder how far the healthcare system is useful to India’s citizens? Can a middle-class family, let alone an impoverished family, afford good healthcare, in India? The answer to that question is still open.

Today we live in the amidst of a host of infections: both known and unknown. How are healthcare organizations and institutions recognizing this fact and acting on this recognition? Are patients treated in a hospital free of infections, and has the treatment been effective? If the answers are yes, do we have evidence to this effect, which is research-based, detailing strategies or protocols? For instance, many bacterial contagions were effortlessly treated with antibiotics previously; unlike the present where such contagions have been difficult to control, on account of the antibiotic resistance built up by the bacteria. Some examples are those of the Methicillin-Resistant Staphylococcus Aureus (MRSA) bacteria (common in hospitals) and the tuberculosis-causing bacteria, Mycobacterium tuberculosis. Under the circumstances, it is not surprising that, more than any disease, antibiotic resistance is rapidly growing as one of the most dangerous threats to individual wellbeing currently, as per the World Health Organization (WHO). Being healthcare paramedics, it is important that we understand the implications of this threat, after every medical or nursing intervention: an understanding that will enable us to ensure effective and quality healthcare delivery.

Let us take a look at how the United Kingdom’s NHS (National Health Service) functions. In the UK, the NHS is primarily sponsored by the government. It delivers a wide array of public well-being services, a majority of which are free at the point of use, for legal resident of the UK. Thus, the healthcare in the UK is structured independently and also operates under different management, rules, and political authority. Complementing this service, the NMC (Nursing and Midwifery Council) keeps updating treatment regimens and protocols, by analysing latest research outcomes on new medical or nursing interventions; which further strengthens the delivery of high-quality care through the NHS.

For example, a nurse witnessing a patient’s fall in a hospital set-up follows the ABCDE approach for client care assessment and uses the SBAR approach to inform senior health personnel, about that patient’s health condition, using relevant processes for the reporting. Such an approach is not widely practised in the Indian Scenario. Applying such an approach in the Indian healthcare system will help healthcare providers prioritise their work, report relevant and adequate information,  and provide effective patient care.

Will Nursing Be The Highest Paid Profession In The Future?

The question is rhetorical, of course, and the answer is no. The reason, though, the question is being asked is because of the large projected worldwide shortage of nurses within the next decade-and-a-half.


The shortage is expected to arise on account of an increase in the demand for nurses. This increase in demand is linked to a variety of factors:

  • The world’s aging population is going to be needing more nursing care. The United Nations’ World Population Aging 2013 report has some interesting facts about the imminent greying of the world’s population. Population aging is happening on account of decreasing mortality and declining fertility, and the global share of older people (aged 60 years and above) will increase from 11.7% in 2013 to a projected 21.1% in 2050; or, in terms of numbers, from 841 million in 2013, to more than 2 billion in 2050.
  • Lifestyle changes are resulting in a spike in chronic conditions such as diabetes, obesity, and hypertension; conditions which will require increased medical intervention.
  • Advances in medical science are making it possible for an individual to survive severe trauma, albeit with significantly reduced functional capabilities. Such individuals will require regular nursing care.
  • The move from therapeutic care to preventative care is going to place additional stress on the nursing fraternity, as nurses will constitute an inordinate proportion of the healthcare professionals driving preventative healthcare.


The demand has started rising in the developed world, and will gradually spread to the less developed world and least developed countries. The US Bureau of Labor Statistics (BLS) projects the employment of registered nurses to grow 19%, in the USA, from 2012 to 2022; faster than the average for all occupations.


As a counterpoint to the increased demand for nurses in the developed world, are the constraints to supply in meeting this demand. The reasons for the supply constraints are primarily:

  • An increase in the number of nurses leaving the workforce, in the developed world, as the “baby boomers” generation reaches retirement age.
  • There is little or no nurse staffing surplus left to cut in large healthcare institutions, as most cuts were carried out at the turn of the last century; and on account of the realization that nurse staffing is closely associated with patient outcomes – quality of care reduces with a decrease in the nurse-to-patient ratio.
  • Given the lead time required to train a registered nurse, and the fact that the nursing profession still carries vestiges of its vocational origins, there is a significant lead time for new supply to narrow the demand gap.


This mismatch between demand and supply, as any person with an understanding of economics will tell you, will first result in an increase in wages. A paper, by Joanne Spetz and Ruth Given, modeling wage growth and supply in the US market, arrives at the conclusion that wages, adjusted for inflation, “must increase 3.2 – 3.8 percent per year between 2002 and 2016, with wages cumulatively rising up to 69 percent, to end the shortage”.

Hence the question: will nursing be the highest paid profession in the future? However, as wages increase, affected parties (healthcare organizations, governments, etc.) will look at tempering this increase through initiatives outside the healthcare profession.


Two developments will have a direct impact on wages that nurses can command:

  • Developments in robotics will make the job of nurses easier, thereby increasing their productivity. While it may be inadvisable and certainly unfeasible in the near future, to have robots play a direct role in patient care, they can certainly assist a nurse deliver better care, more efficiently.
  • Advances in medical science – specifically in genetics/epigenetics and stem cell research – may allow medical practitioners to alleviate the deleterious effects of old age (dementia, lower immunity, disequilibrium, and brittle bones) to such an extent as to reduce the burden on a country’s healthcare system.

Any which way, these are interesting and exciting times for the nursing profession, and the rhetorical question headlining this blog is just a concise articulation of the sign of the times.

We would be interested to hear your thoughts on the wage-potential of the nursing profession.

Florence Nightingale and International Nurses Day

Florence Nightingale and International Nurses DayThe 12th May, each year, is celebrated as International Nurses Day. This day allows nurses to celebrate their profession and to show the world that nurses are the backbone of the healthcare system. Many people wonder why International Nurses Day is celebrated on 12th May. The reason is simple: it is the birthday of the great Florence Nightingale, who was the founder of modern nursing, and who was responsible for establishing nursing as a profession.

Florence Nightingale was born on the 12th May, 1820, into a rich, upper-class British family. Her father William Edward Nightingale named her Florence after the city she was born in: Florence, in Italy. Nightingale was fortunate in that her father believed women should be educated, contrary to social convention during the Victorian era, and he personally taught her Italian, Latin, Greek, philosophy, history, writing, and mathematics.

She took up nursing, against her family’s (mother’s and sister’s) wishes. She learned basic nursing skills at Germany, in July 1850, where she received training at The Institution of Protestant Deaconesses, at Kaiserswerth-am-Rhein.

Florence Nightingale achieved national fame during the Crimean War (1853 – 1856) when she worked very hard to provide the best nursing care to the British soldiers. During the Crimean War she was popularly known as “The Lady with the Lamp”, after her habit of making rounds at night. This fame and popularity allowed her to set up a fund, the Nightingale Fund, in 1855 for the training of nurses.

Florence Nightingale used the fund to set up the Nightingale Training School at St. Thomas’ Hospital on 9th July 1860, the first secular nursing school. The first trained Nightingale nurses began work in 1855. The school still runs, as the Florence Nightingale School of Nursing and Midwifery, and is part of King’s College London. She also took an initiative in training midwives.

In 1859, Florence Nightingale wrote Notes on Nursing: What it is and what it is not, now considered a classic introduction to nursing, to serve as a key component of the curriculum at the Nightingale School and other nursing schools. The book sold well among the general public too. She assisted in setting up nursing schools in the USA, Australia, and Japan, through the alumni of the Nightingale School, and thereby achieved international recognition. She also carried out pioneering work in hospital planning; knowledge that quickly spread all around the world.

Despite suffering from ill-health in her later years, she was phenomenally productive, generating a large corpus of written work. In 1907, she became the first woman to be awarded the Order of Merit, an exclusive award from the British monarch, for her achievements. She died on 13th August, 1910, at the age of ninety. As per her wishes, her family declined the offer of a burial in Westminster Abbey, and she is buried in the graveyard at St. Margaret Church in East Wellow, Hampshire, England.

Her life and her achievements ensure that Florence Nightingale remains the biggest role model for nurses, throughout the world.