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International Review of the

ARMED FORCES MEDICAL SERVICES Revue Internationale des Services de Santé des Forces Armées

Official organ of the International Committee of Military Medicine

www.cimm-icmm.org

Organe officiel du Comité International de Médecine Militaire

SCIENTIFIC COMMITTEE / COMITÉ SCIENTIFIQUE

EDITION / REDA CTION

Col. (Vet.) L. BUCHNER (Germany / Allemagne)

Director / Directeur Maj. Gen. (ret.) G. LAIRE (MD) glaire@cimm-icmm.org

Col. Maj. M. BEJI (MD) (Tunisia / Tunisie)

Editor-in-Chief (a.i.) / Rédacteur en chef par Interim Maj. Gen. Prof. (ret.) H. BOISSEAUX (MD) hboisseaux@cimm-icmm.org

Gp. Capt. Prof. D. LAMB (United Kingdom / Royaume-Uni) Maj. Gen. (ret.) KHALID A. ABU-AZAMAH AL-SAEDI (MD) (Saudi Arabia / Arabie Saoudite) Col. (ret.) Prof. I. KHOLIKOV (MC) (Russian Federation / Fédération de Russie)

Assistant Chief-Editor (a.i.) / Rédacteur en chef adj oint par Interim Maj. Gen. Prof. J.J. LATAILLADE (MD) jj lataillade@cimm-icmm.org Secretary of the Editorial Board Secrétaire du Comité de rédaction Captain Pharmacist L. PIERRE-VICTOR lisepierrevictor@cimm-icmm.org

Col. K. KORZENIEWSKI (MD) (Poland / Pologne)

Secretary of the Editorial Board Secrétaire du Comité de rédaction Chief Warrant Officer C. VAN DEN BERGHE cvandenberghe@cimm-icmm.org

Col. (Dent.) A. KOSARAJU (United States of America / Etats-Unis d'Amérique) Sen. Col. (Pharm.) A. KRAPPITZ (Germany / Allemagne)

Sen. Col. Prof. M. YU (China / Chine)

Editor’s office / Bureau de la rédaction International Committee of Military Medicine Comité International de Médecine Militaire Hôpital Militaire Reine Astrid BE-1120 Brussels (Belgium) & : +32 2 443 26 45 edition@cimm-icmm.org

Lt. Col. D. WINKLER (MD) (Switzerland / Suisse)

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International Review of the Armed Forces Medical Services

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Revue Internationale des Services de Santé des Forces Armées

CONTENTS Sommaire

SPECIAL NURSES ISSUE / NUMERO SPECIAL INFIRMIERS 57

Nursing in Armed Forces: Vision, Value and Voice of Nurse. An Indian Perspective. By R. RAJU and J.G. ROACH. India

Editorial. Florence NIGHTINGALE (1820 - 1910). By H. BOISSEAUX, ICMM

Florence NIGHTINGALE. By A. BONEY THOMAS. India

From Scutari to South Sudan: Lessons in Preparedness. By D. LAMB and RJ. STONE. United Kingdom

Development of a Bespoke Military Preceptorship Programme: From Lamp to Light. By R.G. BEECH. United Kingdom

Establishing Collaborative Relationships. Following Florence Nightingale’s Footsteps to Optimise UK Military Paramedics’ Competence. By R. SCOTT and C. WRIGHT. United Kingdom

Quelques biographies d'infirmières d’exception. Some biographies of exceptional nurses. • Beatrice ALLSOP • Yolande BERTHELOT DE BAYE • Violette THURSTAN • Julia STIMSON • Edith CAVELL • Ellen NEWBOLD LA MOTTE • Mary BORDEN • Marie MARVINGT • Geneviève DE GALARD

102

L’histoire de l’engagement infirmier miitaire; quelques références bibliographiques. The History of Military Nursing Engagement; Some Bibliographical References.

105

Le « petit ange noir » devenue héroïne de guerre. Augusta CHIWY, l’infirmière oubliée.

43 Florence Nightingale’s Influence on Nursing in the Canadian Armed Forces. By S.D. SULLIVAN, J.H. SCHMID, I. DUPUIS and O.A. CARBONNEAU. Canada

Photo on the cover: Photo 1 - The Year of the Nurse and what an eyewitness account reveals about “the lady with the lamp” - (Talking Humanities - School of Advanced Study). - Photo 2 - infirmier belge - ©Peter Leduc - Comopsmed Delcom.

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Views and opinions expressed in this Review are those of the authors and imply no relationship to author’s official authorities policy, present or future.

International Review of the Armed Forces Medical Services

Les idées et opinions exprimées dans cette Revue sont celles des auteurs et ne reflètent pas nécessairement la politique officielle, présente ou future des autorités dont relèvent les auteurs.

Revue Internationale des Services de Santé des Forces Armées

International Committee of Military Medicine Comité International de Médecine Militaire Intergovernmental organization in relation with the WHO (Agreement approved by the 5th World Health Assembly on May 21, 1952), the WMA, the WVA, the ICRC, the CISM, the OIE and the FIP. Organisation intergouvernementale en relation avec l’OMS (Accord approuvé par la 5ème Assemblée Mondiale de la Santé du 21 mai 1952), l’AMM, l’AMV, le CICR, le CISM, l’OIE et la FIP. Founder and Secretary General from 1921 to 1975/Fondateur et Secrétaire Général de 1921 à 1975 : Maj. Gen. J. VONCKEN, MD (Belgium/Belgique). Honorary Secretaries-General/Secrétaire généraux honoraires : Dr. J. SANABRIA, MD. (Belgium/Belgique) - Maj. Gen. (ret.) R. VAN HOOF, MD (Belgium/Belgique).

Chairman of the General Assembly and the Committee / Président de l’Assemblée Générale et du Comité Major General Andreas STETTBACHER (Switzerland/Suisse) Vice Chairmen / Vice-Présidents Lieutenant General Anup BANERJI, SM, PHD (India/Inde) Mr Thomas McCAFFERY (U.S.A./Etats-Unis)

SECRETARIAT GENERAL/SECRETARIAT GENERAL Secretary-General/Secrétaire Général Maj Gen (ret.) G. LAIRE, MD, MSc Deputy Secretary-General/Secrétaire Général Adjoint Maj Gen P. NEIRINCKX, MD Assistant of the Secretary-General/Assistant du Secrétaire Général Brig Gen (ret.) Prof. L. KLEIN, MD Assistant of the Secretary-General/Assistant du Secrétaire Général Lt Col M. E. PRESA GARCIA, MD Director of Communication and Marketing/Directeur Communication et Marketing Mr P. ZABOURI Director of Finances/Directeur Financier Col MMA (ret.) C. DEROUBAIX Legal Advisors of the Secretary-General/Conseillers juridiques du Secrétaire Général Col Prof. (ret.) I. KHOLIKOV, PhD Col (ret.) J. CROUSE Office Manager Secretariat General/Chef de bureau du Secrétariat Général Capt Pharm L. PIERRE-VICTOR Executive Secretary/Secrétaire de Direction CWO C. VAN DEN BERGHE

SCIENTIFIC COUNCIL/CONSEIL SCIENTIFIQUE Chairman (a.i.) of the Scientific Council/Président par Interim du Conseil Scientifique Maj Gen Prof. (ret.) H. BOISSEAUX, MD Deputy Chairman (a.i.) of the Scientific Council/Vice-Président par Interim du Conseil Scientifique Maj Gen Prof. J.J. LATAILLADE, MD Chairman of the Reference Center for Education on International Humanitarian Law and Ethics/ Président du Centre de Référence pour la Formation au Droit International Humanitaire et à l’Éthique Lt Col PD Dr. med. et. phil. D. WINKLER, MD, PhD. (Switzerland/Suisse) Chairman of the Commission for Medico-Military Administration/Président de la Commission d’Administration Médico-Militaire Sen Col Prof. M. YU (China/Chine) Chairman of the Commission for Dentistry/Président de la Commission d’Odontologie Col (Dent.) A. KOSARAJU, DMD, Msed, BS. (U.S.A./Etats-Unis) Chairman of the Commission for Pharmacy/Président de la Commission de Pharmacie Sen Col (Pharm.) A. KRAPPITZ (Germany/Allemagne) Chairman of the Commission for Veterinary Sciences/Président de la Commission des Sciences Vétérinaires Col Dr (Vet.) L. BUCHNER (Germany/Allemagne) Chairwoman (a.i.) of the Commission for Nurses & Paramedics/Présidente (a.i.) de la Commission des Infirmières & Paramédicaux Gp Capt Prof. D. LAMB (United Kingdom/Royaume-Uni) Medico Legal Advisor of the Chairman of the Scientific Council/Conseiller médico-juridique du Président du Conseil Scientifique Col (ret.) J. CROUSE (South Africa/Afrique du Sud) Honorary Chairmen/Présidents d’Honneur Gen A. LAIN GONZALEZ (Spain) - Maj Gen Ö. SARLAK (Turkey) - Gen G. DESCH (Germany) - Maj Gen Z. LU (PR of China) - Gen R. SCHLÖGEL (Austria) Maj Gen T. SAHI (Finland) - Lt Gen J.L. VAN RENSBURG (South Africa) - Dr W. WINKENWERDER, Jr (USA) - Maj Gen A. BELEVITIN (Russian Federation) Brig Gen (MD) M. K. CHEBBI(†) (Tunisia) - Lt Gen Dato’ (Dr) S. bin ABDULLAH (Malaysia) - Brig Gen (Dr) H. MA AGADA (Nigeria) Maj Gen S. M. AL-MALIK (Saudi Arabia) - Lt Gen T. A. PUTRANTO (Indonesia).

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PAY S F O N D AT E U R S / F O U N D E R S TAT E S Belgique, Brésil, Espagne, Etats-Unis d’Amérique, France, Italie, Royaume-Uni, Suisse. Belgium, Brazil, France, Italy, Spain, Switzerland, United Kingdom, United States of America.

ETATS MEMBRES/MEMBER STATES Afghanistan/Afghanistan : Lieutenant General Hashmatullah NAWABI Afrique du Sud/South Africa : Lieutenant General (Dr.) A.P. SEDIBE Albanie/Albania : Brigadier General Bajram BEGAJ, MD, PhD Algérie/Algeria : Médecin Général Abdelkader BENDJELLOUL Allemagne/Germany : Lieutenant General Dr. Med. Ulrich BAUMGÄRTNER, MD Angola/Angola : Lieutenant General Dr Alberto DE ALMEIDA, MD Arabie Saoudite/Saudi Arabia: Brigadier General (Pharm) Ali Ahmed ALKINANI, MSc. Argentine/Argentina : Coronel Fernando Luis POSE Arménie/Armenia : Colonel Tigran AVETISYAN Australie/Australia : Rear Admiral Sarah Edith SHARKEY Autriche/Austria : Brigadier General Silvia-Carolina SPERANDIO, MD, PhD, MBA Azerbaidjan/Azerbaijan : Major General Natig ALIYEV Bahreïn/Bahrain : Brigadier (Prof.) Khalid BIN ALI AL KHALIFA Bangladesh/Bangladesh : Major General (Dr) Fashiur RAHMAN, MD Belgique/Belgium : Colonel Wouter WEUTS, MD Bolivie/Bolivia : Gerente de Salud de COSSMIL Brésil/Brazil : Admiral Médico Antonio Carlos Barbosa NARDIN LIMA Bulgarie/Bulgaria: Brig Gen Prof. Dr Ventsislav MUTAFCHIYSKI, MD, PhD, DSc FACS Burkina Faso/Burkina Faso : Médecin Colonel Major Hamado KAFANDO Burundi/Burundi : Major Docteur Donatien IRAMBONA Cameroun/Cameroon : Colonel Médecin Ambroise Emmanuel MAMA Canada/Canada : Colonel Scott F. MALCOLM, CD, MD Rép. Centrafricaine/Central African Rep.: Médecin Colonel Eudes GBANGBA-NGAI Chili/Chile : Contralmirante Boris SANCHEZ MANRÍQUEZ Chine/China : Major General Jingyuan CHEN Chypre/Cyprus : Lieutenant Colonel Nicholaos MICHAELIDES, MD Rép. Dém. du Congo/Dem. Rep. of Congo: Médecin Général Major Louis KAKUDJI ILUNGA Rép. Congo/Rep. Congo : Médecin Général de Brigade Pascal IBATA Corée/Korea : Brigadier General Woong SEOG Côte d’Ivoire/Cote d’Ivoire: Médecin Général de Brigade Prof. Dowlo N'Dri Athanase YAO Croatie/Croatia : Colonel Velijko VUKIC, MD Danemark/Denmark : Brigadier General Sten HULGAARD Djibouti/Djibouti : Médecin Colonel Ahmed Hassan BOULALEH Rép. Dominicaine/Dominican Rep.: Coronel Med Psi., FARD Pedro Arnald FERNANDEZ TEJADA Egypte/Egypt : Major General Magdy Amin MOBARAK El Salvador/El Salvador : Coronel de Infanteria DEM. Luis Oscar GALDAMEZ AMAYA Emirats Arabes Unis/United Arab Emirates: Staff Brigadier Dr Aysha Sultan AL DHAHERI Espagne/Spain: General de División Médico D. Antonio RAMÓN CONDE ORTIZ Estonie/Estonia : Lieutenant Colonel Targo LUSTI, MD Etats-Unis/U.S.A. : Mr Thomas McCAFFERY Finlande/Finland : Brigadier General Simo SIITONEN France/France : Médecin Général des armées Maryline GYGAX GENERO Gabon/Gabon : Médecin Général Professeur Jean Raymond NZENZE Ghana/Ghana : Brigadier General Ernest CROSBY SAKA Grèce/Greece : Major General Georgios TOLOUMIS, MD Guinée/Guinea : Pharmacien Colonel Ibrahima Kalil TOURE Haïti/Haiti : Docteur Paul BERNE Honduras/Honduras : Coronel de Sanidad Irma Asucena BAQUEDANO CANALES Hongrie/Hungary : Brigadier Dr István KOPSCÓ Inde/India : Lieutenant General Anup BANERJI, SM, PHS, DGAFMS Indonésie/Indonesia : Major General (Dr) Ben Yura RIMBA, MD, MHA, MARS Irak/Iraq : Major General Fadhel Abd AL-HUSSAIN JABER, MD Iran/Iran : Brigadier General Dr Hasan ARAGHIZADEH Irlande/Ireland : Colonel Gerald M. KERR Israël/Israel : Brigadier General Tarif BADER, MD Italie/Italy : Major General Nicola Aldo SEBASTIANI Japon/Japan : Dr Shigeki SHIIBA, MD Jordanie/Jordan : Major General Dr Shawkat AL TAMIMI Kenya/Kenya : Brigadier General Dr George Kiguta NG’ANG’A Koweït/Kuwait : Dr Yousef Ahmed AL-NESEF

Lettonie/Latvia : Lieutenant Colonel Jănis MIČĂNS Liban/Lebanon : General Georges YOUSSEF Libéria/Liberia : Dr Josiah T. GEORGE Libye/Libya: Brigadier General Homdi OMAR ELBASIR Lituanie/Lithuania : Lieutenant Colonel Jolita SESARTIENĖ Luxembourg/Luxemburg : Médecin Lt Colonel Cyrille DUPONT Macédoine du Nord/North Macedonia: Director General of the Armed Forces Medical Services Madagascar/Madagascar : Médecin Général de Brigade A. W. RAKOTOVAO Malaisie/Malaysia : Lieutenant General Dato’ (Dr.) Hj YA’AKOP BIN KOMING Mali/Mali : Médecin Général de Brigade Boubacar DEMBELE Malte/Malta : Surg. Lt. Colonel Dr. Matthew PSAILA, MD Maroc/Morocco : Médecin Général de Brigade Mohammed ABBAR Mauritanie/Mauritania: Médecin Général de Brigade Teyeb Mohamed Mahmoud EBOU Mexique/Mexico : Captain de Navío Javier Nicolás ZEPEDA DE ALBA Mozambique/Mozambique : Lieutenant Colonel Raul Gabriel COSSA, MD Myanmar/Myanmar : Major General (Prof.) Soe WIN Namibie/Namibia : Colonel Bernadette Hilya IITA Nicaragua/Nicaragua : Coronel Médico Dr Marco Antonio SALAS CRUZ Nigéria/Nigeria : Surgeon Rear Admiral Lawan Modu ADAMS Norvège/Norway : Major General Jon Gerhard REICHELT Nouvelle-Zélande/New Zealand : Brigadier General Andrew GRAY Oman/Oman : Brigadier (Dr) Ali Nasser Juma AL MASKARI Ordre de Malte/Sovereign Order of Malta: Chevalier Dr J.-C. De SCHOUTHEETE DE TERVARENT Ouganda/Uganda : Brigadier General Dr Ambrose Keith MUSINGUZI Pakistan/Pakistan : Lieutenant General Zahid HAMID Palestine/Palestine : Dr Maysoun EL BANNA Paraguay/Paraguay: Coronel de Sanidad med. Dr Jacinto Rafael NOGUERA ARZAMENDIA Pays-Bas/The Netherlands : Commandeur (OF-6-Navy) Remco W. BLOM Pérou/Peru : Coronel EP San MED Jaime AVALOS DIANDERAS Philippines/Philippines : Colonel Felix T. TERENCIO MC (GSC) Pologne/Poland : Colonel Slawomir CHMIEL, MD Portugal/Portugal: Brigadier General João Jácome DE CASTRO Qatar/Qatar : Brigadier General (Navy) Staff Naser Mohammed AL-KAABI Roumanie/Romania : Brigadier General Dragos-Marian POPESCU, MD, PD Royaume-Uni/United Kingdom: Air Vice-Marshal Alastair REID Fédération de Russie/Russian Federation : Dr Dmitry TRISKIN Saint-Siège/Holy See : Monsieur l’Abbé Robrecht BOONE Sénégal/Senegal : Médecin Colonel Abdoul Aziz NDIAYE Serbie/Serbia : Colonel Prof. Miroslav VUKOSAVLJEVIĆ, MD, PhD Singapour/Singapore : Colonel Dr Hong Yee LO Slovaquie/Slovakia : Colonel Vladimir LENGVARSKY, MD, MPh Slovénie/Slovenia : Colonel Dr Andrej LIKAR, D.D. Soudan/Sudan : Lieutenant General Khatir Mohamed TOBAY EISA Sri Lanka/Sri Lanka : Surgeon Rear Admiral Sena Rupa JAYAWARDANA Suède/Sweden : Colonel Claes IVGREN Suisse/Switzerland : Divisionnaire Andreas STETTBACHER Syrie/Syria : Director General of the Armed Forces Medical Services Tchad/Chad : Médecin Général de Brigade Salim Ossou SOULEYMANE Rép. Tchèque/Czech Rep. : Brigadier General (Dr) Zoltan BUBENIK, MD Thaïlande/Thailand : Lieutenant General Channarong NAKASAWASDI, MD Togo/Togo : Médecin Colonel Wiyao Kpao ADOM Tunisie/Tunisia : Médecin Général de Brigade Prof. Mustapha FERJANI Turquie/Turkey : Brigadier Durmuş AYDEMİR, MD Union des Comores/Union of the Comoros: Médecin Commandant A. NAOUFAL BOINA Uruguay/Uruguay : General Carlos M. ROMBYS ESTÉVEZ Vénézuela/Venezuela : General de División Médico Pedro Jesus SERRANO DUQUE Viêt Nam/Vietman : Major General Xuan Nguyen KIEN Yémen/Yemen : Brigadier Dr Mohammed A. AL-MEKHLAFI Zambie/Zambia : Brigadier General (Dr) Adrian MALEYA

P AY S O B S E R VAT E U R S / O B S E R V E R S Bielorussie/Belarus - Cambodge/Cambodia - Rwanda/Rwanda

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D ’ HONNEUR /H ONORARY

M EMBERS

Maj Gen Dr E. DELIYANNAKIS (Greece) - Col Dr E. DASKALAKIS (Greece) - Lt Col Méd. L. VAZEOS (Greece) - Maj Gen Dr K. KOSKENVUO (Finland) - Maj Gen Dr S.M. AL-SHAMMA (Iraq) - Méd Col S. NEJMI (Morocco) - Gen Dr A. DOMINGO GUTIÉRREZ (Spain) - Col Dr Prof. K. SAVASAN (Turkey) - Col Dr F. MEISSNER (Germany) Sen Col LI Chaolin (China) - Méd Col H. HARBICH (Austria) - Col Dr Ari PEITSO (Finland) - Maj Gen A.J. LANDMAN (South Africa) - Col Vet R. SHORT (South Africa). - Méd Col HAOUALA (Tunisia) - Méd Col MACHGHOUL (Tunisia) - Brig Gen Dato’ (Dr) Mohd ZIN BIDIN (Malaysia) - Surg Cdre AB AFOLAYAN (Nigeria) - Maj Gen Khalid ALSAEDI (Saudi Arabia) - Lt Gen Terawan Agus PUTRANTO (Indonesia) - Air Commodore Rajesh VAIDYA (India) - Col Daniël Flückiger (Switzerland).

Revue Internationale des Services de Santé des Forces Armées

International Review of the Armed Forces Medical Services

EDIT O

EDITORIAL

FLORENCE NIGHTINGALE (1820 - 1910) The 12th May 2020 marked the 200th anniversary of the birth of Florence NIGHTINGALE, an icon in the world of nursing and particularly within the armed forces. It seems like the perfect time for the ICMM to look back on her life and achievements. Florence NIGHTINGALE grew up in an affluent British family and considered, at an early stage, the level of care provided to the sick and the wounded to be substandard. Before NIGHTINGALE’s time, nursing care had been provided by women of modest backgrounds with no training and had been limited essentially to domestic duties. Having seen and experienced this void in nursing care that was not covered by doctors, NIGHTINGALE set about organising proper training for nursing staff and implementing a formal organisational framework for the profession. The British Army drew on the services of Florence NIGHTINGALE during the Crimean War. She was deployed together with a small group of nurses in extremely poor conditions where disease thrived. NIGHTINGALE is known as a pioneer in the area of hygiene, but she was also a passionate proponent of mathematics and statistics. Not only did she dedicate herself to introducing essential hygiene procedures, she also quantified the results of her work to prove its effectiveness. She was a genuine visionary of the evidence-based medicine, “avant la lettre”, and also paved the way for a new consideration for the nursing profession. Nursing became essential in improving the quality of care and reducing the level of mortality in hospitals. In her efforts to strive for excellence in nursing care to which soldiers were entitled, Florence NIGHTINGALE devoted her entire life to developing training concepts for nursing staff which were demanding and of a high technical standard. They are still reflected in the profession we know today, although, given that caregivers are often close relatives of the sick and wounded, they undoubtedly remain insufficient. It is a profession that still has some way to go both in terms of technology but also needs to be promoted when it comes to the organisation and operation of the systems. The work performed by nursing staff all over the world, in health facilities at all levels, is just as extraordinary as it is irreplaceable – something that has become all the more clearer in the fight against Covid-19! The field of war was the gateway for Florence NIGHTINGALE’s achievements, and it remains an area of innovation that is equal to the challenge posed by the kind of weapons dreamt up by human ingenuity. The International Committee on Military Medicine is open to all who help care for the sick and wounded alongside doctors, and this is particularly the case when it comes to the nursing profession. In our efforts to enable professionals to share expertise on the particular aspects of their jobs in the armed forces and to discuss new developments and innovations, technical commissions have been set up in the spirit of the ICMM to highlight the contribution made by everyone in this field, embracing the principles of interdisciplinary and constructive cooperation. Group Captain Diane LAMD chairs the ICMM’s Commission for Nurses and Paramedics. In celebration of the birth of the “Lady with the Lamp”, it was decided to shine a light on the nursing profession by bringing together a collection of articles that demonstrate the relevance and importance of the approach originally taken by Florence NIGHTINGALE. Di Lamb has worked extremely hard to put together this special feature for the International Review of the Armed Forces Medical Services, for which we thank her.

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The special feature comprises five articles, three relating to NIGHTINGALE’s legacy for the UK’s modern-day National Health Service and two focusing on her influence on two other health services, in India and Canada. Each of the articles sheds light on the high scientific and technical standards upheld by professional nurses who are now university-educated and who, following Florence NIGHTINGALE’s lead, are nowadays able to carry out specific research and to report on it. Here at the ICMM, we feel that all of the technical commission could, like any given field of military medicine, look to focus on the skills and expertise they deploy in the armed forces. As a result our review should evolve, with each issue acting as a reference to a given field when it comes to the latest developments in what makes a particular form of nursing different within the armed forces and no less a source of inspiration elsewhere. This issue is therefore a premiere, in homage to nursing professionals and in acknowledgement of Florence NIGHTINGALE’s service to military medicine.

Maj or General Prof. (ret.) Humbert BOISSEA UX, MD Chairman of the Scientific Council (Ad Interim) Editor-in-chief of the publication.

Florence NIGHTINGALE at the Therap ia Hosp ital

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International Review of the Armed Forces Medical Services

Revue Internationale des Services de Santé des Forces Armées

FLORENCE NIGHTINGALE (1820 - 1910)

Le 12 mai 2020 est le 200ème anniversaire de la naissance de Florence NIGHTINGALE. Il s’agit là d’une figure emblématique du monde infirmier et notamment au sein des armées. Il nous a ainsi semblé légitime que le CIMM lui rende hommage. Cette jeune femme de la haute société britannique a tôt considéré comme insuffisant le niveau de soins apporté aux blessés et malades. La fonction infirmière était en effet assurée jusque-là par des femmes d’origine modestes, sans formation et cantonnées dans des fonctions essentiellement ménagères. Ayant eu la vision de ce qu’il y avait à faire dans cet espace du soin laissé vacant par les médecins, elle s’est attachée à la mise en œuvre d’une véritable éducation pour ces personnels soignants infirmiers et à l’organisation fonctionnelle de leur cadre de travail. C’est à l’occasion de la guerre de Crimée que le service sanitaire de l’armée britannique a sollicité les services de Miss Florence NIGHTINGALE et qu’avec un petit groupe d’infirmières, elle s’est mise à l’ouvrage dans des conditions de grande précarité et marquées par une insalubrité pathogène. Hygiéniste précurseure mais aussi passionnée de mathématiques et de statistiques, elle s’est non seulement attachée à la mise en œuvre de mesures d'hygiène indispensables mais aussi au chiffrage des résultats obtenus afin de prouver la pertinence de son action. Véritable visionnaire d’une médecine par les preuves avant l’heure, elle a ainsi ouvert la voie à une nouvelle considération pour la profession d’infirmière. Celle-ci s’est dès lors imposée comme incontournable pour promouvoir, par la qualité des soins, une baisse de la mortalité hospitalière. Pour pouvoir soutenir cette exigence d’excellence des soins auxquels ont droit les soldats, Florence Nothingale s’est acharnée durant sa vie entière à concevoir pour les infirmières un parcours de formation exigeant et de haut niveau technique. C’est ainsi que le métier infirmier est aujourd’hui reconnu, quoique sans doute encore insuffisamment au regard de ce qu’apportent ces soignants assurément les plus proches repères des blessés et les malades. C’est également une profession qui a encore de vastes horizons à conquérir que ce soit dans le domaine technique du soin mais aussi pour ce qui concerne l’organisation et le fonctionnement des dispositifs nécessaire pour le promouvoir. Désormais sur tous les terrains d’opération, dans les formations sanitaires de tous niveaux, les personnels infirmiers effectuent un travail aussi extraordinaire qu’irremplaçable et ce n’est pas l’actualité de la lutte contre la Covid-19 qui peut le contredire ! Si le champ de la guerre a permis de révéler l’action de Florence NIGHTINGALE, il reste toujours un terrain d'innovation à la hauteur de ce que le génie humain invente d’armes vulnérantes. Le Comité International de Médecine Militaire donne une place à tous les professionnels qui à côté des médecins contribuent aux soins aux malades et aux blessés. C’est notamment le cas du métier infirmier. Ainsi, pour permett re à ces professionnels d’échanger sur les aspects spécifiques à leur exercice au sein des armées, à ses évolutions et innovations, ont été créées des commissions techniques qui dans l’esprit même du CIMM permettent de mettre en lumière l’action de chacun dans un esprit de transversalité et de coopération constructive. La commission technique “infirmiers et paramédicaux” du CIMM est animée par la Gp Cne Diane LAMB. A l’occasion de l’anniversaire de la naissance de la “demoiselle à la lampe”, il a été décidé de mettre en lumière l’activité de la profession infirmière en réunissant un certain nombre d’articles qui témoignent de la pertinence du chemin ouvert par Florence NIGHTINGALE. Di Lamb a coordonné ce dossier spécial de la Revue Internationale des Services de Santé des Forces Armées avec détermination et professionnalisme. Elle mérite d’en être remerciée.

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Ce dossier est composé de cinq articles. Trois d’entre eux rapportent ce qu’est l’héritage NIGHTINGALE pour le Service de santé britannique contemporain mais aussi pour 2 autres, indiens et canadiens. Chacun d’entre eux permet de montrer le haut niveau scientifique et technique atteint par ces professionnels dont la formation est désormais universitaire et qui comme Florence NIGHTINGALE en a indiqué la voie, sont désormais en mesure de déployer une recherche spécifique et d’en rendre compte. Il nous a semblé qu’au sein du CIMM, l’ensemble des commissions techniques pouvaient ainsi, comme tout domaine spécifique à la médecine militaire, s’attacher à mettre en lumière le domaine de compétence qu’elles déploient dans les armées. Cela doit ainsi amener notre revue à évoluer en ce sens, chaque numéro devenant dès lors référent, pour un domaine donné, quant à l’actualité de ce q ui fait la spécificité d’un mode d’exercice qui pour être singulier au sein des armées n’en est pas moins source d’inspiration bien au-delà. Ce numéro est donc une première, avec la légitime mise à l’honneur du personnel infirmier et la reconnaissance que l’on peut avoir pour ce que Florence NIGHTINGALE a apporté à la médecine militaire. Médecin Général Inspecteur Prof. (2s) Humbert BOISSEA UX Président du Conseil Scientifique (par Interim) Rédacteur en chef de la publication

Florence NIGHTINGALE receiving the Wounded at Scutari (by Jerry Barrett)

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Florence NIGHTINGALE. By A. BONEY THOMAS. India

Amala BONEY THOMAS Career Obj ective A Second Generation Army personnel and an Army Nurse, apply ing my nursing science knowledge and hospital experience is an asset to the Organisation and the Nursing Fraternity. Professional Experience - Commissioned on 05 Sept 1997. - Working as a Paediatric Matron in various Command and Peripheral Hospital and has been a key person in reviving many paediatric children for the last 23 years. A wards - General Officer Commanding In chief, Eastern Command, India, Commendation in 2014. Education 1. GNM – School of Nursing Command Hospital, Central Command, Lucknow, India. 2. Post Basic B.Sc (N) – College of Nursing, Armed Forces Medical College, Pune, India. 3. Post Graduate Diploma in Medico Legal Systems, Symbiosis Institute, Pune, India. 4. Post Certificate Diploma in Paediatric Nursing, JJ Hospital, Mumbai, India.

RESUME Florence NIGHTINGALE Florence NIGHTINGALE, est un guide et une source d’inspiration pour toutes les infirmières de ce monde. Florence Nightingale est un modèle à suivre par des millions de personnes tant pour sa capacité à la fois de prévoyance et d’analyse, que pour son dévouement et sa persévérance et les qualités et valeurs qu’elle défendait. L’analyse et les solutions pratiques offertes au monde entier à travers ses expériences dans la guerre de Crimée sont un atout et une ligne directrice, non seulement pour la sphère médicale, mais aussi pour la communauté des infirmières. Sa plus grande contribution pour les infirmiers est de leur avoir transmis le respect de leur profession, et d’avoir transformé l’art infirmier afin d’en faire une carrière et une profession pour toutes les femmes.

KEYWORDS: Florence NIGHTINGALE, Lady with the lamp, Crimean War, Nursing profession, Hygiene and sanitation, Medical care, St. Thomas's Hospital, London. Linda Richards. MOTS -CLÉS : Florence NIGHTINGALE, La Dame à la Lampe, La Guerre de Crimée, La profession d’infirmière, Hygiène et assainissement, Soins médicaux, Hôpital St-Thomas, Londres. Linda Richards.

Nursing, as a profession has undergone constant evolution since the early nineteenth century, having countered complex social, gender and quality education issues. This profession has thus been structured in order to allow nurses to provide the best quality care. One Woman, whose spirit of dedication, sense of conviction combined

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Correspondence: Lieutenant Colonel Amala BONEY THOMAS Paediatric Matron, 92 Base Hospital, C/O 56 APO, Mobile: +91.900.319.0246. E-mail: amalaboneythomas@yahoo.com

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with a profound vision has changed the way Nursing is viewed today and is seriously taken as a profession. This woman, who has become a mentor and guiding light to millions of nurses across the modern world, is Florence Nightingale, “The Lady with the Lamp.”

and poor standard of work of the past female nurses. It is the Battle of Alma that forced the War office to have a re-think on the rehiring of female nurses, because, the British media and their citizens were in an uproar, having known about pathetic state of health care meted out to the ill and injured soldiers, who were not only deprived of the basic medical attention as the hospitals were severely understaffed, but also suffered the unhygienic and inhumane conditions.

She was born the 12 May 1820 into a family with wealth, luxury and power but she dedicated her whole life to serve humanity. Her committed effort to ensure that nursing is a very essential component of health care and incorporate its education as a mainstream academic career has made the nursing profession develop on the solid foundation in modern healthcare worldwide. The strong foundational principles in nursing and the development of the nursing profession as a structured and organised institution was laid by Florence Nightingale, with the experience she obtained from the sick and injured during the Crimean war. Being an able administrator, a good educator based on values and principles and an untiring researcher, Nightingale laid the foundation of nursing practice on evidencebased practice.

The Secretary of War, Sidney Herbert in 1854, wrote to Nightingale, to organize a corps of nurses to give nursing care to the sick and wounded soldiers in the Crimea. Nightingale was more than pleased to venture and fulfil her dreams. She, along with a team of 34 nurses, set sail for Crimea within a few days. On arrival at Scutari in November, she set out to organise the hospitals, its hygiene and sanitation, to improve supplies and quality of food, beds and blankets.

FLORENCE NIGHTINGALE'S INTERVENTION DURING THE CRIMEAN WAR

NURSING BEFORE NIGHTINGALE

The Crimean war was a turning point in the life of Florence Nightingale. Even though they had been apprised of the pathetic conditions there, Nightingale and her nurses came in terms with reality when they arrived at Scutari, the British base hospital in Constantinople.

The nursing profession can be traced over antiquity. The wheels of change have slowly but surely evolved nursing from a care-givers role to one of professionalism which is dynamic in nature, upgrading constantly in terms of professional knowledge, working environment, approach to new diseases and modern technology. In the ancient and medieval periods, there were no professional or career based nurses. Even during wars, the physicians who tended to the wounded were assisted by soldiers, who had no real knowledge of medicine or healthcare. Often, Religious or people who were supposed to have healing powers were looked up to for treatment and medical care. They offered crude and no holistic treatment and medical care and they were like nomads moving from one place to another based on the requirement and the times. However, as Empires became stable, the concept of hospitals started to take shape and practice of medicine and employing care-givers began to get systemised. With the Protestant Reformation of the 17th Century, a change has begun in medical practices paving the way for more rational nursing practices. But for almost two centuries, nursing care was entrusted to nuns and monks.

The hospital was set on top of a large cesspool, which had contaminated the water and the hospital building itself. The stench of the dying patients, smell of urine and faeces, stretchers strewn through the halls, infested with rats and bugs welcomed them everywhere. Even the most basic supplies of bandages and soap was so scarce and the number of ill and wounded steadily increased. The water was rationed. It was evident that the soldiers were dying from infectious diseases like typhoid and cholera rather than from injuries incurred in battle. Nightingale quickly began to set things right. The least injured patients were ordered to scrub clean the hospital from ceiling to floor. She herself spent every minute taking care of the soldiers. As most of the military hospitals were located in Scutari, the sick and wounded were transferred there. With the rapid increase in the number of sick and wounded, it was a challenge for her to maintain the standards of hygiene and sanitation within and outside the hospitals. She set an example by providing personal care to the ill and wounded soldiers and improved their psychological state of mind. Her traits of leadership were beginning to show results and the hospitals had healthier environments. She insisted on providing clean and hygienic medical care, healthy and nutritious food and comfort to the ill and wounded soldiers. She would take extra efforts to attend to the

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The Conflicts brewing between Russia and Turkey led to the declaration of a full-fledged war in 1853 for control of the Ottoman Empire. Crimea was the epicentre of the war and is located on the shore of the Black Sea. Britain had sent thousands of British soldiers to the Black Sea, but the supplies were insufficient to cater to the troops who were dispatched to Crimea. Within one year, in 1854, about 18,000 soldiers had been admitted into military hospitals, which did not have any female nurses. The War Office had indeed stopped hiring nurses keeping in mind unprofessionalism

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Correspondence: Lieutenant Colonel Amala BONEY THOMAS Paediatric Matron, 92 Base Hospiptal, C/O 56 APO, Mobile: +91.900.319.0246. E-mail: amalaboneythomas@yahoo.com

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needs of every sick and wounded and would often help them to write letters to their family so that they would remain psychologically healthy and emotionally connected. It was a step in promoting the well-being of soldiers.

zones was one of her great successes. Her experience during the Crimean war made her determined that the medical mistakes of the two-year long war should never be repeated. Using her good-will, she communicated the need for medical reforms using statistical charts which showed that more men had died from disease than from their wounds. She never hid the facts and expressed what she felt. She was instrumental in initiating a Royal Commission into the health of the army which eventually led to a large number of reforms and improvements which saved the lives of many.

The soldiers in Crimean who were under her care initially named her the “Lady with the lamp” or “The Angel of the Crimea.” because of the compassion and comforting sight of her carrying around a lamp in the night to check on the well-being of the sick and wounded, and this title always remained with her as a token of love and appreciation.

Florence Nightingale expressed her views that the rising high deaths in The British army in India was due to contaminated water, bad drainage, overcrowding and poor ventilation. She concluded that the health of the army and the people of India were intrinsically intertwined and campaigned to improve the living and sanitation conditions of the country as a whole.

The Crimean War exposed her to the pathetic standards of hygiene in the military hospitals during the war. She tirelessly worked to bring down the death rate of soldiers being treated in Military hospitals by strictly maintaining standards of cleanliness and sanitation in the hospitals and surrounding areas. In her book Notes on Hospitals* She explains how this could be achieved by increasing ventilation, adding more windows, improving and covering drainage, and increasing space between beds. Her dedication, vision and hard work reduced the hospital’s death rate by two-thirds.

In 1860, The Nightingale Training School was established with the donations that she received in the Nightingale Fund. Its reputation and the Standards of Nurses which it produced, soon spread and Nightingale nurses were requested to start new nursing schools all over the world, which included Australia, America and Africa.

In addition to improving and standardising the sanitary conditions of the hospital, she identified and implemented patient services that helped to improve the quality of their hospital stay by creating a kitchen for the invalids which catered for appealing and nutritious food for patients. She also set up a laundry for patients as wearing clean linen would affect the very psyche of a patient, a library and a classroom for intellectual stimulation and entertainment of the patients in the hospital.

Often, despite being confined to her sick bed, by what we now believe was a bacterial infection known as brucellosis, Florence Nightingale continued as a driving force and mentor. She wrote more than 13000 letters to promote her campaign. Her meetings with Queen Victoria on many occasions had a ripple effect and both exchanged correspondences on nursing care for over thirty years***. In 1883, Florence Nightingale was honoured with the award of The Royal Red Cross. In 1907 she was the first woman to receive Britain’s highest civilian decoration, The Order of Merit.

Her observations and experience in the Crimea made Nightingale write Notes on Matters Affecting the Health, Efficiency and Hospital Administration of the British Army. It was an 830-page report** which analysed her first hand experience and proposed reforms for other military hospitals which operated under pathetic conditions. This book influenced and resulted in a total restructuring of the War Office’s administrative department, which led to the establishment of a Royal Commission for the Health of the Army in 1857.

INFLUENCE OF FLORENCE NIGHTINGALE ON THE RECOGNITION OF THE NURSING PROFESSION Although nursing, in its crudest form existed before, Nightingale essentially established and gave credence to the profession. Nurses earlier considered their jobs to be of low-status, and had no professional training but acquired through experience. Her efforts made nursing into a respectable profession by raising the standards and also incorporating education and thrusting responsibilities into the job. Professional education of nurses made them respected and appreciated. Nightingale was instrumental in improving the standards and conditions of hospitals which still has a great influence in their modern design.

THE BASES OF A REFORM OF NURSING In 1856, after the Crimean conflict, she returned to her maternal home which was at Lea Hurst. She was given a hero’s welcome, which she did her best to avoid. The Queen rewarded Nightingale’s work by presenting her with an engraved brooch that came to be known as the “Nightingale Jewel” and granted her a prize of $250,000 from the British government. Donations poured in to the Nightingale Fund. The money that was collected, enabled Florence to continue and implement her reform of nursing in the civil hospitals of Britain after the war.

a) A rigorous education of nurses and the foundations of solid knowledge

The inescapable need for the introduction of female nurses to the military hospitals and their role in war

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The experience and efforts during Crimean war greatly influenced her to establish nursing as a profession and

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the need for education of nurses, and this influenced nursing education to a great extent. “Nightingale Nurse's Training School'', at St. Thomas's Hospital, London, was the first training Institute for Nurses established in 1860. The training was based on two principles. First being, that the nurses should have practical training in hospitals specially organized for the purpose, and secondly that they should live in a home fit to form a moral and disciplined life.

Her strong advocacy in developing standards for nursing care is reflected by the fact that, if a staff member refuses to work to the expectations of her standards, it would result in her dismissal, which was the application of administrative standards of care. This is clearly demonstrated in her report to the Governors (May 15, 1854), where she wrote, “I have changed one housemaid on account of her love of dirt and inexperience, and one nurse, on account of her love of Opium and intimidation.”

The foundation of this school set the transformation of nursing from its disreputable past into a responsible and respectable professional career for women. She herself interviewed every candidate and the candidates were selected based on merit. Florence Nightingale believed that every woman at one time or another would be a nurse, in the world. According to her, health is maintained through the prevention of disease. Nightingale said, “Badly constructed houses do for the healthy what badly constructed hospitals do for the sick.” Her experience taught her, that, one could work even on the sick bed, if only one had the will power and determination. Nightingale spent an enormous amount of time and thought as to the ways and means of really establishing the foundation of public health work in a country. Her inspiration on nurses and hospital became the symbol of compassionate health care.

c) The need for nursing research

b) A specific and autonomous field of action Her tone differed from contemporary writers in form, tone, terminology, and style and is considered the First Nursing Theorist. An able nursing administrator, her efforts to improve the quality of the working conditions for effective nursing care is very much applicable even today. Her practice of attempts in coordination with multidisciplinary members, though her exposure to the military officials at Scutari expected her to be obedient and take orders, has in fact thrown light into the autonomy in nursing practice today. She understood and experienced that the availability of adequate supplies for care will result in the efficiency of a hospital. Nursing earlier was confined to a position subservient to physicians. Nightingale wanted to replace autonomy to nurses with advocacy in the working place. Normally as a novice nurse, one is expected to be obedient and submissive throughout the career. Nightingale's effort was implicit to have advocacy in nursing to transform the profession for an effective outcome, which is now considered as a major component in practice of nursing so that nurses advocate for the patients and themselves. During the Crimean war, she asserted to have adequate supplies when it was not provided. It was her demonstration of exceptional skills of advocacy which gave birth to genuine intent of making nursing care as a career and profession.

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Nightingale's advocacy is very much seen in her work in Scutari and Crimea. She herself selected the nurses to work along with her and it was based on interest, commitment and willingness to serve for long duration without questions.

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Florence Nightingale is said to be the first nurse who was also a researcher. In earlier days, nursing was based on trial and error and Nightingale's contribution toward research was reflected by bringing down the mortality and morbidity among the sick and wounded in Crimean war. Her landmark study of maternal mortality from puerperal fever is a classic example of evidence-based decision making in health care. Her systematic approach and motivation to reform the existing practices in health based on the statistics, she collected, was her passion toward the profession, and she undertook the task of graphically presenting the data to convince civil servants to reform public laws. However, her statistical reports were not accepted by statisticians of those days. Jocelyn Keith described her proposal as “the first model for the systematic collection of hospital data using a uniform classification of diseases and operations that was to form the basis of the ICD code used today.” Her contribution to nursing research was unique, to the extent, she analysed the situation and environment in her workplace, systematically recorded data, and based on her analysis, she implemented the appropriate nursing intervention. It was more of practical research that is reflected in her efforts to improve environmental conditions resulting in promotion of health of the clients. The evidence that she collected helped her to incorporate and develop the theoretical frameworks in nursing. Such practices resulted in a statement of standards for nursing care which is a benchmark to assess the delivery of nursing care. Although controversies surrounded Florence Nightingale, the principles of cleanliness, sanitation and nutrition are the guiding principles of nursing practice till this day. Her vision and hard work drove her to improve nursing care which in due course led to her framing policies to improve the working conditions thereby leading to effective and affordable care by the hospitals. The efforts to reform nursing education and improve health care provides strong roots to the philosophy of nursing care. Nightingale had written a series of letters on the experiences gained in the Crimean war and this paved the way for the documentation of the development of nursing and health care.

STRENGTHS OF FLORENCE NIGHTINGALE & IMPACT ON TODAY’S ENVIRONMENT Nursing has grown tremendously as a profession and is more structured. Submissiveness has been replaced by autonomy. The present nursing scenario is shaped by

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which is now the norm of all hospitals across the world. Nightingale’s legacy has elevated the status of nursing as a profession and her concept of an ‘integrated health care’, is adopted in modern nursing and involves treating the patient on the whole and also specialising in various facts of nursing medicine.

Nightingale's contribution in the field of education, research, practice, and administration. Her significant contributions towards modern nursing includes advocacy for egalitarian human rights and leadership roles in centres of medical care. Her ideas and techniques and managerial skills are shaping the nursing of the 21st century.

ESSENTIAL CONTRIBUTIONS TO NURSING

The books written by her on the essentials for nursing practice are the guiding principles even today. Her emphasis on the procedure on sound practice has helped the next person continue even if the other person is not available. She believed that transparency should not be compromised and stressed on competent, effective practice. She was systematic and was convinced that any hospital can be well managed by team work and by being more organised. Nightingale's contribution to advocacy in nursing is immense. She authored numerous official letters to the government to highlight the scope of improvement in health care systems and procedures. She was appreciated by the Queen of England for her tremendous contribution, dedication and foresight in nursing, and utilized every available opportunity for advocacy of the nursing profession to the highest level either socially or politically and this set the tone for modern day advocacy in nursing. Disparity and discrimination in the British society was loathed by Nightingale and dispelled the thinking and attitude of higher authorities that women could do nothing or are inferior to men in a working environment, although she was very cordial and cooperated with health care teams who genuinely wanted to make nursing a profession. Her skills and values have become the founding principles of modern day nursing. She vigorously demonstrated advocacy as a superintendent of the hospital though it was not practiced and unthinkable for women who ventured into the nursing profession.

In the medieval times, hospitals were not guaranteed places for healing safe because the environs did not permit it to be so. However, after the Crimean war, things changed. The first-hand experience, reflecting and taking necessary steps to overcome the shortcomings proved to bring down the death rates. She identified key issues and found simple and effective solutions to those issues that hampered effective and successful health care. She was convinced that a clean and ideal environment could reduce the spread of infections. The hospital environment improved systematically and dramatically after implementing these interventions. Nightingale’s attention to every detail was exemplary which included the conditions within and outside the hospital and the methods of treatment and causes of death. She had great analytical skills and her contribution to Military nursing and war-time nursing care has shaped the Nursing Corps across all armies of the world. As a token of appreciation, The British government gave her $250,000, a huge amount at that time, which she used to fulfil her dream of establishing her own hospital and it included a training school for nurses. Her book, in 1859, described her experiences in the Crimean War and the nursing practices that she evolved and developed on the field ensured that her legacy lives forever. Her principles, values and ideas laid the foundation of modern nursing, and the simple techniques she pioneered are widely practiced even today. She was also elected as the first female member of The Royal Statistical Society. This still wasn't enough for her and she continued her work. When a French chemist first launched the idea that microbes could be the reason for infections, Nightingale became the vocal leader of the antiseptic movement. Hygiene was the difference between life and death. Even though she wasn't healthy, she never gave up on her struggles. In the 1890’s she attacked the medical scientist for transforming “Germ Theory” into an excuse for poor hygiene. She knew that preventing infections is a Titanic struggle and the authorities would rather minimise the impact of hygiene. She dedicated the rest of her life to this cause, and, by doing so, changed and saved the life of countless thousands.

Florence Nightingale began the process of reformation in nursing care, and we are likely to see major inroads in the nursing profession in the 21st century. The main pillars of nursing care which are compassion, dedication, professional knowledge and nursing values are now being compromised in the world of medicine and commercial hospital environment. She made a fine blend of Arts and science and cooperated to promote and offer the finest of health and medicinal care to humanity. Nightingale's influence on the medical profession in general and nursing care in specific, can be experienced across the globe. Undoubtedly, Nightingale paved the way for Nursing to be a career option for millions of women across continents and created self respect and dignity for women who chose nursing as a profession. Florence Nightingale’s firm belief that the environment plays a major part in health care has found credence in modern hospitals and societies. Good hygiene and sanitation reduces infections and sickness thereby reducing death rates was her mantra for healthy living. Her visits to patients during the night rounds to monitor their health has revolutionised the concept of medical care and given rise to the concept of 24 hour patient care,

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AN INFLUENCE THAT HAS CROSSED BORDERS When Nightingale became ill and later bedridden, her zeal and dedication towards nursing kept her going. The impact of Nightingale’s work was felt and recognised globally. She was the undisputed icon of war-time treatment and nursing care. Her advice to Americans during the Civil War saved many lives. Professionals in

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the field of Medicine valued her thoughts on army hospital management and casualty reduction. The United States Sanitary Commission, was established under her guidance and was tasked to attend wounded soldiers.

Her greatest contribution to nursing is that she had given Nurses the self respect and shaped nursing to be a career and profession for all women. BIBLIOGRAPHICAL REFERENCES

Medical officers also consulted and took her advice during the Franco-Prussian War. Many nurses trained by her in her methodologies, became pillars of the Nursing profession in their own right. One of most accomplished Nurse of the Nightingale’s training was Linda Richards, the first trained nurse of the United States of America, who would go on to develop the training programs for Nurses in the U.S. and Japan, thereby spreading Nightingale’s methods of health and nursing care across Continents. At the age of 90, on August 15, 1910 she breathed her last, leaving her inspiration for the nursing profession for generations to come…

COATES T. Florence Nightingale and the Crimea: 185455: Papers from the archive of the British Parliament. Argonaut Paper Book 2018.

NIGHTINGALE F. Notes on Hospitals Scholar's Choice. 2015.

NIGHTINGALE F. Notes on Nursing: What It Is and What It Is Not. Dover Publications Inc. 1969?

NIGHTHINGAL F. Notes on matters affecting the health, efficiency, and hospital administration of the British Army: founded chiefly on the experience of the late war, 1858.

*** NIGHTINGALE F. Florence Nightingale to her Nurses: A Selection from Miss Nightingale's Addresses to Probationers and Nurses of the Nightingale School at St. Thomas's Hospital. Book Jungle; 2007.

ABSTRACT Florence Nightingale, is a guiding lig ht and an inspiration to all nurses across the modern world. Her foresight and analytical skills combined with the dedication and perseverance is a classic example of a role model, whom millions would like to hold close to their hearts and imbibe the qualities and values that she stood for. Her analysis and practical solutions that she offered to the world through her experiences in the Crimean war is an asset and a guiding light, not only for the medical fraternity but also for the nursing community is invaluable.

SHETTY AP. Florence Nightingale; The queen of nurses. Archives of Medicine & Health Sciences, Mangalore. 2016.

HARMELINK B. Florence Nightingale, Founder of Modern Nursing, Franklin Watts. 1969.

HAMILTON LM, NORTH W. Florence Nightingale: A Life Inspired. CreateSpace Independent Publishing Platform. 2015.

The Calling of Nursing by Christoffer H Grundmann, VALPARAISO University, 9 October 2009.

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From Scutari to South Sudan: Lessons in Preparedness. By D. LAMB∑ and RJ. STONE∏. United Kingdom

Di LAMB Group Captain Di LAMB qualified as a Registered General Nurse in 1988 and specialised in critical care before joining the Royal Air Force in 1995. She combined her nursing experience with aeromedical evacuation as a member of the RAF Critical Care Air Support Teams. Thereafter, she was responsible for transfer training for critically ill adults at the John Radcliffe Hospital in Oxford and it was at Oxford Brookes University where she commenced her academic career. In 2004, she was awarded a BSc with first class honours. This was followed with a full-time MA in Research Methodology at Nottingham University in 2005. Her passion for aeromedical evacuation and human factors prompted her desire to further her academic studies to a PhD. In May 2013 she was posted to the Royal Centre of Defence Medicine (Research & Academia) as a Senior Research Fellow. She has continuing her interest in aeromedical transfer by undertaking studies to investigate the psychosocial effects of undertaking such duties on deployed operations and how to improve personnel’s resilience by enhancing their preparatory training. In July 2015 she was appointed as the Defence Professor of Nursing. She is married and has a keen interest in photography, road cycling and running.

RESUME De Scutari au Soudan du Sud : leçons pour une préparation En 1854, Florence Nightingale s 'est déployée, avec un contingent de 38 infirmières, pour soigner les soldats blessés sur le front de Crimée. À leur arrivée à l'hôpital mis en place par l'armée britannique à Scutari, ces infirmières ont trouvé un dispositif hospitalier très sale et insalubre exposant les patients vulnérables aux infections et autres maladies. Ces infirmières n'étaient pas préparées à l'environnement sordide dans lequel elles se sont trouvées plongées, au nombre de victimes qu’elles ont eu à prendre en charge et à la gravité de leurs blessures. Les leçons tirées de cette expérience constituent un héritage qui a conduit à rendre nécessaire la mise en oeuvre d’un apprentissage continu, indispensable l’amélioration de la qualité des soins que mettent en oeuvre les infirmières. Une formation qui permette une meilleure préparation, une meilleure adaptation à la situation et à l'environnement rencontrés lors du déploiement est la clé pour que les personnels des Services médicaux de la Défense puissent faire face aux défis des opérations militaires contemporaines. Le parcours des infirmiers de Scutari j usqu’au Soudan du Sud a permis de mettre en oeuvre la technologie susceptible d'améliorer la préparation et la résilience psychologique des professionnels de la santé. Cet article décrit un proj et de simulation de la réalité permettant d’imiter avec précision l'environnement clinique de déploiement et permettant ainsi de se préparer aux réalités d’une mise en oeuvre réelle. Cela doit permettre de faire face avec plus de confiance et compétence aux défis rencontrés par le dispositif médical militaire déployé.

KEYWORDS: Mixed Reality Training, Military, Operational Preparedness, Medical Emergency Response Team, Psychological Resilience. MOTS -CLÉS : Formation en simulation, Militaire, Médical, Préparation opérationnelle.

for the number of casualties, the severity of their injuries, the spectrum of clinical presentations, the poor sanitary conditions in which they would deliver care and the hostility they would face from the Medical

INTRODUCTION Volunteer nurses, who deployed to Scutari during the Crimean War (1854-1856), were completely unprepared

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Officers for them even being there1. There was no alternative but to cope by learning from the experience they were gaining as the war progressed. They had no evidence-base to support their practice, which is an unthinkable approach to nursing care in society today. Indeed, the lessons learned by Florence Nightingale catalysed the evolution of nursing as a profession.

associated stress of an initial deployment as part of a medical team and provide reassurance to individuals that they would be able to cope with the challenges of their role. Such an approach also honours Florence Nightingale’s unbridled ambition to reform practice by instilling the need for a scientific approach, not only to clinical practice, but to personnel’s preparedness for the environment in which it will be delivered4.

It is essential that healthcare professionals in the 21st century are effectively prepared for their role if they are to deliver the prerequisite high standard of care. Preparedness is the key component of a comprehensive package of pre-deployment training delivered to UK Defence Medical Service’s (DMS) personnel2, 3. The training of nurses in Florence’s era prioritised character over skills4. However, the evolution of the nursing profession since that time demands a multifaceted approach to contemporary operations, such as the recent United Nations humanitarian mission in South Sudan. The latter required a high level of clinical competence as well as situational awareness that focused on the human factors required to work effectively as a confident member of a multidisciplinary team. Effective team work incorporates the need for members with different characters to find a bond that brings them together in support of a shared goal5.

A collaborative project, with the University of Birmingham’s Human Interface Technologies Team, was commissioned by the DMS in 2016 to establish if virtual/augmented reality technology (VR/AR) could be applied to the training need described above. A Medical Emergency Response Team (MERT) was selected as an example of a small team that is required to make accurate and timely critical decisions to optimise patient outcomes. This airborne medical capability would deploy in conflict situations to deliver the forward aeromedical evacuation of casualties from point of wounding to Role 2/3 care. A typical MERT, in support of operations in Afghanistan, comprised an emergency care nurse, two paramedics and a consultant clinician; all qualified and experienced in delivering prehospital emergency care10. Their provision of high quality, life-saving care in austere and dynamic working environments, demands that this small team works cohesively. A highly efficient MERT has been described by onlookers as one that performs as if by well-rehearsed choreography, each critical decision made quickly with no need for words, just the occasional knowing glance8. Everyone within such a team must be competent and confident, immediately responsive to changes in the patient’s clinical condition and that of the evolving military situation, with each activity complimenting that of another.

Florence defined the role of a nurse as putting “the patient in the best condition for nature to act upon him”6. To achieve this, almost two centuries later, the DMS has invested in technology so that nurses, and other members of the multidisciplinary team, can repeatedly rehearse their role within the safety of a “Mixed Reality” (MR)7 training simulator that closely replicates the complex military healthcare environment into which they will deploy. This research and development project aims to mimic reality as closely as possible, such that personnel will perceive they are experiencing the deployment for real.

PROOF OF CONCEPT TRAINING REQUIREMENTS AND DEVELOPMENT

BACKGROUND

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Current MERT Training. The extant MERT training platform (Figure 1) is a basic static replica of a CH-47 Chinook helicopter, which is expensive and affords the rehearsal of only low fidelity patient scenarios. For personnel to rehearse their individual and team skills whilst airborne, various operational aircraft are utilised. However, competing demands from other military tasks means there are no guarantees of aircraft being

Enduring UK military operations in Iraq and Afghanistan (2003-2014) witnessed DMS personnel deploying regularly and repeatedly. This bred a familiarity with the deployed environment that provided practitioners with a developed contextual understanding of the available medical facilities and support infrastructure, number of casualties and the types of injuries they were likely to encounter. This accumulated experience enabled them to develop a degree of confidence in their ability to cope, the latter having been declared, in a number of studies, as a significant stressor prior to deploying for the first time3, 8-9. However, more recently military deployments have comprised a smaller medical footprint, which results in a reduced number of personnel being routinely exposed to real operational environments. The DMS’ corporate memory is further diluted over time as personnel retire. Therefore, there was a need for an innovative solution to ensure that preparedness training for contemporary operations would generate competent and confident practitioners. It would be required to ameliorate the

International Review of the Armed Forces Medical Services

∑ Defence Professor of Nursing. ∏ Professor of XR & Telepresence, Human Interface Technologies Team Extreme Robotics Laboratory College of Engineering & Physical Sciences University of Birmingham Edgbaston Birmingham, West Midlands B15 2TT Correspondence: Group Captain Di LAMB Defence Professor of Nursing Academic Department of Military Nursing Royal Centre for Defence Medicine Medical Directorate Birmingham Research Park Vincent Drive Edgbaston Birmingham, West Midlands B15 2SQ

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Figure 1: Static Chinook p latf orm used f or extant MERT training.

by the camera and VR computing system to generate a detailed 3D representation of the MERT environment. The latter includes the rear cabin of a Chinook as illustrated in Figure 2 (other virtual platforms currently include a Royal Marines Hovercraft, Landing Craft and Army Mastiff). Where elements of the external virtual world can be seen, through the side windows and rear ramp of the Chinook, for example, a technique called “billboarding” has been employed. This supports the projection of in-flight videos (or at-sea videos in the case of the Royal Marines platforms) onto a virtual “screen” located at a fixed distance from the cabin. This, together with the sound effects recorded from real operational platforms, creates a strong illusion of movement for the trainees. Figure 2: Mixed Reality rep resentation of a Chinook helicop ter, illustrating the “blend ” of the real casualty mannequin, Bergens and medical equipment with the virtual aircraf t interior.

available when required. Therefore, a solution was needed that would provide an inexpensive alternative to extant training modalities. It would need to be easily transported and reconfigured to represent a range of operational environments and casualty recovery platforms, thus promoting the possibility of team training being reinforced in the deployed environment 10 . Initial Developmental Design Considerations. The concept of an MR trainer was reached after a number of evolutionary steps rejected the use of a purely virtual environment. It was concluded that a VR-only solution would fail to deliver a credible sense of self within the virtual Chinook environment for a variety of reasons. The primary reason was related to limitations in current-generation haptic feedback (touch and force) technologies. None of the wearable systems available at the time, and indeed for the foreseeable future, are capable of delivering believable and reliable haptic sensations to the human user. Earlier human factors experiences from various Defence training projects 11-12, coupled with more recent observations of DMS trainer and trainee stakeholders, were vital in informing the early MR system design. Given the limitations of haptics technologies, these studies confirmed that it would be essential for individuals to see and manually interact with real, physical items of equipment and other objects deemed to be critical to MERT training. The latter included a synthetic casualty mannequin.

Animated Human Actors. To add further “believability” to the training scenarios, animated virtual characters (“avatars”) were developed, including, in the case of the Chinook scenario, pilot and co-pilot, two loadmasters (who also man the onboard weapons) and characters representing the Quick Reaction Force (QRF). The QRF comprises RAF Regiment personnel who disperse from the rear of the helicopter on landing to provide small arms cover. The simulated QRF then accompanies a second ground medical recovery team loading a casualty onboard the virtual Chinook (Figure 3). Figure 3: The avatars as they app ear within the Chinook MR scenario.

Therefore, the MR solution took the form of a portable enclosure, originally inflatable, but more recently of a modular hard-frame structure, designed to instil a feeling of “confinement” within a military platform for a small team of trainees. Covering the interior of the enclosure with blue material, and by modifying offthe-shelf VR headsets with “pass-through” cameras, the design team were able to exploit chroma key techniques similar to those used in broadcast and film media. In essence, anything that is not blue within the enclosure, including a SIMBODIE™ casualty mannequin and stretcher, critical items of medical equipment, Bergens and other medical “containers”, such as Piggot Pouches, appear in the headset as they do in real life. Users can reach out, acquire and manipulate these items using their real hands. Anything blue is processed

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Instructor Console Development. Another important feature of the simulator, and one that is not often considered in Defence sector VR, AR or MR projects, is the development of a comprehensive and user-friendly instructor’s console (Figure 4). The console design

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allows the instructor to record the activities of the trainees in both real and virtual space, via small cameras mounted within the enclosure and by reproducing the trainees’ views from their headsets. The console also allows the instructor to pre-program, or elicit during a training session, a variety of distracting audio and visual events. These include the sounds of onboard M60 and Minigun weapon’s discharge, fuselage penetration effects caused by external small arms fire, and physiological changes displayed on a simulated patient monitoring device. The instructor can also change environmental conditions, such as night vision conditions to brown-out dust effects entering the Chinook cabin. Finally, the console allows the instructor to “trigger” the animation of the QRF personnel and the arrival onboard of the second ground casualty recovery team, described above. Therefore, each training scenario is unique and can be individually tailored to meet the needs of a particular group of trainees. Figure 4: The instructor console demonstrating various views f rom the cameras and equipment.

Interim Evaluation. In May 2018, a number of subject matter experts from the MERT training faculty and potential end-users were invited to a one-day usability workshop at the University of Birmingham. Participants were asked to interact with the SIMBODIE™ mannequin and with each other within the enclosure whilst wearing the cameramodified VR headsets (Figure 5). An example of the trainees’ views from their headsets is illustrated in Figure 6. This was done individually and then in pairs to determine if their hand-eye co-ordination was impaired thereby limiting their ability to perform tasks such as intubation. They were also asked to complete a simple survey to gauge their sense of ‘presence’ (i.e. if they felt adequately embedded within the simulated environment), their judgements of simulator ‘fidelity’ (i.e. if their experience of the MR felt adequately real) and their technology acceptance scores. Full details of this usability validation exercise are currently being compiled into a separate publication but all scores were judged to be more than satisfactory to continue development without the need for significant or costly modifications. Figure 5: Participants interacting with each other and the SIMBODIE™ mannequin within the MR enclosure.

Figure 6: Examp le views f rom the trainees ’headsets.

Recent Developments. Following feedback from the evaluation, a fourth dimension of sound has been added. This incorporated actual recordings of the Chinook rotors and engines sequenced to match the landing, in-transit and take-off elements of the aeromedical evacuation scenarios. Similarly, contextually relevant aircraft radio communications were also added, which had been another significant stressor reported by participants in a study to explore the psychosocial impact of MERT duties on deploying personnel8 . Indeed, the latter study informed many components of the simulator’s development; none more so than the need to decipher real recordings of radio communications. This was deemed a particular priority in light of the limited access to real flight experience prior to deployment. Effective communication is vital to achieve optimum team performance13-14 . However, aircraft communications require practice to understand what is being said, as messages can be interrupted by static, and to determine (from amongst the aircrew chatter) what is important to convey to the team and what information should be reserved for the post-mission debrief. Vital information such as casualty numbers and clinical updates are required for the team’s preparedness on landing. However, possible damage to the aircraft from incoming fire will serve only to detract the team’s focus from their imminent need for critical decision-making and clinical interventions. Therefore, MERT training scenarios are required to accommodate this essential component. Wider Applicability of the MR Trainer. As well as the virtual Chinook rear cabin environment, developed for this early part of the MERT MR project, it was also possible, by engaging with Royal Marines and Army stakeholders, to demonstrate the power of “instant change” with the simulator. By capturing digital still and video images, plus sounds, during short exposures to actual military platforms, it is possible, via the press of just a single function key, to change the virtual environment from the Chinook to a Royal Marines Landing Craft, or Hovercraft, and to a Mastiff land vehicle. This feature demonstrates the power of the MR techniques in enabling a wide variety of virtual MERT platforms to be developed in a short space of time, from ship-based casualty receiving areas to aircraft of opportunity, and from forward casualty receiving stations to small, fixedlocation field hospitals.

NEXT STEPS A programme of work to complete the project to an off-the-shelf product is about to commence. This will comprise key stakeholders and end-users designing a number of contextually relevant clinical scenarios that

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will generate an appropriate patient response to the trainee’s intervention. This interactivity will overcome the current limitation to simulation training that requires an instructor to provide verbal confirmation of the likely patient reaction to their clinical interventions. The latter is a significant barrier to a trainee’s ability to suspend their disbelief of a simulated scenario and fully engage as they would if it were real15. Expanding the multimedia databases for additional aeromedical platforms is another key development for the MERT MR training system. There is also a requirement to investigate the use of VR headset-integrated eye tracking devices, enabling instructors to assess trainees’ foci of attention during a training session. The instructor’s console will be used as a form of afteraction review for post-training session debriefs during which, amongst other things, the trainee’s attention ‘bubbles’ will be visible on the screen. This will then clearly illustrate particular distracting factors that potentially reduced their reaction times to a particular clinical event within the scenario. Once potential distractions are acknowledged by trainees, they can be discussed with the instructors and remediated within the safety of the simulated environment.

SUMMARY A significant lesson learned during contemporary military operations is that preparedness is key to assuring the optimal standard of care delivery. Personnel must not only be clinically competent to deploy in their designated healthcare roles; they must also have significant situational awareness of the environment in which they will be delivering care. This research and development project successfully achieved its proof of concept in the military healthcare environment but it also has endless applicability to the training needs of all organisational teams. Applying technology to solve training needs echoes Nightingale’s statement that, “Nursing is a progressive art such that to stand still is to have gone back”16 . To ignore the benefits that technology can add to the learning experience, and avoid keeping pace with its rapid development, would indeed be going backwards with regards to the quality of patient care.

ABSTRACT In 1854, Florence Nightingale deployed, with a contingent of 38 nurses, to care for soldiers injured in the Crimean War. On arrival at the British Army hospital in Scutari, the conditions that met them were filthy and unsanitary rendering patients vulnerable to infection and disease. Nurses were unprepared for the squalid environment in which they would deliver care, the sheer number of casualties or the severity of their injuries. Lessons learned during that time created a legacy of continual learning and quality improvement that is perpetuated in the nursing profession today. Training to be better prepared and more situationally aware of the deployed environment is key to Defence Medical Services’ personnel in facing the challenges of contemporary military operations. The nursing journey from Scutari to South Sudan

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has prompted an opportunity for technology to be exploited that might improve the preparedness and psychological resilience of healthcare professionals. This paper will describe a project exploring how Mixed Reality simulation can be applied to accurately mimic the deployed clinical environment, such that personnel will perceive they are experiencing the deployment for real. This will enable them to more confidently and competently face the challenges associated with the deployed military medical environment. REFERENCES 11. FEE, E. and GAROFALO, M.E. Florence Nightingale and the Crimean War. American Journal of Public Health, 2010; 100(9): 1591. 12. GIBSON, C., FLETCHER, T., CLAY, T. and GRIFFIT HS, A. (2016). Foreign medical teams in support of the Ebola outbreak: a UK military model of pre-deployment training and assurance. Journal of the Royal Army Medical Corps, 2016; 162: 163-168. 13. LAMB, D., JONES, N. and GIBSON, C. Measuring the preparedness of military medical personnel for short-notice operations. Occupational Medicine, 2017; 67: 211-216. 14. DHAR, A. Florence Nightingale and nursing in colonial India. Vidyasagar University Journal of History , 2018; 6: 96-104. 15. LAVELLE, M., REEDY, G.B., CROSS, S., JAYE, P., SIMPSON, T. and ANDERSON, J.E. An evidence based framework for the temporal observational analysis of teamwork in healthcare settings. Applied Ergonomics , 2020; 82: 102915; doi: 10.1016/j.apergo.2019.102915. 16. NIGHTINGALE, F. Notes on nursing: What it is and what it is not. London: Harrison and Sons, 1860; p 75. 17. STONE, R. (2019). Virtual, Augmented & Mixed Reality – Basic Definitions. https://www.linkedin.com/ pulse/virtuala ug me nt e d- m ix ed- rea lity - bas ic- d ef in it io ns - bo bstone/ .[Accessed on 31/03/2020]. 18. LAMB, D. and WITHNALL, R.D. Is there a cost to caring? A qualitative study to investigate the psychosocial effects of operational deployments on Medical Emergency Response Team (MERT) personnel. SG/ MD/ Nurs/201701853_02, 2017. 19. LAMB, D. Factors affecting the delivery of healthcare in a humanitarian operation in West Africa: A qualitative study. Applied Nursing Research, 2018; 40: 129-136. 10. STONE, R., GUEST, R., MAHONEY, P., LAMB, D. and GIBSON, C. A “mixed reality” simulator concept for future medical emergency response team training. Journal of the Royal Army Medical Corps, 2017; 163: 280-287. 11. STONE, R. and McDONAGH, S. Human-centred development and evaluation of a helicopter voice marshalling simulator. In Proceedings of the Interservice/ Industry Training, Simulation & Education Conference 2002 (I/ ITSEC; Orlando, Florida), 3-5 December. 12. STONE, R. and REES, J. Application of virtual reality to the development of naval weapons simulators. In Proceedings of the Interservice/Industry Training, Simulation & Education Conference 2002 (I/ITSEC; Orlando, Florida), 3-5 December.

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13. OWEN, C. Leadership, communication and teamwork in emergency management. In : Owen, C. (Ed.) Human factor challenges in emergency management: Enhancing individual and team performance in fire and emergency services. England, Surrey: Ashgate Publishing Ltd, 2014; pp 125-144: ISBN 978-1-4094-5306-2. 14. BALLANGRUD, R., HUSEBØ, S.E., AASE, K., AABERG, O.R., VIFLADT, A., BERG, G.V. and HALL-LORD, M.L. “Teamwork in hospitals”: a quasi-experimental study protocol apply ing a human factors approach. BMC Nursing, 2017; 16:34, doi: 10.1186/s12912-017-0229-z.

16. FLAHERTY, M.J. Rights and responsibilities of nurses as the basis for their contracts with society, with patients, and with colleagues. In : Carmi A., Schneider S. (eds) Nursing Law and Ethics. Berlin, Heidelberg: Springer Medicolegal Library, 1985; p 31. ISBN: 978-3-540-15253-8.

Abbreviations (by order of appearance) DMS: Defence Medical Services. MR: Mixed Reality. VR: Virtual Reality Technology. AR: Virtual Augmented Technology. MERT: Medical Emergency Response Team. QRF: Quick Reaction Force.

15. MUCKLER, V.C. Exploring suspension of disbelief during simulation-based learning. Clinical Simulation in Nursing, 2017; 13(1): 3-9, doi: 10.1016/j.ecns.2016.09.004.

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A RT ICLES

Development of a Bespoke Military Preceptorship Programme: From Lamp to Light. By RG. BEECH∑. United Kingdom

Robbie BEECH After joining the British Army in 1999, Warrant Officer 2 Robbie BEECH qualified as a Registered Nurse (Adult) in 2004 and specialised in Emergency Care. He has undertaken many training roles, both clinical and military educating personnel to ensure readiness for deployment to provide high quality care in kinetic and austere environments. Accompanying this, his passion for education is evident within his sub speciality of Chemical, Biological, Radiological and Nuclear Medicine, for which he is the British Defence Specialist Advisor within this subject. In 2011, he was an integral part of the team selected as the Best Education and Training Team, at the Military and Civilian Health Partnership Awards, for the development and delivery of clinical CBRN courses, both for UK forces and NATO Partners. His appetite for education pushed him to formalise this role by successfully completing a PGCE at Cumbria University in 2017. In April 2017, he was assigned to his current role at Joint Hospital Group (South), where he continued his interest in healthcare education by developing a Nursing Preceptorship Programme. This has enabled the transition from student to registered healthcare practitioner within the military. The programme was awarded the accolade of Best Preceptorship Progra mme at the Nursing Times Workforce Awards in 2019. He is married, enjoys cooking and plays drums in a pop band.

RESUME Développement d'un programme de préceptorat militaire sur mesure : de la lampe à la lumière Contexte : Le passage d’étudiant à praticien peut être une période particulièrement difficile, souvent vécue avec tension et inquiétude. Il est donc apparu nécessaire d’envisager un programme de soutien sous la forme d’un préceptorat permettant d’aider l’étudiant à passer cette étape. La mise en place d’une expérience de préceptorat sur mesure pour les militaires a donc été testée au Royaume-Uni dans un hôpital de Portsmouth. Obj ectifs : Evaluer l’avis des professionnels de la santé militaires concernant ce programme de préceptorat expérimenté au cours de sa première année de mise en œuvre. Méthodes : Deux groupes distincts ont suivi le programme durant 12 mois, à 6 mois d'intervalle. Au terme de chaque programme, un groupe de discussion a été constitué pour recueillir les réflexions et l’expérience des préceptés sur ce programme. Les deux groupes comprenaient des infirmières intégrées DMS (n = 26), des praticiens des services d'exploitation (n = 5) et des scientifiques biomédicaux (n = 3). Les données ont été étudiées par analyse thématique. Résultats : Quatre thèmes ont été identifiés; Durée du programme, validité du programme, avantages du programme et qualité du soutien des animateurs / pairs. Les deux groupes ont indiqué que la durée du programme de 12 mois était app rop riée pour permettre une mise en œuvre efficace de ce programme. La validité du programme a également été établie, les préceptés estimant qu'il améliorait leur connaissance des aspects cliniques et militaires de leur métier. Ce programme sur mesure a été l'occasion d'expériences qui ont permis de réduire l'écart théorie-pratique et donc de faciliter la transition d'étudiant à professionnel qualifié. Le soutien attentif de l'équipe de formation pratique a également facilité la formation de liens étroits entre pairs. Conclusions : La mise en œuvre de ce programme inclusif a été le moyen de mesurer la capacité des professionnels de santé militaires à réussir cette transition d'étudiant à professionnel avec l’aide d’un soutien académique adapté. Les résultats soulignent que comme moyen de développement pour les personnels militaires, le programme a été accueilli favorablement en ce qui concerne le soutien fourni à la fois clinique et intégratif en vue d’un exercice au sein du DMS.

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KEYWORDS: Preceptorship, Preceptee, Framework, Programme, Transition, Training, military Nursing, Defence Medical Services.

MOTS-CLÉS : Préceptorat, Précepté, Cadre, Programme, Transition, Formation, Soins infirmiers militaires, Service médical de la défense.

INTRODUCTION

completed. Therefore, in the Defence Medical Services (DMS) there was a need for a structured preceptorship programme to facilitate newly qualified health professionals achieving this transition, not only in their chosen career pathways but also their military roles and functions.

Florence Nightingale1 remarked that observing nursing practice, in isolation, is a futile endeavour but using these observations with an applied understanding would allow nurses to save lives as well as increase the comfort and health of their patients. As a profession, nursing has embraced Nightingale's philosophy of developing from a role undertaken by women in domestic service, or those employed by the wealthy, through a vocational call and onwards to an evolved formal nursing training programme. However, aligned to Nightingale’s ideology, it is clear that continued development of the nurse is what is required to nurture the individual, progress the profession and increase patient wellbeing.

JOINT HOSPITAL GROUP (SOUTH) PRECEPTORSHIP PROGRAMME In the absence of UK military hospitals, Joint Hospital Groups (JHGs) are National Health Service (NHS) facilities to which military personnel are assigned. Their location is designated using a geographical identifier i.e. S = South, N = North, SW = South-West, etc. Here, military personnel are embedded within a 'host' NHS hospital, where they work alongside civilian colleagues to deliver high quality care to the local population. This placement of personnel allows for healthcare professionals to develop their clinical skills and to undertake face-to-face patient care. These retained clinical competencies will enable the delivery of high-quality medical care on military Operations. The partnership between JHGs and the NHS, is very symbiotic and allows the organisations to work together and develop a shared understanding of each other’s clinical delivery, learning lessons from each other. This in turn allows for healthcare personnel to learn, understand and implement best practice within civilian practice as well as on deployed Operations within the military.

After completing an undergraduate nursing degree, newly qualified nurses embark on a steep learning curve, attempting to negotiate the transition from student to registered professional. This transition is seen as a stressful time for nurses2 and can be alleviated by the completion of a preceptorship programme during which they feel of benefit to the organisation3. This is even more important in light of additional factors that may increase feelings of stress and lack of confidence in skills or ability, such as applying their new role to the military context4. Research by Finnegan et. al.4 reported that military nurses had expressed a need for a formalised preceptorship programme that would augment that offered by the UK civilian healthcare sector.

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Preceptorship programmes are perceived as being supportive for newly qualified healthcare professionals as they begin their journey in their new role5. This is supported by Price6 who suggested that new registrants find the student to professional transition difficult and continued to postulate that this is in areas such as: pace of engaged reasoning, levels of patient engagement but more importantly, defining their own role6. These observations are not just seen at a local level. The UK Government Department of Health (DH)7 highlighted the need for newly qualified healthcare professionals to undertake a period of preceptorship, which allowed them to engage in reflection and self-directed learning. This stance supports that of the UK’s central nursing regulatory body (Nursing and Midwifery Council (NMC))8 in advocating a preceptorship period will enable the registrant to become safe, effective and competent within their role and environment. However, both the DH7 and NMC do not prescribe a model or further direction as to how this should be

International Review of the Armed Forces Medical Services

THE JHG(S) PRACTICE EDUCATION TEAM Initially, the JHG(S) Practice Education Team consisted of two Senior Non-Commissioned Officers, the author, an Army Warrant Officer 2 rank (OR-8) and one Royal Navy Chief Petty Officer (Naval Nurse) rank (OR-7). The main remit of this small team was to deliver advice, both clinically and educationally, and training to all JHG(S) healthcare professionals. With the development and subsequent introduction of the preceptorship programme, a decision was made to augment the team with a further 3 ∑ Warrant Officer 2, BSc(Hons), Dip Med Tox, PGCE, Dip HE/RN(A) QARANC. Correspondence: RG BEECH Warrant Officer Practice Education Joint Hospital Group (South) Albert House Queen Alexandra Hospital Southwick Hill Road Cosham, Portsmouth PO6 3LY

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personnel. A Commissioned British Army Officer (OF-3) was assigned to the team to oversee the day to day functional outputs. In addition, a British Army Staff Sergeant (OR-7) and one Royal Air Force Fight Sergeant (OR-7) were assigned. This augmented manning reflected the increase in the Practice Education Team outputs, which had expanded its remit to supporting the entire JHG(S) Unit. An explanation of the structure and areas of work for the Practice Education Team is outlined in Figure 1.

would embark on a combined programme facilitating their transition from student to a fully deployable registered practitioner, able to function effectively both in the UK and overseas.

DESIGN CONSIDERATIONS To ensure the programme contained the correct information, a combination of Health Education England (HEE) Standards for Preceptorship9, Defence Operational Nursing Competencies (DONC)10 and host Hospital Preceptorship Standards11, provided the necessary guidance. The use of these documents, as a framework, was to ensure the completion of all requirements of the military and host civilian hospital were met. The DONC10 is a professional development framework devised to ensure that military nurses demonstrate a level of competence in providing safe and effective care in an operational environment. The host civilian hospital standards, are requirements that set out what is expected of all newly qualified healthcare professional they employ. Completion of these mandated standards affords the military programme equal recognition and does not place military healthcare professionals at a disadvantage when compared to their civilian colleagues. Guidance provided by HEE, on what a preceptorship programme should deliver, is a nationwide framework, so this would allow for further parity of the programme by its inclusion. A summary of the elements, required by each of these documents, can be found at Box 1. The combined

The author explored the literature associated with extant preceptorship programmes being delivered throughout the United Kingdom (UK) and other JHGs. This established that civilian healthcare organisations delivered a preceptorship programme that varied in content, structure and timeline. It was also identified that each of the 5 JHGs, across the UK, delivered programmes very differently. They would implement some aspects of the host civilian hospital to deliver the professional components of preceptorship but would not address the nuances of healthcare delivery within the military context. Therefore, a decision was made to develop a bespoke course for the personnel at JHG(S). Despite there being a plethora of literature relating to civilian preceptorship, there was a paucity exploring the specifics of military programmes. There was also a need for a multidisciplinary approach that would include Operating Department Practitioners (ODPs) and Biomedical Scientists (BMSs). Therefore, newly qualified healthcare professionals assigned to JHG(S)

Figure 1: JHG(S) Practice Education Team Personnel and Responsibilities.

British Army Maj (OF-3) Intensive Care Specialist Officer in Charge of the Prac Ed Team Responsibilities: -Policy Development British Army WO2 (OR-8) Emergency Care & CBRN Specialist WO Prac Ed -Preceptorship Programme Development -Training Plan Development -Discipline Educational Lead -Financial Planning -Preceptee Appraisals

Royal Navy Chief Petty Officer (OR-7) Surgical Specialist -Royal Navy Lead -Clinical Support Non-Precptee Development -Educational Support -Pastoral Support -Preceptee Appraisals

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Royal Air Force Flight Sergeant (OR-7) Emergency Care Specialist RAF Lead -Clinical Support -Nurse in Charge Development -Educational Support -Clinical Supervision -Preceptee Appraisals

British Army Staff Sergeant (OR-&) Emergency Care Advanced Nurse Practitioner Army Lead -Clinical Support -Specialist Nurse Development -Educational Support -Pastoral Support -Specialist Course Liaision

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documents were also used to guide a variety of teaching opportunities that could be delivered using a multitude of pedagogies. To ensure a suitable length of time was devoted to each of the elements, to both deliver and assess understanding, a total amount of face-to-face time was approximated to be 90-hours, which could then be evaluated later. In addition to this time, structured clinical supervision sessions would be offered. Clinical supervision is defined as non-judgemental support given by fellow professionals with the aims of enabling honest discussions and/or additional learning opportunities to address the practitioner’s individual needs12. It is designed to encourage self-reflection, expand knowledge and skills and reduce or prevent burnout12. The provision of clinical supervision was highlighted as a positive recommendation in the UK Government's reports, authored by Sir Robert Francis13 and Professor Don Berwick14. Therefore, it was also seen by the author as a positive and necessary addition to the JHG(S) programme. The provision of clinical supervision sessions is mandated in Military Healthcare policy15; it was regarded by the author as being an important opportunity to assess any concerns voiced by the novice healthcare professionals. Preceptees would be afforded 12-hours of clinical supervision and 6-hours of feedback to address any individual concerns. This feedback mechanism would enable the author, as the senior co-ordinator of the new programme, to better understand concerns and

ensure they were being addressed to reassure preceptees that their voices were being heard. In addition, preceptees would be allocated 12-hours of protected time to conduct a Quality Improvement Project (QIP). Indeed, such projects play an integral part in the improvement of safe and cost-effective care delivery16. The conduct of a QIP was designed to increase group cohesion, promote interprofessional working and to positively reinforce to junior personnel that they also make a significant impact upon healthcare17, 18. The presentation of each group’s QIP, to members of military Chain of Command (CoC), senior executives from the host NHS hospital and their peers would mark the end of their 12-month programme. Finally, in addition to the previously mentioned face-toface hours, preceptees would be given the opportunity to meet key members of the military clinical hierarchy to acknowledge that they are an important part of the clinical team. To ensure that preceptees were understanding the programme’s content, two formalised Table Top Exercises (TTX) would be undertaken. The latter would assess student's learning transference in scenarios that would explore their ability to apply prior learning to solve problems in a safe environment19. This would be conducted over two 6-hour periods, programmed 6-months apart. In total, the programme comprises 128-hours of face-toface preceptee contact time, including clinical supervision

Box 1: Elements required by the Defence Operational Nursing Competencies, Health Education England and Host NHS Trust for completion as part of a preceptorship programme.

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DEFENCE OPERATIONAL NURSING COMPETENCIES (LAND ENVIRONMENT)10

HEALTHCARE EDUCATION ENGLAND STANDARDS9

HOST HOSPITAL STANDARDS11

• Chain of Command • Reports & Returns • Personnel Management • Maintenance of Security • Care of Captured Persons • Equipment Tables & Medical Logistics • Pharmacy & Controlled Drugs • Promote, Monitor & Maintain Health, Safety & Security • Equipment Use & Maintenance • Medical Aid to Civil Authority • Healthcare Governance Management & Reporting • Healthcare Governance & Assurance • Patient Safety • Quality Improvement • Information Management / Confidentiality & Caldicott • Risk Management • Communication • Legal and Ethical • Medicines Management • Infection, Prevention & Control • Blood Transfusion • Acute Pain (Assessment) • Acute Pain (Pharmacological Approach) • Acute Pain (Non-Pharmacological Approach) • Acute Pain (Delivery Devices) • Operational Stress Management

• Accountability • Career Development • Communication • Dealing with conflict / managing difficult conversations • Delivering Safe Care • Emotional Intelligence • Leadership • Quality Improvement • Resilience • Reflection • Safe Staffing / Raising Concerns • Team Working • Medicines Management (where relevant)

• Human Factors • Importance of Raisin Concerns • Medication Safety • Action Learning • Deteriorating Patient • Future Nursing Standards • Mental Health Awareness • Resilience • Managing Difficult Conversations • Accountability • Leadership & Management

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and support during QIP studies. Additionally, preceptees would be able to undertake a 5-day water sport orientated adventurous training package. This helps with reengaging preceptees with military ethos, by helping to develop strong leanings toward mental and physical robustness, teamwork, determination and 'Esprit de Corps'. Preceptees would also undertake a 3-day Battlefield Tour through Ypres in Belgium, during which they would research and deliver presentations about sites of military medical significance from the biggest battles of World War 1. This would serve to establish the preceptees’ understanding of how the DMS has evolved from a nursing perspective since the teachings of Florence Nightingale to what it is today. A ceremony takes place at the Menin Gate each night at 2000hrs and has done so every night since 1928. This marks the site of the recital of the Kohima Epitaph, which is carved on a memorial for the 2nd British Division in the cemetery of Kohima and is accompanied by buglers playing the Last Post. This ceremony is attended by 200-1000 local, and battlefield tourists, both military and ex-military. Participation helps to instil pride and honour amongst preceptees in wearing military uniform and allows them to remember the fallen and the sacrifice they made.

took the programme from October 2018 to February 2020. This allowed for participants from 2 iterations of the programme, which were delivered concurrently, six months apart. At the end of each group’s programme an external validation of the course was conducted. This took the form of a focus group using a semi-structured question schedule, which is outlined in Box 2. This was conducted by an Officer, who was a Subject Matter Expert (SME) in healthcare course design and who was also impartial to the programme and the Practice Education Team. This impartiality was seen as a means of gathering data without bias. The discussion was transcribed, by the SME and the elicited data was summarised with the preceptees at the end to ensure that the interpretation of their responses was correct. A time period of 1-hour was allocated to facilitate the focus groups and 32 preceptees participated. Two of the initial preceptees, one from each cohort, were unable to participate as they left the programme midway through. The completed data set was then given to the author. Simple analysis was conducted to identify those themes associated with transitioning between student and registered professional within a new military context21. In discussion with other Practice Education Team members the main themes identified were; programme length, programme validity, programme benefits and facilitator/peer support. The question schedule can be found in Box B.

The JHG(S) structured 12-month preceptorship programme was approved and implemented in October 2018. It is attended by preceptees who complete rotations in medical and surgical areas (22-weeks in each), followed by a 4-week placement in a higher acuity area (Emergency Department, Intensive Care Unit, etc.) To complement this, preceptees are required, one-day per week, to complete military specific training. This time allows them to develop a greater understanding about their own single Service ethos and wider triService specific training, during which they also learn about working in the joint space of all 3 UK Armed Forces.

The data gathered was intended to evaluate the revised programme’s perceived efficacy and if there were any required amendments; therefore, it qualified as a service evaluation rather than a primary research study. This did not require formal favourable opinion from the UK Ministry of Defence Research Ethical Committee. Approval from JHG(S) CoC was instead sought and granted for the external validation of both programmes.

AIM

RESULTS

This paper explores the perceptions of a cohort of Registered Nurses, ODPs and BMSs regarding the efficacy of the 12-month military preceptorship programme previously described.

All preceptees were within their first year of practice, after completion of their Undergraduate qualification.

METHOD

DISCUSSION

The study’s sample was drawn from 26 Registered Nurses, 5 ODPs and 3 BMSs (n=34) based at JHG(S), who under-

When a registered practitioner completes their undergraduate, they embark on a lifelong journey of continued

Box 2: Focus Group Question Schedule. JHG(S) PRECEPTORSHIP PROGRAMME EXTERNAL VALIDATION •

The aim of the preceptorship period is to enable a smooth transition from student to a competent and deployable medical asset for Operations. Preceptees were asked how well they feel prepared for this role?

•

What are the positive aspects of the preceptorship programme?

•

What are the limitations and what could be done better?

•

Was the programme too short, too long, or about right to achieve its objectives?

•

Did this preceptorship programme promote cohesion between your peers?

•

Did you feel that you were appropriately supported through the programme by the Practice Education Team?

•

In your opinion, did you find the programme useful to help reduce the gap between what is required as a civilian and military healthcare professional?

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Table 1: Preceptee Demographics. VARIABLE

Completion of Undergraduate qualification • Within the military • Prior to the military

23 11

67.7 32.4

Service • Royal Navy • British Army • Royal Air Force

9 16 9

26.5 47.1 26.5

Rank • Officer (Commissioned) • Junior Non-Commissioned Officer (JNCO)

1 33

2.9 97.1

Prior Military Healthcare Related Trade • Yes • No

7 27

20.6 79.4

Table 2: Preceptee's Responses During the External Validation. Theme One - Programme Length • "It was the perfect amount of time". • The time was right as it allowed me to consolidate both my military and clinical skills". • "Overall I feel ready”. Theme Two - Programme Validity • "The programme assisted in my development for military preparedness and overall I now feel competent to deploy on Operations". • "The table-top exercises were beneficial, allowing us to put into practice what we had learnt". • "I feel competent to deploy on Operations and have already been scoped for contingencies and exercises". Theme Three - Programme Benefits • "It was beneficial to be included in the programme alongside the JNCOs as they are all essentially at the same stage of nursing and also require the development". • "The opportunity to attend AT and a Battlefield study were appreciated, and I think I benefited hugely from these experiences". Theme Four - Facilitator/Peer Support • "The Practice Education Team were very supportive and helpful on the wards when discussing competencies and professional practice". • "The Practice Education Team are enthusiastic and motivated to ensure everyone achieves their potential". • "The Practice Education Team are very approachable". • "We are very lucky to have been part of the JHG(S) preceptorship programme as we are aware this programme isn’t standard for all units".

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learning. In order to support this transition, support should be given to the preceptee, in a constructive and safe environment, fostering newly qualified professionals to develop confidence, enhance competence and offer a structured support network22. The benefits of a structured preceptorship period are seen for both the individual as well as an organisation23. To enhance a preceptees experience, the implementation of a structured programme is essential24, although this structure isn't alway evident. After highlighting the requirement for this at JHG(S), the author implemented a structured and bespoke programme for newly qualified healthcare professionals. During this study, JHG(S) preceptees were asked if they felt the length of time, for them to undertake the preceptorship programme, was adequate to complete DONC. Thirty-three of the preceptees stated they felt that the programme length was suitable. This allowed them to undertake the programme alongside clinical placements and develop their knowledge without feeling anxious and overwhelmed. None of the preceptees felt the length of time was too long, although some respondents did

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state that their inability to participate in external activities was hindered whilst on the programme. Thirty-two preceptees stated that they felt the content of the programme was both appropriate and valid to the current and their future roles. Of this large group of preceptees, the main reasons for this postive finding was that they gained the necessary clinical and practical skills to deploy on Operations, from the structured and informative programme. This finding supports the literature22, 23, 24 suggesting that having a programme that is coordinated and educationally edifyable was of benefit to them, within their preceptorship year. Preceptees reported that they felt the lessons throughout the programme were delivered in a fun yet professional manner by the presenters. It was also clear that the use of SMEs to deliver specific course material was regarded as a positive aspect. It ensured that not only relevent and interesting information was provided, but that preceptees received confidence in the provision

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of credible answers. Military preceptees are required to deliver the skills learnt, on the JHG(S) preceptorship programme, within austere conditions on Operational deployments; therefore, completion of the DONC was essential. The completion of this document has been mandated prior to deployment and nurses are unable to deploy on Operations without doing so4 . However, from the study by Finnegan et. al.4 it was suggested that the DONC document, in isolation, was not enough to provide a high level of confidence amongst deploying healthcare professionals. Finnegan et. al.4 also highlighted that the process of completing this document was often rushed and, due to its lack of formal assessment strategy, there was a high level of disparity in the assessment of competence.

Preceptees also felt that this bespoke military programme was a strong advocate of peer and/or facilitator support, as instructors could empathise with them, giving them a contextually relevant support network and a sense of security. This feeling of support, during their first year, by named preceptors, is both recommended and seen to enhance decision-making, problem solving, and technical and clinical skills28 . A product of the programme, which was not anticipated by the author, was the strong sense of team ethos and camaraderie. The latter has been identified in small cohesive groups within the military as a strong rationale for the commitment they demonstrate to undertake and achieve challenging tasks29 . The undertaking of one of these sessions is illustrated at Figure 4.

Two of the participants felt the programme content was not useful, the main reason for negative responses was that preceptess were unable to determine how the lectures relating to the deployed setting developed them whilst they were working in a civilian clinical environment. They were unable to appreciate its true importance without being able to contexulise it at that time. One respondent was unsure if the training was beneficial, but stated that they could see the rationale for undertaking training with a specific focus on military deployed healthcare. Although, at present, the efficacy and positive benefits of this programme may not be identified at present, the increase in knowledge and skills the long term effects of the programme, would need further research, a point argued by Kamolo, Vernon and Toffoli25. Despite these results highlighting an overall positive perception of the programme from all Career Employment Groups (CEGs), the BMS preceptees stressed that a lot of the taught aspects of the programme did not bare any significance to their practice. Through deeper questioning, areas such as acute pain and blood transfusion related more specifically to RNs and ODPs and its relevence upon interaction between registered professional and patient. This was noted, by the author and will be included in programme revisions to ensure it bares equal relevance to all CEGs for future iterations of the programme.

CONCLUSION This paper describes the implementation of a bespoke military preceptorship programme, delivered to RNs, ODPs and BMSs at JHG(S). This inclusive prog ramme Figure 2: Precep tees taking part in surf ing, during a 5-day Adventurous Training Package.

Figure 3: Precep tees taking part in the Menin Gate Ceremony in Yp res, Belgium.

However, of note was the positive feedback received for incorporating an integral Adventurous Training (illustrated at Figure 2) and Battlefield Study into the programme (Figure 3).

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Preceptees are restricted in undertaking external activities, as it was identified by the author that their main focus, within this first year, should be on consolidating their undergraduate healthcare course and completing the stipulated requirements for deployment. The focusing on a role, with support, has been identified as an effective way of reducing the theory-practice gap and also increasing professional and personal satisfaction26. Despite 33 of the preceptees having perceived the programme to be useful and beneficial to their career within the DMS, one stated that because they had never undertaken anything like it before they felt they could not answer this question. The validity of this comment is fully accepted by the author as making a comparison between one programme, when there is no benchmark, is difficult to quantify27.

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Figure 4: Precep tee QIP discussion group during a p recep torship p rogramme study day.

can be a challenging period, often with feelings of trepidation, anticipation and pressure. Therefore, a preceptorship support package, in the form of a preceptorship programme, was required to help bridge the gap. This service evaluation explored personnel’s experiences of undertaking a bespoke military preceptorship programme at a hospital in Portsmouth, United Kingdom (UK). Aims: To capture the views of military healthcare professionals in relation to the preceptorship programme that they completed within their first year of being registered.

was a means of measuring military healthcare professionals’ perception of being able to effectively transition from student to professional, in a supported and educationally developed manner. The results highlight that the programme has been perceived as a positive way of developing military personnel and supporting them both clinically and within their roles in the DMS. The insight gained from this programme has supported the need for a bespoke training programme and that with minor adjustments, it can accommodate multiple CEGs. The strategy adopted by the author, was intended to provide a level of input and support, early in the careers of these personnel, which should provide a strong grounding throughout their career. This is congruent with other studies, looking into the benefits of structured preceptorship programmes2, 30, 31, Taking into account the views of the preceptees, further refinement of the programme will ensure that it will continue to provide junior healthcare professionals with a good foundation and level of knowledge to support the DMS.

FUTURE RECOMMENDATIONS

Methods: Two separate groups undertook the 12-month programme, 6-months apart. At the end of each programme a focus group was undertaken to ascertain preceptees’ thoughts and experience of the programme. Both groups contained Registered Nurses (n= 26), Operating Department Practitioners (n=5) and Biomedical Scientists (n=3). Data were analysis via thematic analysis. Results: Four themes were identified; Programme length, programme validity, prog ramme benefits and facilitator/peer support. Both groups expressed that the programme length of 12 months was appropriate to enable this programme to be effectively delivered. The validity of the prog ramme was also established, with preceptees feeling that it enhanced their knowledge of both the clinical and military aspects of their role. The perceived benefits of this bespoke programme were the opportunity to undertake experiences that reduced the theory-practice gap, which enabled their easier transition from student to qualified professional. The tangible support provided by the Practice Education Team also facilitated their ability to form close networks with their peers.

To aid the development of this programme, facilitating an opportunity for preceptees to provide feedback individually may obtain a deeper understanding of their feelings regarding the programme. These responses can then be further utilised to ensure the needs of all preceptees are fully met. Furthermore, to assess the wider level of impact that this programme has the potential to deliver, implementation into other JHG's is recommended. Although the journey of a preceptee is different within each of the five JHG's, exploration is required to identify if one standard course could replace the multitude that are currently being delivered. To facilitate this, further research to investigate the wider needs of newly qualified practitioners across Defence to determine if this bespoke programme would meet all of their needs. Also, further enquiry may show that the implementation of a standardised approach to preceptorship may have application within the civilian setting.

Conclusions: This inclusive programme was a means of measuring military healthcare professionals’ perception of being able to effectively transition from student to professional, in a supported and academically manner. The results highlight that the programme has been positively received as a means of developing military personnel and supporting them both clinically and within their roles in the DMS.

ABSTRACT

12. MARKS- MARAN, D., OOMS, A., TAPPING, J., MUIR, J., PHILLIPS, S., et. al. (2013). A preceptorship programme for newly qualified nurses: a study of preceptees' perceptions. Nurse Education Today , 13(11), pp. 1428-1434.

Conflict of Interest

The author has no conflict of interest to declare. REFERENCES 11. NIGHTINGALE, F. (1859). Notes on nursing: what it is, and what it is not. New York, D. Appleton and Company.

Background: The transition from student to registered practitioner

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13. SANDAU, K. & HALM, M. (2010). Preceptor-based orientation programs: effective for nurses and organizations? American Journal of Critical Care, 19(2), pp. 184-188.

21. RILEY, R., ENSOR, J., SNELL, K., DEBRAY, T., ALTMAN, D., et. al. (2016). External validation of clinical prediction models using big datasets from e-health records or IPD meta-analysis: opportunities and challenges. British Medical Journal, 353, pp. 1-11.

14. FINNEGAN, A., FINNEGAN, S., BATES, D., RITSPERIS, D., McCOURT, K., et. al. (2015). Preparing British military nurses to deliver nursing care on deployment. Nurse Education Today, 35(1), pp. 104-112.

22. LOFMARK, A., THORKILDSEN, K., RAHOLM, M-B., & NATVIG, G. (2012). Nursing students' satisfaction with supervision from preceptor and teachers during clinical practice. Nurse Education in Practice, 12(3), pp.164169.

15. McCUSKER, C. (2013). Preceptorship: professional development and support for newly registered practitioners. Journal of Perioperative Practice, 23(12), pp. 283-287.

23. CLOETE, I., & JEGGELS, J. (2014). Exploring nurse preceptors' perceptions of benefits and support of and commitment to the preceptor role in the western cape province. Curationis, 37(1), pp.1-7.

16. PRICE, B. (2013). Successful preceptorship of newly qualified nurses. Nursing Standard, 28(14), p. 51. 17. Department of Health (2010). Preceptorship framework for newly qualified nurses, midwives and allied professional. London, Department of Health.

24. FORDE-JOHNSTON, C. (2017). Developing and evaluating a foundation preceptorship programme for newly qualified nurses. Nursing Standard, 31(42), pp. 42-52.

18. Nursing and Midwifery Council (2006). NMC circular Preceptorship guidelines. NMC London. Retrieved from: https://www.nmc.org.uk/globalassets/sitedocuments/circulars/2006circulars/nmc-circular-21_2006.pdf on 11 Apr 20.

25. KAMOLO, E., VERNON, R., & TOFFOLI, L. (2017). A critical review of preceptor development for nurses working with undergraduate nursing students. International Journal of Caring Science, 10(2), pp. 1089-1100.

19. Health Education England. (2017). Preceptorship and return to practice for nursing (Version 1). Health Education England: London.

26. DADGARAN, I., PARVIZY, S., & PEYROVI, H. (2012). A global issue in nursing students' clinical learning: the theorypractice gap. Procedia-Social Behavioural Sciences, 47, pp. 1713-1718.

10. Ministry of Defence. (2015). Defence Operational Nursing Competencies (Land Environment) (Version 1.1). Ministry of Defence: London.

27. LOVALIO, P. (2012). Benchmarking strategies for measuring the quality of healthcare: problems and prospects. The Scientific World Journal, 2012,

11. Portsmouth Hospitals NHS Trust. (2015). Preceptorship programme: preceptee personal handbook& log (Version 2). PHT: Portsmouth.

28. McCARTY, M. & HIGGINS, A. (2003). Moving to an all graduate profession: preparing preceptors for their role, Nurse Education Today, 23(2), pp. 89-95.

12. CLIFTON, E. (2002). Implementing clinical supervision. Nursing Times, 98(9), p. 36. 13. FRANCIS, R. (2013). Report of the Mid Staffordshire NHS foundation trust public enquiry. The Stationary Office: London.

29. GROSS, M. (2011). Comradery, community, and care in military medical ethics. Theoretical medicine and bioethics, 32(6), pp. 337-359.

14. BERWICK, D. (2013). A promise to learn - a commitment to act. Improving the safety of patients in England. Department of Health: London.

30. PGCHER, R. (2013). A qualitative evaluation of a preceptorship programme to support newly qualified midwives. Evidence Based Midwifery, 11(3), pp. 93-98.

15. Ministry of Defence. (2015). Joint Service Publication 950; Part 1, Leaflet 5-2-1 Clinical supervision for nurses (Version 2). MoD: London.

31. HYRKAS, E., LINSCOTT, D., & RHUDY, J. (2014). Evaluating preceptors' and preceptees' satisfaction concerning preceptorship and the preceptor-preceptee relationship. Journal of Nursing Education and Practice, 4(4), pp. 120-133.

16. HAM, C., BERWICK, D., & DIXON, J. (2016). Improving quality in the English NHS: A strategy for action The King's Fund: London.

Abbreviations (by order of appearance)

17. McFADDEN, K., STOCK, G., & GOWEN, C. (2015). Leadership, safety climate, and continuous quality improvement. Health Care Management Review, 40(1), Pp. 24-34.

DH NMC DMS JHGs NHS ODPs BMSs HEE DONC QIP CoC TTX SME JNCO CEGs

18. WILCOCK, P., JANES, G., & CHAMBERS, A. (2009). Health care improvement and continuing interprofessional education: continuing interprofessional development to improve patient outcomes. Journal of Continuing Education in the Health Professionals, 29(2), pp. 84-90. 19. EVANS, C., BAUMBERGER-HENRY, M., SCHWARTZ, R., and VEENEMA, T. (2019). Nursing students' transfer of learning during a tabletop exercise. Nurse Educator, 44(5), pp. 278-283.

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20. NOWELL, L., NORRIS, J., WHITE, D., & MOULES, N. (2017). Thematic analysis: striving to meet trustworthiness criteria. International Journal of Qualitative Methods, 16(1), pp. 1-13.

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The UK Government Department of Health. Nursing and Midwifery Council. Defence Medical Services. Joint Hospital Groups. National Health Service. Operating Department Practitioners. Biomedical Scientists. Healthy Education England. Defence Operational Nursing Competencies. Quality Improvement Project. Chain of Command. Table Top Exercises. Subject Matter Expert. Junior Non-Commissioned Officer. Career Employment Groups.

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A RT ICLES

Establishing Collaborative Relationships. Following Florence Nightingale’s Footsteps to Optimise UK Military Paramedics’ Competence. By R. SCOTT∑ and C. WRIGHT∏. United Kingdom

Richard SCOTT Flight Sergeant Richard SCOTT joined the Royal Air Force (RAF) in 1991. As a RAF Medic he completed operational tours in Bosnia, Kuwait and Turkey. Completing extended training within the RAF, he registered with the Health and Care Professions Council in 2005 as a paramedic. Subsequently deployed on the United Kingdom's Operation HERRICK in 2006, completing seven operational tours of Afghanistan. Six on the Medical Emergency Response Team retrieving casualties from Point of Injury and one ground role supporting the RAF Regiment protecting the Air-Bridge at Kandahar. Later deployed to Kenya providing a MEDEVAC capability to overseas training and Iraq on Operation SHADER, providing an embedded medical capability. Continues to support the delivery of MEDEVAC clinical training delivered by the RAF as a Subject Matter Expert. More recently, he has supported the introduction of policy to develop paramedic capability within the RAF as Trade Specialist Officer for Paramedics. Whilst in this position, he was instrumental in shaping the delivery of this novel approach to optimising clinical competence for paramedics. In recognition for his efforts he was awarded RAFMS Air Marshal Evans Award during 2019. Trustee for the College of Paramedics 2018-2020, he has supported the national paramedic agenda. He maintains his professional registration by working on the frontline with a NHS ambulance service and has completed Paramedic Batchelor of Science to enhance his vocational paramedic pathway.

RESUME Établir des relations de collaboration. Sur les traces de Florence Nightingale pour optimiser les compétences des ambulanciers paramédicaux militaires britanniques. Cet article examine les défis et les opportunités interorganisations pour conserver les compétences cliniques d’une population militaire centrée sur la préparation opérationnelle. Alors qu’au Royaume-Uni les services médicaux de la défense ont des personnels infirmiers, médicaux ou d’autres professionnels de santé intégrés depuis de nombreuses années, la nécessité d’une capacité paramédicale n’a été pris en compte que depuis ces 10 / 15 dernières années. Plus de 150 ans après le retour de Florence Nightingale de Crimée et la création d’un dispositif de formation infirmière, le domaine paramédical suit la même voie afin d’optimiser les compétences cliniques nécessaires au déploiement opérationnel. Il y a maintenant 15 ans que le dernier hôpital militaire britannique a fermé ses portes. Cela impose désormais un fonctionnement conj oint entre les organismes pour permettre à la nouvelle génération de personnels DMS de relever les défis opérationnels futurs.

KEYWORDS: Paramedic, Competency, Readiness, Interorganisational, Florence Nightingale. MOTS -CLÉS : Paramédic, Compétence, Préparation, Interorganisationnel, Florence Nightingale.

to mitigate preventable mortality in the pre-hospital phase of the patient care pathway and has many similarities to nursing. Paramedics offer the military a predominately pre-hospital focussed workforce that has a greater skillset than the traditional medics across the Defence Medical Services (DMS) who struggle to access clinical experiences2 . Changes in the roles undertaken

BACKGROUND Florence Nightingale is widely acknowledged to be the strongest advocate for the development of a professional nursing profession1. The paramedic profession was created, in part, by the requirement to professionalise the UK ambulance service in the early 1980's. It aimed

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by civilian paramedics have seen the profession expand into other care settings such as Primary Care networks, minor injury units and hospital emergency departments, making the role much more agnostic. Florence was a keen statistician and would undoubtedly have acknowledged the use of Key Performance Indicators, periodic performance appraisals and Ambulance Quality Indicators; all measuring aspects and trends in the safety, effectiveness and quality of service provision within an accredited framework. The provision of basic nursing care was the foundation for nurse training under Florence's influence and can be observed in university delivered paramedic training syllabuses. The latter are governed by the Health Care Professions Council (HCPC), as opposed to the Nursing and Midwifery Council, but there is clear evidence of Florence’s influence within the HCPC's Standards of Proficiency for paramedics3.

Whole Force. The Whole Force is the UK military term for all components of manpower including full time (regular), part time (reserves) and combinations of both being considered under the Future Employment Model. The term 'pre-hospital' was added to the North Atlantic Treaty Organisation (NATO) AJP-4.109, as recently as September 2019 after a specific request from the UK. With the pre-hospital phase of care now recognised and defined, the provision of care within this phase should be appropriately scaled to support Defence tasks. The deployment of an appropriate medical capability is designed to mitigate the clinical risk associated with operating in remote locations, with resource limitations and extended Medical Evacuation (MEDEVAC) timelines in accordance with NATO Allied Joint Doctrine for Medical Support9. The vast majority of generic medical support roles are undertaken by military medics within the Royal Navy, British Army and Royal Air Force. However, specialist tasks, or where significant clinical risk has been identified, is assigned to emergency nurses and paramedics with their wider scope of practice and clinical experience10. MEDEVAC operations in Afghanistan, Iraq and more recently in supporting short-term training teams and humanitarian responses (Operation RUMAN), provide examples of where nurses and paramedics have provided this pre-hospital capability. Whilst many of the enduring operational tasks can be undertaken by reservists, roles supported at Very High Readiness require regular DMS personnel that are Suitably Qualified Experienced Personnel (SQEP). The delivery of safe, effective, evidence-based deployed healthcare requires many aspects to function synergistically. The Royal Air Force Medical Services (RAFMS) recognised that SQEP amongst its paramedic personnel could be improved, which led to a group of them being embedded within an NHS regional ambulance service to optimise their clinical competency.

The majority of regular UK DMS medical, nursing and Allied Healthcare Profession (AHP) personnel are based within Secondary Health Care (SHC) establishments. These are National Health Service (NHS) hospitals due to the last UK military hospital having been closed in 1995. Ergo, professionally registered DMS personnel are generally embedded within NHS organisations, contracted on a Whole Time Equivalent (WTE) basis. This WTE approach means that a number of DMS personnel cover one position within a department (for example a ratio of 7:1). This is designed to provide the DMS with flexibility in ensuring personnel retain their clinical competence, preparedness for deployed roles and any structured return to practise after extended absences. It also provides an environment where personnel can access bespoke multifaceted clinical experiences, which is anecdotally acknowledged to be retention positive. Deployment to Operation HERRICK, the UK name given to operations in Afghanistan (Operation Enduring Freedom - United States of America or Operation Slipper - Australia) has been cited as providing retention positive opportunities that are unavailable within an average NHS career where experience of trauma is modest4.

HISTORICAL CONTEXT

The longevity in any collaborative relationship relies in part on the mutual benefit to all organisations involved. Military experiences in resource limited environments has contributed to NHS practice through the sharing of research and innovation5. The deployment of blood products on UK Air Ambulances is directly linked to military operations in Afghanistan6. Relationships across multi-national military healthcare providers in the deployed environment is being commented upon with studies concluding that collaboration, internationally recognised training supported by universal standards and equipment provides considerable benefit7.

The DMS has had paramedic personnel within its regular forces for over ten years. They were originally trained for the Joint Personnel Recovery role, more commonly known as Combat Search and Rescue. Operation HERRICK 2006-2014 saw the additional value of deploying higher skilled medical providers further forward on the ∑ Paramedic Research Fellow, ∏ Paramedic Station Medical Centre RAF Northolt C/O Paramedic Ambulance Secondment Ruislip, Middlesex HA4 6NG. Correspondence: Flight Sergeant Richard SCOTT Paramedic Research Fellow Academic Department of Military Nursing Royal Centre for Defence Medicine Medical Directorate Birmingham Research Park Vincent Drive Edgbaston Birmingham, West Midlands B15 2SQ

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On deployed operations, there remains a requirement to deliver a standard of healthcare equivalent to the standard provided in the UK8, this includes a military pre-hospital capability that is fit for purpose across the

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pre-hospital medical capability would benefit from incorporating a paramedic component. Together with the RAFMS, a Joint training pathway was established in January 2019 with a civilian university. The generation of registered paramedics is now entirely by HCPC accredited educational pathway. This is currently being delivered as a diploma, at academic level 5, but is transitioning to a BSc pathway (academic level 6) during 2021. Such a partnership delivers a suitable educational syllabus, including all clinical placements that meet the requirements for professional registration with the HCPC. Military personnel are also trained to drive civilian ambulances under a nationally recognised emergency driving qualification. This is a significant advantage in accessing contracts with NHS ambulance services, as they usually have to pay (commercial costs in excess of £4,000/ € 3,600) to train a Newly Qualified Paramedic (NQP) who joins after registration.

battlefield. Tactical Forward Aeromedical Evacuation capabilities, such as the Chinook-based Medical Emergency Response Team (MERT), evacuated over 6,000 casualties from close to their point of injury. The success of MEDEVAC capabilities, such as MERT, were recognised in decreasing mortality amongst severely injured casualties with Injury Severity Score (ISS) >1511. The delivery of care during operation HERRICK was positively reported upon by the Care Quality Commission (CQC) 12 . Since 2009 the CQC, a non-departmental public body of the Department of Health and Social Care, has regulated and inspected health and social care services in England. There is no statutory requirement for CQC inspections as the DMS is not obliged to be registered under the Health and Social Care Act. However, a former Surgeon General, invited the CQC to inspect DMS premises to provide valuable external validation and transparency for the general public, which has been benchmarked against recognised standards of best practice.

DMS regular paramedic personnel face significant challenges in accessing appropriate clinical activities, referred to as CCE, alongside conventional medical roles. This CCE is essential in supporting professional competency, clinical growth and professional registration, especially when being temporarily employed in non-clinical military roles. CCE is not the sole means of generating SQEP amongst practitioners. A suite of DMS internal medical competency-based residential courses and simulation training15 augment experiences not easily encountered through civilian CCE alone. Barriers to achieving CCE can be significant and include access to viable ambulance service contracts, robust job plans that include time allocated to the clinical space, and the availability of CCE activities against competition from civilians (student paramedics take up significant capacity within NHS ambulance services). There is no doubt that the ability to embed DMS personnel within a civilian ambulance service, in order to generate SQEP for deployed roles is a natural evolution. Adoption of the SHC model for a percentage of regular paramedics is understood to improve work life balance, competency and retention.

The scope of practice of paramedic personnel exceeds that of vocational DMS internally trained non-registered personnel such as the RAF Medic, Combat Medical Technician and Royal Navy Medical Assistant. This latter group are non-professionally registered cadres, supported by a limited list of non-prescription based pharmaceutical interventions, and have minimal scope to provide unsupervised care beyond immediate emergency care. Their unregistered status can be an advantage in the flexibility of their deployed roles but also severely limits access to Continuous Clinical Experience (CCE), more so since the publication of the Francis report 13 . This report recommended that medical practitioners who deliver direct patient care should be professionally registered. This professional registration provides paramedic practitioners with easier access to CCE. The latter is underpinned by a nationally agreed scope of practice, and pharmaceutical provision under extended Patient Group Directions and Joint Royal College Ambulance Liaison Committee guidance. Together with extended clinically focused military competencies, DMS-based paramedic personnel provide greater utility than their non-registered colleagues and arguably mitigate clinical risk in challenging, resource poor environments. The extensive training syllabus and clinical experiential learning14 provides crucial differences between the two groups. The majority of professional training for military nursing and paramedic personnel is delivered by civilian academic institutions. The curricula have subtle differences to civilian training pathways due to the unique requirements of the military. The generic differences in training individuals to meet the standards of the HCPC and professional registration as a paramedic in the RAFMS and civilian setting are illustrated in Figure 1.

There has been growing recognition nationally of the competency gap between a paramedic’s performance at initial professional registration and implied competence as an autonomous practitioner. This has been nationally validated in the UK by the introduction of a formal clinical consolidation model under NHS Health Education England's (HEE) NQP pathway. This national guidance has an impact on DMS paramedics’ recognition as autonomous practitioners. The NQP pathway mirrors other DMS healthcare profession’s clinical consolidation periods. It similarly recognises the requirement to provide a structured nurturing transition from the academic and the supervised clinical placement environment to safely establishing individuals as competent practitioners. The appropriate delivery of the NQP pathway should reduce any instances of the Dunning-Kruger effect 16, which is the mismatch between competency and perceived competency, on individual's perceptions of their own abilities. This can contribute to clinical over reach, an anathema to the reduction of clinical risk during Defence tasks.

Mimicking opportunities across the NHS, DMS-based paramedics will, in future, be able to develop as advanced practitioners to provide an enhanced specialist scope of practice to casualties within the Operational Patient Care Pathway (OPCP). The Army Medical Services in the UK decided that their

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Figure 1: Comparison between DMS & NHS generation of paramedic capability.

DMS VS NHS PARAMEDIC TRAINING ROUTES

RAFMS Health Directorate

2 years

NHS

Regular RAF Medic

Selected for Paramedic Trg

Direct to Paramedic Trg via University

Internally selected from lower clinical speciality

HCPC Registration Commence NQP Pathway

2 years

Academic

HCPC approved Trg delivered by University

Clinical Placements

Attain Brand 6

Reserve Paramedic Pathway mirrors NHS

Emergency Driving Trg Frontline Ambulance HCPC Registration Commence NQP Pathway BATLS Specialist Role Complete DMS Clinical Trg during NQP period

Attain Band 6 Join Trained Strength

MERT

Specialist role

Join Unit

MPHEC

Embedded role

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BRIDGING THE GAP FROM NOVICE TO AUTONOMOUS PRACTITIONER

MENTAL HEALTH RISKS TO EMBEDDED PERSONNEL

The RAFMS identified an opportunity to embed registered paramedic personnel within a regional NHS ambulance service. There were several motivations behind this initiative. It was already organisationally recognised that established CCE options were being limited by the lack of access to pre-hospital clinical activities and competing priorities to undertake other military tasks. Other national challenges exist as the UK does not have one single ambulance service; instead there are 14 regional ambulance services, each adopting separate employment models. This means that DMS paramedics have to apply for a new contract every time they geographically relocate throughout their military career. The intent of the DMS initiative was to provide an embedded group of DMS regular paramedics mirroring arrangements with the NHS that have been established for other professionally registered practitioners (nurses, bio-medical scientists, doctors, operating department practitioners) and offer employment to appropriately selected and vetted17, registered personnel within an ambulance service. This would be managed under a WTE style contract in return for frontline emergency ambulance clinical experience.

Stress, fatigue, the non-specialist nature of the role and burnout have all been cited as a risk to the mental wellbeing of health workers24-25. The DMS and NHS ambulance services both have systems in place to provide mental health support to pre-hospital practitioners. Symptoms of self-reported burnout amongst ambulance crews have been increasing as the workload demand grows, adding pressure to finite resources. The DMS is actively engaged in identifying all ongoing lessons including the close review of any sickness absence behaviour and any subsequent impact on the ability to deploy through reduced health. Establishing whether inherent risk factors are mitigated by the DMS strategy is essential to provide a retention positive career and personnel that are fit to deploy.

RETENTION OF CLINICAL COMPETENCIES IN LOW ACUITY MILITARY OPERATIONS Observationally, it is understood that even at OR2 rank (Senior Aircraftsman: Private equivalent), the value in a consolidated period of clinical practise cannot be understated. Concerns raised elsewhere about skill fade of DMS practitioners26 whilst on low-tempo operations, should be adequately addressed during an individual's return to the ambulance service under a structured graduated return to work plan. The significance of assumed competency versus actual competency is not fully recognised by many organisations27. The DMS generally assigns responsibility for maintaining competency to the individual, where it is measured by the completion of courses, either via e-learning or residential alternatives. Competency cannot be accurately reflected in a list of completed courses; this only provides an indication of academic exposure. Whilst the importance of days off work and an organised mental health awareness brief during Psychological Decompression is formally recognised in the post operational space, there is a lack of focus regarding any degradation of clinical competence. There appears to be an assumption that clinical skills are inherently lifelong skills and they are retained regardless of practice. In order to protect personnel when they engage in these embedded NHS roles, individuals are exempt from deployment for the first 12-18 months on joining the ambulance service. This would equate to 12months if band 6 practise (autonomous practitioner) had been achieved prior to commencing the role and 18months if individuals still had to complete the post registration consolidation phase introduced nationally as the NQP pathway.

The opportunity to embed a team of regular RAFMS paramedic personnel within an ambulance service arose when Operation HERRICK concluded in 2014 and a surge in paramedic training was planned. There was a step change in strategic direction from enduring to contingency operations that resulted in an increased requirement for a more flexible paramedic capability.

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Improvements to automobile and road safety, and an industrial health and safety culture in the UK have reduced the incidence of trauma presentations, whilst urgent care-related cases have increased demand on ambulance services perceptively since 200518. The majority of UK-based NHS ambulance attendances are to older patients, with multiple co-morbidities, mental health crises, social issues and paediatrics19. Despite suggestions that civilian demographics do not mirror the typical young sailor, soldier, or serving members of the RAF deployed on operations, engagement across the full range of national demographics still provides substantial benefit to practise. Structured patient assessment, including identifying patients that are acutely ill, provides an essential element to experiential learning. Teamwork, clinical decision-making, non-technical skills, communication, planning and reflection all provide positive contributions to appropriate practise. Primary care presentations are increasing and this directly translates to the operational space. The vast majority of presentations operationally are classified as Disease NonBattle Injury; predominantly primary care or a primary Musculo-Skeletal Injury (MSKI)20, 21, 22, 23. This demonstrates how a suitably experienced paramedic may contribute to mitigating clinical risk and appropriately managing risk along the OPCP.

International Review of the Armed Forces Medical Services

GENERATION AND RETENTION OF SQEP The DMS initiative described above is understood to provide additional non-remunerative retentive measures for regular paramedic personnel. Internal DMS annual surveys28 have demonstrated a decreasing confidence in respondents being able to retain clinical proficiency for deployed tasks whilst undertaking non-deployed roles. Comparative concerns surrounding preparedness for deployed healthcare have been raised by General

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Practitioner colleagues29, which resonate with both RAFMS paramedic and nursing personnel working in the operational pre-hospital setting. The opportunity to embed practitioners at both Band 5 (consolidating professional practise) and Band 6 (autonomous life-long learning) generates benefit in mentoring experience30. Band 5 practitioners benefit from the experience of being mentored, which enables them to develop good mentoring habits through formative learning. This acquired knowledge represents valuable skills that permeate into the DMS environment. On attaining Band 6 status, DMS paramedics can mentor civilian colleagues representing value to the ambulance service and deepening the collaborative nature of the relationship. It also supports practitioners in gaining the clinical credibility to deliver DMS clinical courses as external faculty subject matter experts. Supporting professional growth in areas such as mentoring is also believed to be a retention positive measure.

personnel had to pass a selection day with the ambulance organisation and reach the standard expected of any other external applicant. There was an opportunity to embed the most senior member of the team (Sergeant/OR6) six-weeks prior to the main body. This ad-hoc decision proved to positively contribute and flatten any friction generated by introducing a small group of DMS practitioners to work within another established civilian team. This also mitigated some of the issues faced by those arriving in the main body on joining the ambulance service. Enabling elements including NHS orientation, induction, organisational hierarchy and stakeholders, procedures, uniform, Information Technology access and J1 (Personnel, Manning and Administration) issues were all organised with the assistance of the Sergeant/OR6. The advance party SNCO was able to organise accommodation and office space on the hosting military unit to assemble, discuss and plan activities. The size of the team was appropriate for the ambulance station; it did not overwhelm established work patterns, yet the numbers ensured flexibility if the DMS were required to re-deploy anyone of them on military tasks.

Embedded personnel are additionally well placed to support the delivery of clinically based pre-deployment training such as Battlefield Advanced Trauma Life Support, Military Pre-Hospital Emergency Care, Military Major Incidents Management and the Medical Emergency Response Team competencies. This is especially significant as these DMS courses are delivered with support from clinically credible external faculty members to optimise context and fidelity. The DMS is exploring opportunities to increase its footprint in other regional ambulance services for paramedics and nurses to provide them with appropriate pre-hospital experience.

An individual embedded with the ambulance service as a Band 5 (transition to Band 6 autonomous practitioner) provided the following insight into their experience after 14 months: "I now consider myself an autonomous professional who is experienced in responding to emergencies in uncertain situations with sometimes minimal information. Because I am in a full-time patient-facing role I can quickly recognise and act when I am presented with a sick patient. I am predominantly the senior clinician on scene making independent decision regarding patient care". Cpl X, dated 15 Mar 20.

LESSONS IDENTIFIED Many lessons were identified during the 'plan and implement' stage of this initiative. Project timelines were the primary issue, which affected all areas of the plan's hierarchy. As a project, the coordination of different aspects across niche sub-organisations was a significant theme. Clear communication regarding realistic timelines were essential to maintain all aspects of the projects progress. The most exhaustive work strands were related to two areas: developing and providing momentum to the relationship with the ambulance service through an intermediary (Placements Cell) and the staff work related to establishing these novel embedded roles. The staff work required significant focus to ensure the chain of command was aware of the benefit related to the successful integration of DMS paramedics within an NHS ambulance service. An outline of the projectâ&#x20AC;&#x2122;s components is provided at Figure 2, which illustrates where close engagement with stakeholders is pivotal to a successful outcome.

ASSESSMENT OF EMBEDDED ROLES The programme has been active for 15-months and evidence suggests that this pre-hospital initiative has been a success. Embedded personnel are engaged in a higher volume of clinical patient-facing activities. In some case this equates to six times31 more clinical activity when compared to that of personnel employed in non-clinical roles. The ambulance service, like many others, record activities under their Key Performance Indictors (KPI). As a statistician, this is something that Florence Nightingale would equally recognise as beneficial. Whilst some of these KPIs focus on response times, which are of limited value to the RAFMS, other data comprise conveyance and non-conveyance rates based against local and organisational trends. This information provides crucial assurance that military personnel are performing to the required standard. It is an example of healthcare interoperability, which was identified as a theme both within post Operation HERRICK literature32 and since the closure of military hospitals33.

Naturally, every stakeholder involved in supporting an aspect of the implementation had to deconflict other competing priorities for their time. Retrospectively, an electronic project plan with agreed timeframes would have provided additional visibility and context to the initiative. Formal acknowledgement that the ambulance service would make the last decision regarding the suitability of selected personnel was not clear in the earlier stages. Indeed, their acceptance had been assumed; however,

International Review of the Armed Forces Medical Services

SUMMARY Despite the modest numbers of personnel involved, analysis of data and experiences amongst this cohort

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Figure 2: Wire Diagram of Project Management.

ESTABLISHING EMBEDDED UK DMS PARAMEDIC ROLES

RAFMS Health Directorate

Parenting

Placements Cell Direct liaison with ambulance services & broker for Commercial Contracts

Provision of Real Life Support: accomodation, food, transport, finance, medical, dental services

Commercial Contracts

Accomodation

Ensuring embedded roles are supported by suitable contract confirming working hours, military commitments, remuneration, provision of uniform, ID & ambulance service email accounts.

Suitable accomodation for enduring period, close proximity to ambulance hub.

Selection Criteria for Personnel

Selection by Ambulance Service All military personnel have to complete selection process with ambulance service.

Establishment Changes Provides organisation record of funded positions

Career Employment Policy Revise policy

Capture Lessons Periodic review of experiences to adjust embedded employment model. Engagement with Defence Organisational Learning Strategy to inform other initiatives.

Appraisal hierarchy & Admin Support Establish Reporting Chain Career Manager Engagement Length of assignment creation of Assignment Order

Internal Actions

Project Lead

Primary Enablers

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External Actions

strongly supports the presumption that this pre-hospital initiative has been a success. Whilst the majority of other DMS paramedic roles access CCE on a more ad hoc basis, paramedics embedded within the ambulance service have so far experienced six times the CCE that their colleagues have experienced. Given the nature of UK NHS ambulance presentations, this has resulted in more experience of critically unwell patients and the clinical decision making that this requires. By focusing

International Review of the Armed Forces Medical Services

on the two priorities of clinical and military competence, embedded personnel are more likely to reach SQEP, over a shorter period, making them available much sooner for deployment on military tasks. Understandably, this is difficult to prove comprehensively across a small cohort over a relatively short period. Data will continue to be harvested and analysed as the roles mature with the view of presenting an update in the future. As the roles mature and are influenced by

Revue Internationale des Services de SantĂŠ des Forces ArmĂŠes

lessons identified, embedded personnel are additionally well placed to support the delivery of clinically based pre-deployment training.

15. WOOLEY, T., ROUND, J. and INGRAM, M. Global lessons: developing military trauma care and lessons for civilian practice. British Journal of Anaesthesia. 2017. 119, pp.i135i142. Available at: http://dx.doi.org/10.1093/bja/aex382.

It is envisaged that the creation of additional embedded clinical opportunities will generate SQEP, and a much more rounded practitioner, whilst improving morale and retention rates amongst regular DMS paramedics. As Florence Nightingale demonstrated years previously, there is merit in establishing interorganisational relationships between civilian medical organisations and the military that are mutually beneficial. Akin to nursing, paramedic training is now internationally and professionally recognised and delivered through university-led higher education syllabuses. Universally, regardless of formal profession title, military medical practitioners can benefit from collaborative interorganisational relationships with civilian healthcare systems. Experiential learning within suitable environments supports competency and a robust scope of practice suitable for the deployed environment that mitigates clinical risk on future operations.

16. DOUGHTY, H. Recent developments in military transfusion practice and their impact on civilian healthcare. 2018. Available at: http://bora.uib.n0/handle/1956/17811. 17. DaCAMBRA, M., KAO, R., McALISTER, V. Utilisation profile of the Canadian-led coalition Role 2 Medical Treatment Facility in Iraq: the growing requirement for multinational interoperability. Canadian Journal of Surgery. 2018. 61(6 Supp 1), pp.195-202. Available at: https://www.ncbi.nlm.nih.gov/pmc/?term=PMC6281465. 18. Ministry of Defence. Defence Medical Direction 17. 2017. 19. North Atlantic Treaty Organisation. AJP-4.10 Allied Joint Doctrine for Medical Support. NATO Standardisation Office (NSO). 2019. 10. SHARPE, D., McKINLAY, J., JEFFREYS, S. AND WRIGHT, C. Military Prehospital Emergency Care: defining and professionalising the levels of care provided along the Operational Patient Care Pathway. Journal of the Royal Army Medical Corps. 2018.165(3), pp.188-192. Available at: https://dx.doi.org/10.1136/jramc-2017-000896.

ABSTRACT This article discusses the challenges and interorganisational opportunities in retaining clinical competency in a military cohort where the focus is on operational preparedness. Whilst the United Kingdom (UK) Defence Medical Services (DMS) has had registered nurses, other Allied Healthcare Professions and organic military medics established for many years, it has only generated a paramedic capability in the last 10-15 years. Over 150 years since Florence Nightingale returned from the Crimea to create systems to promote nursing competency, the DMS paramedic cadre is retracing these steps to optimise success in achieving the clinical competencies they need for deployment. It is fifteen years since the last UK military hospital closed; therefore, developing interorganisational relationships was essential to support the next generation of DMS personnel in meeting future operational challenges.

11. EASTRIDGE et al., Death on the Battlefield (2001-2011). Journal of Trauma and Acute Care Surgery. 2013. Death of the battlefield (2001-2011). 74(2), pp.705-706. Available at: https://journals.lww.com/jtrauma/Abstract/2012/12005/Death _on_the_Battlefield_2001_2011_10.aspx. 12. Care Quality Commission. Defence Medical Services Report June 2012. http://www.cqc.org.uk/sites/default/files/documents/20120621_dms_report_full_final.pdf. 13. FRANCIS, R., Report of The Mid Staffordshire NHS Foundation Trust Public Inquiry Executive Summary. HM Government. 2013. 14. RANDALL-CARRICK, J. Experiences of Combat Medical Technician Continuous Professional Development on Operations. Journal of the Royal Army Medical Corps, 2012. 158(3), pp.263-268. Available at: <http://dx.doi.org/10.1136/jramc-158-03-24>. 15. VAN DILLEN, C., TICE, M., PATEL, A., MEURER, D., TYNDALL, J., ELIE, M. and SHUSTER, J. Trauma Simulation Training Increases Confidence Levels in Prehospital Personnel Performing Life-Saving Interventions in Trauma Patients. Emergency Medicine International. 2016. pp.1-5. Available at: http://dx.doi.org/10.1155/2016/5437490.

Conflict of Interest The authors have no conflict of interest to declare. REFERENCES 11. KARIMI, H. and MASOUDI ALAVI, N., Florence Nightingale: The Mother of Nursing. Nursing and Midwifery Studies, 2015. 4(2).

16. DUNNING, D., The Dunning-Kruger effect: On being ignorant of one's own ignorance. Advances in experimental social psychology. 2011. 44, pp.247-296. Available at: https://doi.org/10.1016/B978-0-12-385522-0.00005-6.

12. GODFREY, K., Francis in Brief: Key Nursing Recommendations. Nursing Times, 2013 (Vol 109 No 7). Available at: https://cdn.ps.emap.com/wpcontent/uploads/sites/3/2011/05/Francis-report-3.pdf.

17. HM Government Disclosure and Barring Service. Available at: https://www.gov.uk/government/collections/dbschecking-service-guidance--2.

13. https://www.hcpc-uk.org/standards/standards-of-proficiency/paramedics/.

18. BULGER, J., DRISCOLL, T., HUSSAIN, A., EDWARDS, A., EVANS, B., GRIFFITHS, L., JAMES, M., KEEN, L., KINGSTON, M., McLEAN, G., PHILLIPS, C., PORTER, A., SNOOKS, H. and WATKINS, A., PP17 Ambulance paramedics responding to urgent patient requests in general practice for home visits - evaluation development (ARRIVE). Emergency Medicine

14. THOMPSON, L., HILL, M., McMEEKIN, P. and SHAW, G. Defining major trauma: a pre-hospital perspective using focus groups. British Paramedic Journal, 2019 4(3), pp. 16-23. Available at: http://dx.doi.org/10.29045/14784726.2019.12.4.3.16.

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Journal, 2019. 36(10), pp.e8.2-e8. Available https://dx.doi.org/ 10.1136/emermed-2019-999abs.17.

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28. The DMS Continuous Attitude Survey Highlights Report RAF Paramedic 2018 and 2019. Ministry of Defence. 2018/2019.

19. HENDERSON, T., ENDACOTT, R., MARSDEN, J. and BLACK, S., Examining the type and frequency of incidents attended by UK paramedics. Journal of Paramedic Practice . 2019. 11(9), pp.396-402. Available at: http://dx.doi.org/ 10.12968/jpar.2019.11.9.396.

29. BARLOW, A. and SMITH, M., Do UK military General Practitioners feel adequately skilled in the provision of care to the acutely unwell or injured patient? Journal of the Royal Army Medical Corps, 2018 165(5), pp.342-345. Available at: <http://dx.doi.org/ 10.1136/j ramc-2018001035>.

20. BISWAS, J ., LENTAIGNE, J., BURNS, D., OSBORNE, J., SIMPSON, A., HUTLEY, E., HILL, N. and BAILEY, M., Undifferentiated febrile illnesses in South Sudan: a case series from Operation TRENTON from June to August 2017. BMJ Military Health . 2020. pp. jramc-2019-001238. Available at: https:// militaryhealth.bmj.com/search/jramc2019-001238%20jcode%3Ajramc

30. JADZINSKI, M., JACK, E. and DARBY, I., What value does peer-assisted learning have in the training of student paramedics? Journal of Paramedic Practice, 2019 . 1198), pp.342-347. 31. Clinical Information Support Overview Reports dated 8 January to 12 December 2019. NHS Ambulance Service.

21. DRIVER, J., SIMPSON, R., WALL, C. and NELSON, T., Dermatology on Operation HERRICK. Journal of the Royal Army Medical Corps, 2012 158(3), pp.232-237. Available at: <http://dx.doi.org/ 10.1136/jramc-158-03-18>.

32. BRICKNELL, M. and NADIN, M., Lessons from the organisation of the UK medical services deployed in support of Operation T ELIC (Iraq) and Operation HERRICK (Afghanistan). Journal of the Royal Army Medical Corps, 2017 163(4), pp.273-279. Available at: https://dx.doi.org/ 10.1136/jramc-2016-000720.

22. HAURET, K., TAYLOR, B., CLEMMONS, N., BLOCK, S. and JONES, B., Frequency and Causes of Nonbattle Injuries Air Evacuated from Operations Iraqi Freedom and Enduring Freedom, U.S. Army, 2001-2006. American Journal of Preventive Medicine, 2010. 38(1), pp. S94-S107. Available at: <http://dx.doi.org/ 10.1016/j.amepre.2009.10.022>.

33. 2008. Medical care for the Armed Forces. House of Commons Defence Committee. Available at: https://www.nhs.uk/ nhsengland/ militaryhealthcare/documents/defence%20committee.pdf.

23. WOJCIK, B., HUMPHREY, R., CZEJDO, B. and HASSELL, L., U.S. Army Disease and Nonbattle Injury Model, Refined in Afghanistan and Iraq. Military Medicine, 2008 173(9), pp.825835. Available at: https://pubmed.ncbi.nlm.nih.gov/ 18816921/

Abbreviations (by order of appearance) DMS: HCPC: SHC: NHS: WTE: MEDEVAC: SQEP: RAFMS: MERT: CQC: CCE: OPCP: NQP: HEE: MSKI: KPI:

24. COURTNEY, J., FRANCIS, A. and PAXTON, S., Caring for the Country: Fatigue, Sleep and Mental Health in Australian Rural Paramedic Shift workers. Journal of Community Health, 2012 38(1), pp.178-186. Available at: <http://dx.doi.org/ 10.1007/s10900-012-9599-z>. 25. HOFFMAN, J., I can't turn my brain off: PTSD and burnout threaten medical workers. The New York Times. 2020. Available at: https://www.nytimes.com/2020/05/ 16/health/coronavirus-ptsdmedical-workers.html. 26. JOHNSTON, A., Deskilling and return to practice on lowtempo operations. Journal of the Royal Army Medical Corps, 2019. 165(5), pp.310-311. 27. HAGER P., BECKETT D. Issues Concerning Related Topics Such as Skills, Competence, Abilities and Capabilities. In The Emergence of Complexity: Perspectives on Rethinking and Reforming Education. Springer, 2019. Cham.

Defence Medical Services. Health Care Professions Council. Secondary Health Care. National Health Service. Whole Time Equivalent. Medical Evacuation. Suitably Qualified Experienced Personnel. Royal Air Force Medical Services. Medical Emergency Response Team. Care Quality Commission. Continuous Clinical Experience. Operational Patient Care Pathway. Newly Qualified Paramedic. Health Education England's. Musculo-Skeletal Injury. Key Performance Indictors.

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A RT ICLES

Florence Nightingale’s Influence on Nursing in the Canadian Armed Forces. By S.D. SULLIVAN∑, J.H. SCHMID∏, I. DUPUISπ and O.A. CARBONNEAU∫. Canada

Shellie SULLIVAN Major Shellie SULLIVAN, BSc, BScN, MA, RN, commissioned as a Nursing Officer in the Canadian Armed Forces in 2004 and completed a specialization in Critical Care Nursing in 2006. Major SULLIVAN is currently posted to the Canadian Forces Health Services Group Headquarters in Ottawa as the Staff Officer to the Chief of Nursing Services. Deployments: Op ATHENA: Role 3 Multinational Medical Unit at Kandahar Airfield, Afghanistan (January – August 2007 & September 2008 – May 2009) – Critical Care Nursing Officer. Op HESTIA: CAF Role 2 Hospital at Leogane, Haiti (January – March 2010) – Critical Care Nursing Officer. Op ATTENTION: NATO Training Mission Afghanistan in Kabul (September 2011 – March 2012) – Advisor to nursing instructors of the Armed Forces Academy of Medical Sciences. Degrees: Bachelor of Science, 2001 – University of Calgary. Bachelor of Science in Nursing, 2004 – University of Alberta. Master of Arts in Human Security and Peacebuilding, 2018 – Royal Roads University.

RESUME L'influence de Florence Nightingale sur les soins infirmiers dans les Forces armées canadiennes A l’occasion du bicentenaire de la naissance de Florence Nightingale et de l’année internationale de l’infirmière, l’obj et de cet article est d’examiner de quelle façon cette femme a influencé la pratique des soins infirmiers dans les Forces armées canadiennes. L'héritage de Florence Nightingale en tant que figure emblématique de la profession d’infirmière et de la défense des patients continue à avoir une forte résonance auj ourd’hui au sein des Forces armées canadiennes (FA C). Son courage et la qualité des actions cliniques qu’elle a pu mener pendant le conflit en Crimée ont indirectement influencé le déploiement d’infirmiers à l’appui des missions militaires auxquelles a récemment participé le Canada. De plus, son travail statistique et épidémiologique a contribué à valider ce rôle infirmier dans le domaine de l'amélioration des conditions de soins aux patients et du contrôle des épidémies voir de pandémies lorsqu’elles se développent. Nightingale a été une ardente défenseure des populations vulnérables qui n'avaient pas accès à des soins comme ce peut être encore le cas en situation humanitaire ou de conflit armé. C’est avec ces valeurs et sa compassion que les FA C continuent à prodiguer des soins infirmiers aux populations mal desservies. Bien que ceux-ci aient techniquement considérablement évolué depuis l'époque de Nightingale, c’est son travail qui a j eté les bases du paysage actuel de l'enseignement infirmier. Au Canada, les infirmières des FAC sont maintenant des officiers préparés dès le baccalauréat pour suivre un enseignement et une formation approfondie afin de pouvoir répondre aux exigences des rôles cliniques et administratifs qui leur sont attribués. Cela leur permet d’occuper pleinement et de façon transparente les places de mentor, de clinicien et de leader que l’on attend d’elles lors de leur déploiement sur des missions inconnues et souvent en situation précaire, tout comme Nightingale l'a fait à son époque.

Keywords: Nightingale, Canadian, CAF, Nurse, Nursing Officer, Deploy. MOTS -CLÉS : Nightingale, Canada, Forces Armées Canadiennes (FA C), Infirmière, Déploiement opérationnel. International Review of the Armed Forces Medical Services

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Doctor, Nursing Sister and two orderlies draining an inf ected leg of a soldier at the No. 7 Canadian General Hosp ital, 1917 É tap les, France.

INTRODUCTION As the International Year of the Nurse and the Midwife unfolds, it is important for nurses to reflect on their current practice and on how the past has influenced the profession today. In particular, Florence Nightingale’s work, whether deploying to a war zone, establishing education standards, or advocating for improved hospital sanitation and healthcare reform, firmly established her as an important historical figure who is often considered the founder of modern day nursing. Her efforts and work significantly contributed to professionalizing nursing and to demonstrating the value of nursing care in community, hospital and austere settings 1. Nightingale’s leadership, innovation and advocacy remain a cornerstone for nursing practice today and her example continues to influence modern nursing. In honor of the 200th anniversary of Florence Nightingale’s birth, this article will review some of her strengths which have particularly influenced the practice of nursing in the Canadian Armed Forces (CAF) and how the CAF nursing profession has evolved since her time.

(Photo courtesy of Library and Archives Canada/ W.L . Kidd collection/e002283126).

Nursing sister and patients outside a ward tent, No. 2 Canadian General Hosp ital, Le Trép ort, France, 1917. (Photo courtesy of Library and Archives Canada/ Alice E . Isaacson f onds/e007150658).

PROFESSIONAL TRAINING AND EDUCATION FOR NURSES Early in Nightingale’s career she identified the need for nurses to possess specific skillsets and qualifications2 . She understood that appropriate training was essential to ensure patients received appro priate quality care. Therefore, when she returned from Crimea a war heroine, she capitalized on her public popularity and in 1860 opened a school of nursing within the St. Thomas’ Hospital3 4 5. Her nursing school had a threefold purpose: to prepare ‘matrons’ in administration and teaching; to train nurse supervisors to ensure safe and effective care was delivered by untrained nurses; and to train individual nurses6 . The Nightingale School of Nursing became the model of nurse training and spurred the formation of practical nursing education programs across the Western world. More importantly, her aspiration to educate nurses and improve standards of care was the impetus that propelled the professionalization of the nursing occupation as we know it today.

The post-WWI period was when Canadian nursing education began to evolve, away from the traditional Nightingale model towards higher education. For example, nurse education during and after WWI was based on an apprenticeship model, where hospital staffing was largely centred on the use of nursing students throughout their training. These student nurses would progress through each year of education, towards more

In Canada, nursing professionalization accelerated during World War I (WWI) as it was a period of medical modernization and advancement, particularly for the military medical services. During this time, patient care was pushed forward from field hospitals to casualty clearing stations to provide advanced and more rapid treatment to critically injured soldiers near front lines7. Canadian military nurses were essential members of these casualty clearing stations, providing comfort as well as advanced nursing skills to patients. For example, in addition to their regular clinical duties, many were also expected to administer anesthetics and assist in surgeries8 .

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∑ Major, Critical Care Nursing Officer, Royal Canadian Air Force. ∏ Lieutenant-Colonel, Critical Care Nursing Officer, Canadian Army. π Captain, General Duty Nursing Officer, Canadian Army. ∫ ļLieutenant, General Duty Nursing Officer, Royal Canadian Navy.

For their contributions and efforts during WWI, military nurses earned the public’s admiration, which helped to gain recognition for nursing as a profession and gave a voice to both military and civilian nurses alike9 10 . This enabled nurse leaders to establish improved education standards across Canada.

International Review of the Armed Forces Medical Services

Correspondence: Lieutenant-Colonel Joanne Schmid CF H Svcs Gp HQ NDHQ (Carling Campus) 101 Colonel By Dr., Ottawa, ON, K1A 0K2, Canada E-mail: joanne.schmid@forces.gc.ca

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Nursing Off icers, Cap t Carbonneau (lef t) and Lt (N) Maynard (f ar right) participating in a simulated multidiscip linary trauma team exercise while on dep loyment to the Role 2 medical treatment f acility Op IMPACT, Iraq, 2016© Government of Canada.

complex clinical and administrative responsibilities until graduation11. However, immediately after WWI, in 1919 the first university baccalaureate degree program was established in British Columbia12 . Over the years, and with the expansion of nursing roles and increased complexity of care, the entry-to-practice in most Canadian provinces eventually evolved to a baccalaureate degree in 199813 14 . This educational shift has been supported by research which demonstrates that patient safety and outcomes are improved with baccalaureate pre pared nurses15. Canadian nurses are now largely educated through universities/colleges in all provinces, with the exception of Quebec, and must obtain a Bachelor degree in Nursing in order to become a Registered Nurse. As such, this degree is the minimum standard to serve as a Nursing Officer in the Canadian military, and is the first phase of their professional education and training requirement.

(Photo credit: Canadian Forces Combat Camera).

After graduation, military Nursing Officers are expected to complete a number of occupational training and education courses prior to full employment in the CAF. This modern-day approach demonstrates how nursing continues to professionalize in order to meet operational and patient needs. For example, once CAF Nursing Officers graduate from nursing school, they undergo at least nine months of a clinical phase training to consolidate their skills in medicine, surgical, and emergency department environments. This ensures they solidify their clinical skills to occupationally meet the various demands of the CAF. Upon completion of clinical phase training, Nursing Officers may then train as Primary Health Care nurses, or can continue to gain exposure within the realm of medical-surgical nursing (including focused clinical ex posure to pediatrics and wound care). After one to two years of practice, Nursing Officers may elect to apply for specialty training in mental health, perioperative or critical care nursing. Specialty trained nurses must undergo a formalized didactic course within their specialty, followed by approximately one year of full-time specialty clinical training before deploying as a military nurse. All full-time military nurses are provided continuing professional educational opportunities and encouraged to continue to grow and learn throughout their career.

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Anesthesiologist, Cdr Power (lef t) and Critical Care Nursing Off icer, Cap t Mitchell (right) discussing clinical interventions during a simulated exercise while on dep loyment to the Role 2 f acility Op IMPACT, Iraq 2016© Government of Canada. (Photo credit: Canadian Forces Combat Camera).

INFECTION CONTROL AND DISEASE OUTBREAKS

Regardless of specialty, all Nursing Officers must undergo specific pre-deploy ment training prior to overseas missions. Along with specific military skills, medical training is also conducted in preparation for working in an operational military environment. Conducted with the multidisciplinary team deploying, this focused training covers mission-specific knowledge, skills, equipment, standard operating procedures, as well as an emphasis on building cohesive teams. This approach is critical to the readiness of CAF Nursing Officers and ensures preparedness, clinical best practice, and avoids issues that can arise with training gaps. Looking back, this training reinforces the vision of Nightingale, to educate and train in order to provide safe and competent quality care to patients. However, training and education has significantly advanced since her time and reflects the diverse clinical roles, both inside and outside the hospital setting, as well as the expanded scope of practice required of nurses to meet today’s complex care needs.

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At the core of Nightingale’s work was the use of evidence to inform her practice, particularly when it came to infection prevention and control. Throughout her life she was an avid statistician, apply ing clinical findings, evidence and statistics to steer interventions. For example, while in Crimea, she documented patient and hospital conditions alongside interventions she initiated to inform on their efficacy and patient mortality. This information provided evidence on the positive impact sanitation, patient hygiene, and nutrition had on patient outcomes 16 . Despite not fully understanding the theory and reasons behind infection prevention and control (IPAC), Nightingale’s environmental theory, which included improving sanitation, cleanliness, and ventilation, became building blocks of what is now known as public health nursing 17 .

Revue Internationale des Services de Santé des Forces Armées

Canadian military nurses have continued Nightingale’s legacy to improve sanitation and hygiene for soldiers on deployments, where conditions are often dirty and resources scarce. For example, during WWI deployed nurses were responsible for hospital sanitation and patient nutrition, while others were burdened with balancing their bedside care duties with the added responsibility of battling influenza, tuberculosis and dysentery outbreaks 18 . Throughout WWI and WWII, competent and skilful nursing care were sometimes the only treatments available during such disease outbreaks 19 . After both world wars, many military nurses moved into the civilian sector and made positive contributions to public health nursing in Canada. Military nurses were particularly well-suited for this specialty because their war-time experiences gave them the selfconfidence to work independently and provided an intimate knowledge of prevention and control of diseases in austere environments20 21. Throughout Canada’s history, military nurses have also been integral to national and international public health crises and disease outbreaks. For instance, during the 1953 Manitoba polio epidemic, military nurses were mobilized and deployed to provide specialized care for Canadian patients in iron lungs22.

Parallel to these efforts, Nursing Officers were also engaged in supporting the broader CAF’s Infection Prevention and Control (IPAC) response during the pandemic. For example, a Nursing Officer who was the only member Certified in Infection Control in the CAF, was seconded to Force Health Protection to provide IPAC expertise and guidance at the strategic and tactical level to CAF/Department of National Defence (DND) healthcare workers, military members and leadership alike. The clinical skills and leadership provided by Nursing Officers often bridged care gaps as well as increased infection control measures and are testaments to the expertise Nursing Officers offer during disease outbreaks. In similar fashion to Nightingale, military nurses throughout history have played substantial roles in improving conditions and providing quality care to those most in need during epidemics and pandemics.

MILITARY NURSING AND DEPLOYMENTS Nightingale was a true pioneer when it came to deployed nursing. Her deployment to Scutari not only Nursing Off icer, Cap t Moreau (2nd f rom the lef t) teaching Health Services staff bedside care in p reparation of their dep loyment to Long-Term Care f acilities during the COVID-19 pandemic, 2020© Government of Canada.

More recently, military nurses have been employed in civilian Intensive Care Units during the 2003 SARS-CoV-1 epidemic, deployed to Sierra Leone to care for local healthcare workers suffering from the Ebola Virus Disease, and repatriated Canadian citizens from China, Japan, and the United States during the COVID-19 pandemic. The pandemic continues to evolve and military nurses remain integral to Canada’s response. In late April 2020, Nursing Officers as well as many other CAF members were deployed to Quebec, Ontario and Nova Scotia Long Term Care facilities which were hard hit by COVID19. Their presence was in support of civilian healthcare facilities understaffed and unable to meet the demands of Canada’s most vulnerable population.

(Photo credit: Canadian Forces Combat Camera).

Patient in Iron Lung, with Nursing Lt. H .F. Ott and Surg. Lt. K .R . Flegg© Government of Canada.

Cap tain Myriam Moreau, Nursing Off icer, p roviding care to a resident at Auclair residential and long-term care centre in Montreal, Quebec during Op eration LASER on May 9, 2020© Government of Canada.

(Photo courtesy of Library and Archives Canada/ Department of National Def ence f onds/e010777499).

(Photo credit: Canadian Forces Combat Camera).

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demonstrated nurses’ capability to work in dangerous and austere conditions, but more importantly, it established nursing value in the provision of quality care and the conservation of the fighting force23 . Her deployment to Crimea led to significant improvements to patient care, hospital lay out and supply chain systems. This resulted in a significant reduction in mortality rates, which decreased from 42.7% in early 1855 to 2.2% in June 185524 . Nightingale’s impact to patient care improvement led to governmental recognition of nursing value to military healthcare, where she remained employed by the War Office as a nursing and healthcare consultant for an additional 26 years25. Her adaptability, clinical expertise and fearless approach in confronting priority issues while in Scutari laid the foundation of deployed military nursing, and remains an exemplar for CAF nurses who deploy on operations today.

given the rank and title ‘Nursing Sister’(called as such because they were originally drawn from the ranks of religious orders), granted officer status, and received the relative pay of a Lieutenant33 34 . In fact, up until mid-century, these Canadian Nursing Sisters were the only women to be integrated into military service and led the way towards continued nursing and female employment in the CAF35. Miss Minnie Aff leck, Nursing Sister, 1st Canadian Contingent, So. Af rican, 1899-1902 War, South Af rica, 1900. (Photo courtesy of Library and Archives Canada/ Minnie Aff leck collection/c051799).

CANADIAN MILITARY NURSING ROLES IN COMBAT OPERATIONS In Canada, deployed nursing in support of military operations began in 1885 with the North-West Rebellion. While this armed conflict lasted only 14 weeks, it became a landmark in Canadian military medical history as it spurred the formation of field hospitals in Canada26 . During this Rebellion it was quickly noticed orderlies and dressing staff weren’t adequately prepared or qualified to care for the wounded. This resulted in the forward deployment of small contingents of nurses to field hospitals27 . These nurses provided essential care to wounded soldiers, and their expertise was recognized as an important contributor to the conflict28 29 . For their efforts, the nurses were awarded the North-West Canada Medal, marking the first time nurses were decorated in Canadian history30 . Following the North-West Rebellion, Canadian nurses, under the leadership of Georgina Pope, received another call of duty; the South African (Boer) War in 189932 . The Boer War drove the need for Canada to officialise the military nursing service and established the Canadian Army Nursing Service (CANS). This was a turning point in military nursing history, as nurses were North West Canada Medal, 1885.

(Photo credit: Veterans aff airs Canada)31 .

For her leadership and outstanding accomplishments during this war, Pope was awarded the Royal Red Cross and was the first Canadian to receive this distinguished award36 . She was later appointed as the first Matron in the Canadian Army Medical Corps, which formalized a nursing leadership position within the Canadian military. In 1914, Nursing Sisters were once again mobilized. They deployed overseas in WWI under the leadership of Margaret Macdonald, Matron of the Nursing Services37 . During this war, the Canadian military medical service saw significant innovation, which required advanced education and recruiting standards for nurse applicants38 . For example, WWI nurses were responsible for a number of duties outside their typical bedside care role including patient sedation, patient nutrition and camp sanitation39 . Throughout WWI, Nursing Sisters were often deployed near front lines where their contributions helped to improve early access to care, the organization of care and supported the mental health of soldiers40 . However, forward deployments also meant nurses worked in harm’s way, which resulted in the loss of 53 Nursing Sisters from enemy action and disease41. The most tragic incident occurred on 27 June 1918, when the Canadian Hospital Ship Llandovery Castle was torpedoed by a German U-boat south of Ireland and sunk with the loss of 14 Nursing Sisters on board42 . The compassion, sacrifice and dedication the Nursing Sisters displayed throughout WWI earned a revered reputation within the Canadian public. This reputation and praise helped to legitimize the nursing profession in Canada, much like how Nightingale’s successes in Crimea also legitimized the nursing profession in England43 44 .

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Canadian nursing sisters working amongst ruins of the 1st Canadian General Hosp ital, which was bombed by the Germans, three nurses being killed, Etap les, France, June 1918 .

evolved to keep pace with operational demands, patient care needs and advancements in clinical care. More importantly, CAF nursing contributions to each of these missions have positively contributed to quality care and survivability rates for their patients45 46; similar to the influence of Nightingale’s work in Crimea. It is certainly clear that throughout Canadian history, CAF nursing has been influenced by Nightingale’s strengths as a leader and fearless nurse on deployed operations, as this legacy continues today.

(Photo courtesy of Library and Archives Canada/ Ministry of the Overseas Military Forces of Canada f onds/a003747).

Cap t Brett, Critical Care Nursing Off icer (right), participating in a Forward Aeromedical Evacuatio exercise during her dep loyment to the UN Multidimensional Integrated Stabilization Mission in Mali, 2018© Government of Canada. (Photo credit: Canadian Forces Combat Camera).

Funeral of Nursing Sister Margaret Lowe, who died of wounds received in a German air raid, Etap les, France: May, 1918.

(Photo courtesy of Library and Archives Canada/Ministry of the Overseas Military Forces of Canada f onds/a002574).

Each operation Canadian nurses have deployed to helps validate the role of the nursing profession within the Canadian military. Since WWI, military nurses have consistently deployed with the Canadian Armed Forces to all major conflicts, including WWII, Korea, Persian Gulf War, Somalia, Rwanda, Former Yugoslavia, Afghanistan and Iraq, typically to provide in-hospital care. In recent years, nursing positions have been established within Canadian Special Forces Mobile Surgical Response Teams which deploy to missions globally in often extreme conditions and with severely wounded patients. As well, nurses have been integrated into the CAF’s new Forward Aeromedical Evacuation capability, named the Canadian- Medical Emergency Response Team, where they successfully completed an 18-month mandate with the United Nations Multidimensional Integrated Stabilization Mission in Mali, flying medical missions.

CANADIAN MILITARY NURSING ROLES IN HUMANITARIAN, PEACE SUPPORT OPERATIONS, AND CARE OF VULNERABLE POPULATIONS Much of Nightingale’s work, and particularly her writings later in life, highlighted the importance of addressing the social determinants of health47 . This was especially important during her time, as lower socioeconomic status often limited or restricted access to quality healthcare. Nightingale was a driving force to upset this system, particularly in support of improved care for socially disadvantaged populations such as the poor, mentally ill, disabled, elderly, children and indigenous populations in India48 49 . Her strengths in recognizing the link between poor social conditions and health was

In each of these conflicts, nursing roles have shifted and

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foundational to her advocacy efforts for underserved populations, which he lped to improve access and quality of care for society’s most vulnerable50 51. While health equity has significantly improved since her time, there are many underserved populations globally who remain without access to care, including those in remote locations, in conflict zones or experiencing humanitarian crises. CAF nurses have followed in Nightingale’s footsteps throughout history, deploying to conflict zones, humanitarian crises and working in isolated posts in Canada, bridging healthcare gaps for various underserved and vulnerable populations. After WWII, many Nursing Officers were historically posted to remote and isolated Canadian military bases, often near the Distance Early Warning (DEW) Line, where healthcare access was limited52 53. In these locations, CAF nurses and other health care workers provided essential care to military members, their families and the local community; often working with limited resources and support. Nursing Sister evacuating a patient f rom Fort Churchill, Manitoba, ca. 1943-1965© Government of Canada. (Photo courtesy of Library and Archives Canada/ Department of National Def ence f onds/e010781669).

ages care, delivering culturally sensitive care and improving their decision making capabilities related to limited medical, material and human resources. These lessons are particularly useful and transferrable to humanitarian or military operations where significant language and cultural barriers often exist and resources are scarce. Beyond Canada’s borders, CAF Nursing Officers have also long been engaged in caring for underserved populations, often in complex conditions. During the 1990s, CAF Nursing Officers deployed to an array of conflicts and humanitarian crises including Somalia, the former Yugoslavia and Rwanda55. On these missions, CAF Nursing Officers provided essential care to some of the world’s most vulnerable populations, including refugees and children56 . Between 1993 and 1995, Canada was the only country to perform aeromedical evacuations out of Sarajevo, where Canadian Nursing Officers and Medical Assistants evacuated 990 refugee patients to the Italian Red Cross57 . Parallel to this mission, Canadian Nursing Officers were deployed to provide care in refugee camps in Rwanda and to fly aeromedical evacuation missions of UN members and refugees out of Kigali, Rwanda and Mogadishu, Somalia58 . Cap t (ret ’d) Sorokowski assessing a p ediatric patient at the Mareru ref ugee camp , Rwanda 1994 . (Photo courtesy of Cap t (ret ’d) Hop e Sorokowski).

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Most of these bases were closed in the post-Cold War era, however, in 2015, DND re-established clinical nursing opportunities with its federal partner, Indigenous Services Canada, in northern Ontario. This nurse-led initiative permits military nurses to embed within one of 22 nursing stations, providing primary and emergency care to remote and isolated indigenous populations. Due to the remoteness of these communities, local populations are relatively underserved compared to other Canadians who have access to a range of clinical services in larger urban centers. For example, populations in Northern Ontario are more likely to die prematurely and report less access to a primary care giver than the rest of Ontario’s population54 . These federally run nursing stations provide an essential healthcare service to underserved populations. The military nurses who rotate into these communities work alongside seasoned outpost nurses to improve access to care while at the same time gain an array of clinical and professional experiences. These include expanding their knowledge related to all-

International Review of the Armed Forces Medical Services

Since the 1990s, Canadian Nursing Officers have deployed to other humanitarian missions as part of the CAF Disaster Assistance Response Team (DART) which stood up in 199859 . The DART medical section has a mandate to provide primary medical services to CAF and local populations during natural disasters and humanitarian crises. Due to the nature of these missions, local governments are often unable to provide adequate healthcare services to their citizens following a disaster. As such, CAF Nursing Officers, alongside other medical professionals, bridge those gaps and provide access to essential care. CAF nurses have also been integral to additional recent missions including the Role 2 hospital deployment to Haiti in 2010 (post-earthquake), the joint mission to Sierra Leone in 2014-15 (in response to the Ebola virus disease outbreak), and the Syrian refugee screening mission in 2015-16, amongst others.

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Nightingale’s vision of increasing access to care for underserved and vulnerable populations continues to influence modern nursing and remains a core pillar to the work CAF Nursing Officers perform today. This is indeed one of the main reasons many nurses join and continue to serve in the Canadian Forces Health Services.

Lieutenant-Colonel through a wide variety of career paths, which include nursing specialization, training, administration and policy development. The Chief of Nursing Services (CNS) is the CAF’s most senior Nursing Officer position and is established at the rank of Lieutenant-Colonel. The appointed CNS is the Nursing National Practice Leader (NNPL) and Nursing Military Occupation Structure Identification (MOSID) Advisor (Nur MOSID Adv). The NNPL advises the Surgeon General on professional-technical concerns specific to nursing, provides professional leadership and clinical guidelines to all DND nurses, and prioritizes nursing practice issues and policies. The Nur MOSID Adv has the authority to make decisions for the MOS ID with regard to career postings, courses, clinical education, and deployments. The primary responsibility of the MOSID Adv is to ensure the sustainability of the Nursing occupation. The CNS also leads a team of Senior Practice Leaders for each nursing specialty, who advise on personnel and practice issues within their specialty domain. Finally, the CNS holds the title of “Honorary Nurse to the Queen”, as a long standing tradition with the British monarchy. The CNS role continues to follow in the footsteps of former military nurse leaders, whose responsibilities remain steadfast: lead, develop and advocate for military nurses and excellence in patient care.

Cap t Raj otte-Caron (Nursing Off icer) p erf orms triage while dep loyed on Op eration RENAISSANCE as part of the DART mission to Sara, Philipp ines 2013© Government of Canada. Photo credit: Canadian Forces Combat Camera).

The multifaceted and often concurrent roles CAF Nursing Officers are employed in, such as clinician, manager, mentor, leader and administrator, demands that they develop and utilize leadership knowledge and skills to best support and contribute to collaborative and quality patient care environments. While leadership expectations and positions have considerably

LEADERSHIP Another of Nightingales’ strengths that continue to influence CAF nursing was her remarkable management and leadership. Nightingale possessed innate leadership attributes which helped her to influence healthcare reform as well as advance nursing to a respected profession60 . These leadership attributes include collaborator/team member, risk taker, advocate for quality care, role model and visionary61. Today, just as in Nightingale’s time, possessing and honing these leadership skills are essential elements to the development of a strong and effective nurse leader.

Royal Canadian Army Medical Corps Matron-in-Chief Elizabeth Smellie, the f irst woman in the world to reach the rank of Colonel62 ca. 1943-1965 © Government of Canada. (Photo courtesy of Library and Archives Canada/ Department of National Def ence f onds/e010778626).

In the CAF, all registered nurses are enrolled as Officers, and their duties demand a great deal of leadership in both clinical and non-clinical capacities. For example, Nursing Officers are often employed in clinical and non-clinical leadership positions in garrison and on deployed operations, such as Senior Nursing Officers (SNO), Administrative Officers, Course Directors, Primary Care Service Managers, Company Commanders, Officers in Charge of In-Patient Services and High Readiness Detachment Commander. These leaders, as well as all Nursing Officers, play a vital role in fostering teamwork and cohesion among members of the multidisciplinary health services team by encouraging communication and facilitating coordination of effective patient care. While some nurses transfer to the Health Services Operations Officer occupation to take on command positions in field and clinical units across the CAF, many remain in nursing to lead and inspire the next generation. VOL. 93/3

Those Nursing Officers who remain in nursing have the opportunity to progress from the rank of Lieutenant to

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Current CAF Chief of Nursing Services and Queen ’s Honorary Nursing Off icer, LCol C. Blanchard, 2020.

throughout recent Canadian history. Additionally, her statistical and epidemiological work helped to solidify the role nurses would take on in improving patient care conditions, providing quality care and disease outbreak control in deployed settings or during epidemics and pandemics. Nightingale was also a staunch advocate for vulnerable populations who lacked access to quality care and worked tirelessly to reduce barriers surrounding this issue. CAF nursing continues to reflect these compassionate values through the provision of care to vulnerable and underserved populations, such as in remote, humanitarian or conflict settings. While nursing has significantly evolved since Nightingale’s time, her work to establish standards of care laid the foundation for today’s nursing education landscape. In Canada, CAF nurses are now baccalaureate prepared officers and leaders who undergo extensive training and education to meet the demands of their clinical and administrative roles. This helps CAF nurses to seamlessly move between the roles of mentor, clinician and leader and to deploy to unknown and often precarious missions, j ust as Nightingale did in her day. REFERENCES

evolved since the turn of the century, it is clear that Florence Nightingale’s example as a leader and influencer remains at the heart of nursing, and particularly nursing in the CAF.

11. HARPER, D., K. DAVEY, and P. FORDHAM. “Leadership Lessons in Global Nursing and Health from the Nightingale Letter Collection at the University of Alabama at Birmingham.” Journal of Holistic Nursing 32, no. 5 (2014): 44-53. https://doi.org/ 10.1177/0898010113497835.

CONCLUSION

12. SELANDERS, L., and P. CRANE. “The Voice of Florence Nightingale on Advocacy.” OJIN : The Online Journal of Issues in Nursing 17, no. 1 (January 2012): Para 6. https://oj in.nursingworld.org/ MainMenuCategories/ANA Marketplace/ANAPeriodicals/OJIN/TableofContents/Vol17- 20 12/ No 1-J a n- 20 12/ F lo re nc e- Nig ht ing a le- o nAdvocacy.html?css=print.

Florence Nightingale’s legacy not only set the foundation for modern day nursing, but the foundation for military nursing in the CAF as well. She selflessly answered the call to duty by deploying to Crimea and by later working for the war office to improve military healthcare conditions. History illustrates her as an exceptional clinician, leader and mentor, who had the ability to move between these different roles seamlessly. In the same manner, CAF military nursing expects its nurses to be able to shift between clinician, leader and mentor roles, and to deploy to unknown and often precarious missions. While nursing itself has tremendously evolved since her time, it is clear that Nightingale’s strengths continue to influence many of the core elements that define CAF nursing, which sets it apart as a unique practice role in Canada.

13. DEAN, E. “Florence Nightingale’s Life and Legacy in Objects.” Nursing Standard 35, no. 1 (2020): 14-17. 14. McDONALD, L. ed. Florence Nightingale and Extending Nursing: Collected Works of Florence Nightingale Volume 13. Waterloo, ON: Wilfred Laurier Press, 2009. 15. BATES, C., D. DODD, and N. ROUSSEAU, eds. On All Frontiers: Four Centuries of Canadian Nursing. Ottawa: University of Ottawa Press, 2005. 16. BAKER, C., E. GUEST, L. JORGENSEN, K. CROSBY, and J. BOYD. “The Ties that Bind: The Evolution of Education for Professional Nursing In Canada from the 17th Century to the 21st Century.” Canadian Association of Schools of Nursing, 2012. https://www.casn.ca/wpcontent/ uploads/2016/ 12/ History.pdf, p. 6.

ABSTRACT The purpose of this article is to reflect on Florence Nightingale’s influence on nursing in the Canadian Armed Forces, in recognition of her bicentennial birthday and as part of the International Year of the Nurse and Midwife commemoration.

17. “Nursing Sisters of Canada,” Veterans Affairs Canada, accessed February 24, 2020, https://www.veterans.gc.ca/eng/ remembrance/those-whoserved/women-veterans/ nursing-sisters

Florence Nightingale’s legacy as an adaptable leader and patient advocate continues to resonate with the occupation of nursing within Canadian Armed Forces (CAF) today. Nightingale’s courage and clinical actions during the conflict in Crimea indirectly influenced the establishment of deployed nursing in support of military missions

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18. STUART, M. “War and Peace: Professional Identities and Nurses’ training 1914-1930.” In Challenging Professions: Historical Contemporary Perspectives on Women’s professional work, edited by E. Smyth, S. Acker, P. Bourne, and A. Prentice, 171-193. Toronto: University of Toronto Press, 1999.

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25. HAY, I. One Hundred Years of Army Nursing. London: Wyman and Sons Ltd, 1953, p. 39.

19. Ibid. 10. TOMAN, C. “The Value of a Nursing Sister: “Worth five to ten bottles of blood or plasma in the eventual outcome of a case.” SITREP: The Journal of the Royal Canadian Military Institute 80, no. 1 (February 2020): 5-6.

26. Director General Health Services. Canadian Forces Medical Service: Introduction to its History & Heritage. Ottawa: Department of National Defence, 2003. 27. Members of the Hospital Staff Corps. The Medical and Surgical history of the North-West Rebellion of 1885. Montreal: John Lovell & Son, 1886. https://www.royalcdnmedicalsvc.ca/wp-content/uploads/2017/10/NW-RebellionMedical-Surgical-History.pdf.

11. BATES, C., D. DODD, and N. ROUSSEAU, eds. On All Frontiers: Four Centuries of Canadian Nursing. Ottawa: University of Ottawa Press, 2005, p. 80. 12. BAKER, C., E. GUEST, L. JORGENSEN, K. CROSBY, and J. BOYD. “The Ties that Bind: The Evolution of Education for Professional Nursing In Canada from the 17th Century to the 21st Century.” Canadian Association of Schools of Nursing, 2012. https://www.casn.ca/wpcontent/uploads/2016/12/History.pdf

28. Ibid. 29. “Nursing Sisters of Canada,” Veterans Affairs Canada, accessed February 24, 2020, https://www.veterans.gc.ca/eng/remembrance/those-whoserved/women-veterans/nursing-sisters.

13. Ibid. 14. “RN and Baccalaureate Education,” Canadian Nurses Association, accessed March 2, 2020, https://www.cnaaiic.ca/en/nursing-practice/the-practice-of-nursing/education/rn-baccalaureate-education.

30. NICHOLSON, G.W.L. Canada’s Nursing Sisters. Toronto: Hakkert Ltd, 1975. 31. “North West Canada Medal,” Veterans Affairs Canada, accessed April 24, 2020, https://www.veterans.gc.ca/eng/remembrance/medalsdecorations/details/3.

15. Ibid. 16. MIRACLE, V. “The Life and Impact of Florence Nightingale.” Dimensions of Critical Care Nursing 27, no. 1 (2008): 21-23. doi: 10.1097/01.DCC.0000304670.76251.2e.

32. LANDELLS, E.A. The Military Nurses of Canada Volume II, Recollections of Canadian Military Nurses. British Columbia: Co-Publishing, 1999.

17. HEGGE, M. “Nightingale’s Environmental Theory.” Nursing Science Quarterly 26, no. 3 (2013): 211-219. doi: 10.1177/0894318413489255.

33. LANDELLS, E.A. The Military Nurses of Canada Volume I, Recollections of Canadian Military Nurses. British Columbia: Co-Publishing, 1995.

34. LANDELLS, E.A. The Military Nurses of Canada Volume II, Recollections of Canadian Military Nurses. British Columbia: Co-Publishing, 1999. 35. TOMAN, C. “The Value of a Nursing Sister: “Worth five to ten bottles of blood or plasma in the eventual outcome of a case.” SITREP: The Journal of the Royal Canadian Military Institute 80, no. 1 (February 2020): 5-6.

19. TOMAN, C. “The Value of a Nursing Sister: “Worth five to ten bottles of blood or plasma in the eventual outcome of a case.” SITREP: The Journal of the Royal Canadian Military Institute 80, no. 1 (February 2020): 5-6.

36. LANDELLS, E.A. The Military Nurses of Canada Volume I, Recollections of Canadian Military Nurses. British Columbia: Co-Publishing, 1995.

20. STUART, M. “War and Peace: Professional Identities and Nurses’ training 1914-1930.” In Challenging Professions: Historical Contemporary Perspectives on Women’s professional work, edited by E. Smyth, S. Acker, P. Bourne, and A. Prentice, 171-193. Toronto: University of Toronto Press, 1999.

37. Ibid. 38. “Nursing Sisters of Canada,” Veterans Affairs Canada, accessed February 24, 2020, https://www.veterans.gc.ca/eng/remembrance/those-whoserved/women-veterans/nursing-sisters.

21. TOMAN, C. “Ready, Aye Ready: Canadian Military Nurses as an Expandable and Expendable Workforce, 19202000.” In On all frontiers: Four centuries of Canadian Nursing, edited by C. Bates, D. Dodd, and N. Rousseau, 153-167. Ottawa: University of Ottawa Press, 2005.

39. LANDELLS, E.A. The Military Nurses of Canada Volume I, Recollections of Canadian Military Nurses. British Columbia: Co-Publishing, 1995. 40. ALLARD, G. “Caregiving on the Front: The Experience of Canadian military nurses during World War I.” In On all frontiers: Four centuries of Canadian Nursing, edited by C. Bates, D. Dodd, and N. Rousseau, 153-167. Ottawa: University of Ottawa Press, 2005.

22. Ibid, p. 174. 23. COOK, E. The Life of Florence Nightingale, Vol 1. 18201861. London: Macmillan and Co, 1914.

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41. Ibid.

24. MIRACLE, V. “The Life and Impact of Florence Nightingale.” Dimensions of Critical Care Nursing 27, no. 1 (2008): 21-23. doi: 10.1097/01.DCC.0000304670.76251.2e, p. 22.

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42. “Nursing Sisters of Canada,” Veterans Affairs Canada, accessed February 24, 2020,

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Role II Field Hospital

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Following the publishing o� a public tender by the Belgian Ministry o� De�ence, UTILIS-G3S consortium won the tender in December 2019 to supply a mobile and modular �eld hospital. This solution will enable Belgium to respect its’ obligations to NATO and member nations whilst ensuring continued reliable service in support o� allied partners. With a budget o� 12 Million euros, the Ministry o� De�ence has the possibility to upgrade the ROLE II �eld hospital (MTF) to a ROLE II E (Enhanced) �eld hospital. Additionnal capability modules (dental care, mental health, isolation module �or in�ectious diseases, etc.) can be attached to achieve an enhanced con�guration. When deployed to �ull capacity, the �eld hospital o��ers surgical and care capacity �or 16 patients per 24 hour period using two surgical teams. This solution allows the Belgian Ministry o� De�ence to provide high-grade medical support to operations carried out with NATO and EU partners.

https://www.veterans.gc.ca/eng/remembrance/those-whoserved/women-veterans/nursing-sisters.

54. “Health in the North: A Report on Geography and the Health of People in Ontario’s Two Northern Regions.” Health Quality Ontario, accessed February 24, 2020, http://www.hqontario.ca/portals/0/Documents/systemperformance/health-in-the-north-en.pdf.

43. NICHOLSON, G.W.L. Canada’s Nursing Sisters. Toronto: Hakkert Ltd, 1975. 44. ALLARD, G. “Caregiving on the Front: The Experience of Canadian military nurses during World War I.” In On all frontiers: Four centuries of Canadian Nursing, edited by C. Bates, D. Dodd, and N. Rousseau, 153-167. Ottawa: University of Ottawa Press, 2005.

55. LANDELLS, E.A. The Military Nurses of Canada Volume II, Recollections of Canadian Military Nurses. British Columbia: Co-Publishing, 1999. 56. GAGNÉ M. “Airevac Nurses in War Zones.” Canadian Nurse 92, no. 2, 1996: 31–34.

45. TOMAN, C. “Ready, Aye Ready: Canadian Military Nurses as an Expandable and Expendable Workforce, 1920-2000.” In On all frontiers: Four centuries of Canadian Nursing, edited by C. Bates, D. Dodd, and N. Rousseau, 153-167. Ottawa: University of Ottawa Press, 2005.

57. Ibid. 58. Ibid. 59. “Disaster Assistance Response Team (DART) Deployments,” Government of Canada, last modified 2018, https://www.canada.ca/en/department-nationaldefence/services/operations/militaryoperations/types/dart/deployments.html.

46. TOMAN, C. “The Value of a Nursing Sister: “Worth five to ten bottles of blood or plasma in the eventual outcome of a case.” SITREP: The Journal of the Royal Canadian Military Institute 80, no. 1 (February 2020): 5-6. 47. HINES-MARTIN, V. and W. NASH. “Social Justice, Social determinants of health, Interprofessional Practice and Community Engagement as Formative Elements of a Nurse Practitioner Managed Health Center.” International Journal of Nursing & Clinical Practices 4, no. 218 (2017): 5 pages. https://www.graphyonline.com/archives/IJNCP/2017/IJNCP-218/.

60. SELANDERS, L., and P. CRANE. “The Voice of Florence Nightingale on Advocacy.” OJIN: The Online Journal of Issues in Nursing 17, no. 1 (January 2012). https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/A NAPeriodicals/OJIN/TableofContents/Vol-17-2012/No1Jan-2012/Florence-Nightingale-onAdvocacy.html?css=print.

48. McDONALD. L. “Florence Nightingale and the Early Origins of Evidence-based Nursing.” Evidence Based Nursing, 4 (2001): 68-69.

61. “Leadership,” Canadian Nurses Association. Accessed February 27, 2020, https://www.cna-aiic.ca/en/nursingpractice/the-practice-of-nursing/health-humanresources/leadership, para. 1.

49. McDONALD, L. ed. Florence Nightingale and Extending Nursing: Collected Works of Florence Nightingale Volume 13. Waterloo, ON: Wilfred Laurier Press, 2009.

62. TOMAN, C. “Ready, Aye Ready: Canadian Military Nurses as an Expandable and Expendable Workforce, 19202000.” In On all frontiers: Four centuries of Canadian Nursing, edited by C. Bates, D. Dodd, and N. Rousseau, 153-167. Ottawa: University of Ottawa Press, 2005.

50. HEGGE, M. “Nightingale’s Environmental Theory.” Nursing Science Quarterly 26, no. 3 (2013). 211-219. DOI: 10.1177/0894318413489255.

Abbreviations (by order of appearance)

51. HARPER, D., K. DAVEY, and P. FORDHAM. “Leadership Lessons in Global Nursing and Health from the Nightingale Letter Collection at the University of Alabama at Birmingham.” Journal of Holistic Nursing 32, no. 5 (2014): 44-53. https://doi.org/10.1177/0898010113497835.

CAF: Canadian Armed Forces. WWI: World War I. IPAC: infection prevention and control. DND: Department of National Defence. CANS: Canadian Army Nursing Service. DEW: Distance Early Warning. DART: Disaster Assistance Response Team. SNO: Senior Nursing Officers. NNPL: Nursing National Practice Leader. MOSID: Military Occupation Structure Identification. Nur MOSID Adv: Nursing Military Occupation Structure Identification Advisor.

52. LANDELLS, E.A. The Military Nurses of Canada Volume II, Recollections of Canadian Military Nurses. British Columbia: Co-Publishing, 1999. 53. TOMAN, C. “Ready, Aye Ready: Canadian Military Nurses as an Expandable and Expendable Workforce, 19202000.” In On all frontiers: Four centuries of Canadian Nursing, edited by C. Bates, D. Dodd, and N. Rousseau, 153-167. Ottawa: University of Ottawa Press, 2005.

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A RT ICLES

Nursing in the Armed Forces: Vision, Value and Voice of the Nurse, an Indian Perspective. By R. RAJU∑ and J.G. ROACH∏. India

Rajusha RAJU A qualified Nurse Educator and Researcher adept at coordinating and facilitating Nursing education and research for graduate Nurses, Nursing students as well as for the combatant Nurses of the Armed Forces Medical Services of India. Commissioned into Military Nursing Service as a Lieutenant in 2000 after successful completion of the Baccalaureate Programme in Nursing from the Armed Forces Medical College (AFMC), Pune. She was Awarded the Cariappa Rolling Trophy for the Best all round student of the year 2000. Served for 10 years in the Indian Armed Forces Hospitals as a nurse clinician in various capacities. Acquired Masters Degree in Paediatric Nursing from College of Nursing, AFMC, Pune in the year 2013 and had the opportunity to work as an educator & researcher in the Flagship establishment of the Armed Forces Medical Services (Army Hospital Research & Referral, New Delhi) before assuming the present appointment of Research Pool Officer at Directorate General of Medical Services (Army). The career span of 20 years in Nursing unfolds sheer determination, commitment and initativeness. The MNS Officer was awarded with Gen- Officer-Commanding Commendation Card for her meritorious Service in 2016.She is a registered member of the Critical care Nursing, Neonatal Nursing as well as Nursing Research Society of India. Presented papers in the national and International forums and is awarded twice for her research work in the field of Neonatal Pain Management. She has served as an executive editor multiple times for the in-service publications such as News Letters & Conference Bulletins of the Military Nursing Service. Privileged to be in the Editorial team of the publication of The Coffee Table Book of the Military Nursing Service released in the Year 2018.

RESUME Soins infirmiers dans les forces armées : vision, valeur et parole d’infirmière. Une perspective indienne. Le service infirmier militaire en Inde est l'un des plus anciens services professionnalisés, développ és à partir du début du XIX ème siècle sur l’expérience des grandes guerres. L'héritage de Florence Nightingale et l'impact du colonialisme britannique ont conj ointement ouvert la voie à l'établissement d'un service infirmier militaire bien structuré qui maintient un obj ectif d'excellence dans les soins apportés aux patients. Au-delà d'être un service de soutien, ce Corps a pris toute sa place au sein de l’effort de guerre de l’armée indienne et du pays tout entier. Les infirmiers militaires ont pris en charge les victimes lors de la Seconde Guerre mondiale, lors de diverses opérations armées (Cactus Lilly, Pawan, Rakshak, Vij ay …), des opérations d'assistance humanitaire et de missions de maintien de la paix mondiale. Les vastes compétences des officiers des services infirmiers militaires leur permettent de faire face aux demandes croissantes de consommateurs touchés par la modernisation, ses spécificités et diversités géographiques. La dynamique de formation du Service infirmier militaire a fortement évolué depuis l’indépendance avec de vastes programmes de formation dans des domaines variés. Ce développement est lié aux besoins des hôpitaux des forces armées et aux types d'opérations dans lesquelles est engagé le pays. Actuellement, la capacité de formation interne se répartit entre les six écoles d'infirmières du sous-continent indien avec une augmentation exponentielle du nombre de candidats aspirant à intégrer le service infirmier militaire indien.

KEYWORDS: MNS (Military Nursing Service), IANS (Indian Army Nursing Service), Queen Alexandra’s Military Nursing Service India (QAMNS). MOTS -CLÉS : Service infirmier militaire (MNS), Service infirmier de l'armée indienne (IANS), Service infirmier militaire de la Reine Alexandra (QAMNS).

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INTRODUCTION

during the British era. In 1664 the East India Company started a hospital for soldiers in a house at Fort St George, Madras. The first sisters were sent from St. Thomas hospital, London to this military hospital. In 1797 a Lying-in-Hospital (Maternity) for the poor in Madras was built with the help of subscriptions by Dr John Underwood. In 1854 the Government sanctioned a training school for midwives in Madras.

Military Nursing in India was the earliest type of Nursing evolved in British era1. Today it exists as a unique and exclusive women officer’s organization of the Indian Armed Forces with more than five thousand members. In Indian history, the Military Nursing Service (MNS) stands out as one of the oldest Services, where women have contributed directly to the nation’s war efforts by providing care to the sick and wounded soldiers.

(a) Legacy of Miss Florence in India The dawn of a new concept bloomed in the history of nursing by Florence Nightingale through her work in Crimea, which was instrumental in bringing about some pioneering health and sanitary reforms in India. Though the primary focus was on the British soldiers, it eventually turned towards India, where so many of them were stationed. Miss Nightingale never visited India but her accurate knowledge of conditions in the hospitals there was remarkable.-. The ‘Circular of Enquiry’ drafted by Miss Nightingale was a milestone in planning healthcare services for soldiers in India3. This draft was focused on a vast range of facts regarding mortality, invalidity, age and length of Service of a person at the time of death or invalidity, barrack accommodations, and other amenities for soldiers at each station. In addition to this, she also wrote to twohundred of the larger stations asking for all regulations related to sanitary administration of the Indian Army. After many delays and setbacks, the reform of the military Barracks and hospitals gradually became an accomplished fact for British and Indian soldiers alike. This inevitably led to similar reforms in civil hospitals in India3. Echoes of Nursing Reforms Across India: In 1860 through the establishment of the first school of Nursing in St Thomas Hospital England in the latter part of the 19th Century, technical and moral standards of nursing were raised. Florence Nightingale exalted the importance of the nurse's integrity and changed the approach of society towards nursing. She notified the valuable contribution nurses could make in health care to the authorities and promulgated the vision value and voice of nurses to the world.

BACKGROUND War in Crimea broke out in 1854, between Turkey and Russia. England and France were helping Turkey in the war against Russia and there were no nurses to care for the wounded soldiers. An appeal was sent out for help and Miss Nightingale who was looking for “a field worthy of her power” read this appeal and offered her services to the Minister of War. Amidst this obscurity and despair, Florence Nightingale laid the foundation of Modern Nursing2, 3.

NURSING IN ANCIENT INDIA (a) Vedic period The history of Nursing in India dates to about 1500 BC Atharvaveda (a sacred text of Hindus) contains the earliest accounts describing health care. In 700 BC “hall of healing” was founded, and Benaras was the centre of medical education. The Ayurvedic surgeon Sushruta (6th century BC) and the physician Charka (300 B.C.) were famous in the ancient world through their teachings in Samhita about asepsis and techniques of caesarean section, plastic surgery, eye and brain surgeries.

(b) Post-Vedic period Sushruta asserted that cure rest on four feet-the ideal relationship of physician, patient, Nurses, and medicine. In Charka-Samhita, chapter 9 lists the four qualifications of the attending nurse as knowledge of drugs to be compounded, cleverness, devotedness, and purity of mind and body. During the rise of the Buddhism from 500 BC to AD 300 with its philosophy of mercy and compassion, India witnessed the development of medical education.

(b) Birth of the Auxiliary Nursing Service in India as a part of the British Army

In 1865, Miss Florence Nightingale sent out some graduates from the Nightingale School of Nurses at St. Thomas’ Hospital, England to start similar schools in our country. In 1881 the initiatives of Florence Nightingale helped the formation of Auxiliary Nursing Service in the British Army1, 3.

The glorious era for ancient health care (Ayurveda) ended with the decline of Buddhism. By AD 200, the public hospitals, medical schools and pharmaceutical gardens had disappeared. India experienced an increasing influx of foreign traders from across the globe, who came seeking their fortune. As time passed there was a real revolution in health care practices, which were introduced by the French and British colonists.

∑ Lt. Col., Research Pool Officer, Directorate General Of Medical Services-4, IHQ Of MoD(Army), New Delhi, India. E-mail: 2016rajusha@gmail.com

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∏ Maj Gen., Addl DGMNS, Military Nursing Service, Directorate General Of Medical Services-4, Integrated Head Quarters Of MoD(Army) New Delhi, India.

Military Nursing was a prototype of Modern Nursing introduced by the Portuguese in the 17th century, evolved

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were forced to remain in the shadows to keep the flag high. No other profession has struggled as heroically as Military Nursing in India. The terms and conditions for the grant of a regular commission in the Service were laid in 1950. The first cadre structuring was done in 1959 with a cadre strength of 1,110 Officers. Uniform was revised in 1950, 2000 and 2004 to the current pattern. There was a constant shortage of manpower in the MNS due to the ever-increasing demands of specialized fields. Hence it was decided to induct eligible candidates from the civilian sector. The manpower augmentation took place in three phases from 2009 -20192. They served in medical establishments of the Army, Navy, and Air Force. Promotion in any organization is a motivating factor; the same applies to the MNS.

The Indian Army Nursing Service was initiated by a good friend of British Soldiers, Lord Roberts, then the Commander-in-Chief in India and Lady Robert. Lord and Lady Roberts even raised a fund for the nursing of Officers until the government of India recognized a need for it. Accordingly, the first batch of 10 qualified nurses arrived in India on 28 March 1888 as the pioneers of nursing services in India1, 5.The Nursing service in India was re-designated in 1896 as the Indian Army Nursing Service (IANS)1, 2. This draft was focused on a vast range of facts regarding mortality, invalidity, age and length of Service of a person at the time of death or invalidity, barrack accommodations, and other amenities for soldiers at each station. In 1902 Queen Alexandra’s Imperial Military Nursing Service was established and the IANS was renamed Queen Alexandra’s Military Nursing Service India QAMNS (I).

Nursing in the Armed Forces has transformed from narrow sets of skills, which were mastered in the clinical settings, to a Bachelor’s degree from a recognized University as the minimum requirement. Apart from rendering routine nursing care to the Armed Forces clientele, nurses also provide highly specialized and skilled professional care in a myriad of clinical disciplines such as: cardiothoracic and vascular surgery, organ transplantation (heart, liver and renal), haematology and stem-cell transplantation, burns and reconstructive surgery, nephrology, oncology, neurology, psychiatry, artificial reproductive technology, critical care, paediatrics, obstetrics and gynaecology, operating theatre nursing and neonatal intensive care1.

EVOLUTION OF THE MILITARY NURSING SERVICE IN INDIA DURING THE GREAT WARS At the outbreak of World War-I in 1914 there were just fewer than 300 nurses in the QAIMNS. In World War-I, the forerunner of IMNS served with the Indian troops at every front in Europe and Asia. They provided care in base camps, evacuation stations, and mobile surgical hospitals in India, Aden, Mesopotamia, Egypt, Italy, and France. They nursed the wounded soldiers on hospital ships ferrying them home across the Indian Ocean. The Army Nurses served in Flanders, the Mediterranean, the Balkans, the Middle East, and onboard hospital ships. Over 200 Army Nurses died on active service, many were Indians2. After World War I, on 01 October 1926, the QAMNS (I) and the Temporary IMNS (raised during the war) were amalgamated to form the Indian Military Nursing Service (IMNS).

The Officers of the MNS perform the most challenging task of transporting critically ill patients to the next higher or definitive echelons of care through difficult terrains at any time. The MNS absorbs the preventive promotive and curative aspects of health into its essentials. They organize and conduct various health education programmes and outreach activities for the troops and their families. They take part in various health camps, veteran’s health clinics, and other major AFMS health-related initiatives.

During World War II, they served across the globe and witnessed action in Hong Kong, Singapore, Burma, Italy, Mesopotamia, Ceylon, Egypt, and Western Africa. In the Far East, the fall of Hong Kong and Singapore led to many Indian Army nurses being captured by the Japanese; they endured terrible hardships and deprivations as Prisonersof-War. On 14 February 1942, 15 Indian Army Nurses died during the sinking of SS Kaula by Japanese bombers at Pom Pong Island, near the Indonesian Archipelago. During the middle of the war in 1943, the Indian arm of the Nursing Services was separated through Indian Military Nursing Service Ordinance (1943) and constituted the MNS in its present form(1, 2, 5, 6). Thereafter, the MNS was authorized to use the state emblem on its crest, badges, and buttons to showcase the distinct status and function of the corps in the country’s war efforts.

Professional education and ongoing training is the hallmark of progressive Nursing. The MNS Officers are the backbone of training the combat medics for the Armed Forces. The nurse educators add lustre to Nursing by training the budding Nightingales. The in-house training ability at present is distributed among six colleges of Nursing across the Indian subcontinent. These preservice education programmes pick up the best in the country and train them at the right age. The Nursing Colleges of the Armed Forces Medical Services are counted among the country. The training dynamics of the MNS has been changing drastically with extensive training programmes in multiple disciplines since Independence. Apart from offering a Bachelor's degree in Nursing, the Colleges of Nursing also conduct Post Graduate programmes, Post Basic Diploma programmes as well as short-term certificate courses to the nurse educators and clinical nurse specialists. The growth commensurated with the requirements in the Armed Forces Hospitals and the type of operation the country demanded.

DISCUSSION: A SWOT ANALYSIS OF MILITARY NURSING IN INDIA TODAY The MNS outgrew the cradles of war and cross-border skirmishes to become a well-structured Nursing Care Service of one of the world's largest armies. Each injured soldier owes his life to those brave women who

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India has fought 4 wars with Pakistan; in 1947, 1965, 1971, 1999, and the MNS Officers worked hard indeed for injured and sick Indian soldiers. In 1962 war with China yet again witnessed that the MNS Officers on the frontline nursing the Indian soldiers back to life. They also served with Indian Peace Keeping Force in Sri Lanka during 1987-89. Being an integral part of the country’s war efforts, humanitarian assistance, rescue operations, ambulance trains, hospital ships, and even in submarines, they strengthen the health services. Serving in advanced echelons of care for the troops in armed conflicts in India, UN Missions to Congo, Sudan, Lebanon, Foreign Friendly missions to Tajikistan, etc. highlight the significant contributions of MNS Officers even in the global health care arena. The provision of comprehensive care to the combat troops in the troubled States of Jammu and Kashmir and the North Eastern States confirm the preparedness and endurance of the Officers.

though nursing is shaped by medical science and technology its impact is rooted in professionally sound humanistic care. Modalities of care may change rapidly to align with expanding technology and knowledge. The Nursing profession needs to do a quantum upgrade of professional practices in terms of patient safety, accreditation, patient satisfaction, etc. The MNS envisions their officers to be future-ready with digitization, advanced methods of monitoring, use of Augmented Intelligence, paperless records, global standards in nurse training, soft skills laced with social intelligence to face the future.

A shift in the paradigm of war & conflicts such as regional, ethnic, religious, terrorist attacks, disasters, pandemics, and use of weapons of mass destruction (NBC) constantly poses escalating health care demands on the military Nurses across India. The "epidemic of overwork", unmanageable patient loads, longer shifts, forced overtime laced with intrinsic manpower deficiency are the true bottlenecks of the organization. As the Indian subcontinent possesses the most varied terrains from the highest battlefield to vast desert lands, the Officers are subjected to various challenges such as physical, emotional, climatic, and professional. They have silently endured the varying environment over the years and continued to deliver the best nursing care.

The MNS in India is one of the oldest professions, developed from the cradles of great wars, during the early part of the 19th Century. The legacy inherited from Florence Nightingale, together with the impact of British colonialism, paved the way for establishing a well-structured Nursing Service in India. The MNS upholds ‘excellence in patient care’ with unmatched benchmarks for quality. Besides being a supportive service, the Corps has etched its marks in the war efforts of the Indian Army and country at large. The MNS Officers are professionally competent to handle the rising consumer demands caused due to influx of modernization, multiple specializations, consumer awareness, and geographical diversity. The training dynamics of the Military Nursing Service has been changing drastically with extensive training programmes in multiple disciplines since Independence. The growth of the Service was commensurate with the requirements in the Armed Forces Hospitals and the types of operation the country demanded. The in-house training ability at present is distributed among six Colleges of Nursing across the Indian subcontinent. There has been an exponential rise in the number of applicants to the MNS in India.

The Nursing profession in the Indian Armed Forces has been at its pinnacle of glory because of their commitment, selflessness, grit, and preparedness. The MNS Officers walk that extra mile to ensure the well-being of their clientele. Indian Army provides the best of avenues to enable the MNS Officers to achieve the highest level of professionalism through training, education, supervision, mentorship/preceptorship, sports, and other adventure activities. They are expected to offer care in a variety of practice areas with proficiency. Enthusiasm and zeal to put patients first are instilled in each military Nursing Officer during their Service. The growing challenges of proliferating medical innovations offer multiple opportunities to newer aspects of robotic surgery, minimally invasive surgical Interventions, and various other innovative treatment modalities in the Armed Forces. When various challenges present, staff are reassigned to address the associated surge activity, which demands greater physical endurance and professional efficiency.

CONCLUSION

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To explore the new challenges and opportunities in nursing, we need to focus on interdisciplinary collaboration. A multidisciplinary team can provide high-quality, evidence-based care with compassion and commitment to clientele. Even

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The MNS vision is to cruise along the journey of excellence in every facet of its functioning to serve the Indian soldiers and their families beyond the conventional precincts of nursing care.

ABSTRACT

REFERENCES 1. Lt Col. JEET. K., Lt Col. RAJU. R., Lt Col KUMARI. S., Maj MANN. K. Healing Hands and Caring Hearts 1888-2018. New Delhi: Directorate General Of Medical Services (Army), 2018. Chapter 1: MNS an Unsung Saga; p11-51. 2. Maj Gen. BALA. S. Healing Hands, Eight Decades of Nursing Service 1926-2007. New Delhi: Directorate General of Medical Services (Army), 2007. Chapter 1: Genesis of Military Nursing Service; p16-39. 3. Trained Nurses Association of India. History and Trends in Nursing in India. New Delhi: Trained Nurses Association of India, 2001. Chapter 2: Military Nursing; pp.8-21. 4. Maj Gen. JOHN. E., Lt Col. RAJU. R. 10th Brigs MNS WorkStudy Bulletin. New Delhi: Directorate General of Medical Services (Army), 2015. Chapter 4: History of Military Nursing Service; pp19-27. 5. https://en.wikipedia.org/wiki/Military_Nursing_Service (Accessed on 12 Mar 2020).

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DES INFIRMIÈRES D’EXCEPTION

La situation catastrophique des structures de soins durant la guerre de Crimée a permis à Florence Nightingale de poser les bases de ce à quoi devait répondre un dispositif de traitement des blessés, et par là même le cadre d’une profession et les impératifs de formation nécessaires à son développement. Nul doute qu’aucune autre infirmière n’a fait autant pour permettre que soit reconnue l’importance de la fonction infirmière et l’absolue nécessité, pour tout service de santé militaire, de disposer d’un véritable corps infirmier. Mais pour la médecine militaire dans son ensemble, nul autre conflit que celui de la première guerre mondiale, la « grande guerre », n’a à ce point révolutionné les pratiques soignantes. Elle a conduit à des innovations majeures et montré toute la pertinence des orientations dessinées par Nightingale. Lorsque se déclenche la première guerre mondiale, l’activité militaire est encore exclusivement une affaire d’hommes et le champ de bataille n’est guère accessible aux femmes. Mais la nouvelle forme prise par ce conflit armé, son impact industriel, la durée dans laquelle il s’installe en fait une guerre totale qui va impacter toute l’organisation sociale des pays impliqués. L’élan patriotique qui emporte les soldats vers le front touche aussi l’ensemble des pays qui se mettent en ordre de marche pour tenir dans la durée. Les femmes autant que les hommes sont impliquées dans l’effort de guerre. Si elles prennent une place essentielle pour faire fonctionner l’économie des pays en guerre, elles deviennent aussi nécessaires près des combats. C’est particulièrement le cas des personnels infirmiers qui apparaissent indispensables face à l’hécatombe humaine des champs de bataille. Avant ce conflit, le secours au soldat blessé relevait en grande partie de la responsabilité des sociétés nationales de la Croix-Rouge qui n'offraient souvent pas à leurs membres de véritable statut professionnel. C’était une affaire de bénévolat qui imposait à celles qui s'engageaient de disposer des moyens suffisants pour subvenir à leur existence quotidienne. Les besoins de la guerre ont imposé le recours à de très nombreux personnels soignants. Si ces nécessités de recrutement ont malheureusement pu conduire à réduire le temps et les impératifs de formation, ils ont aussi permis de donner une place reconnue et un statut à ces personnels.

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De nombreuses infirmières souvent mues par un puissant idéal patriotique se sont engagées dans cette voie faisant preuve de qualités de courage et de dévouement exceptionnels. Nombre d’entre elles y ont laissé leur vie

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et pour la majorité en ont gardé des traces qu’elles ont eu à porter pour le restant de leur existence. Ces femmes sont restées pour la plupart dans l'anonymat. Certaines sont parvenues à s’en extraire plus ou moins fortuitement, que ce soit grâce au travail d’historiens désireux de leur rendre justice ou par elles-mêmes lorsqu'elles sont parvenues à témoigner de ce qu’elles avaient vu et vécu. Beaucoup, sur le terrain et face aux dangers, se sont attachées à faire évoluer les choses, améliorer la condition du blessé de guerre, la qualité des soins dans toutes leurs dimensions, individuelles et collectives, dans le domaine technique du soin, de l’hygiène, du suivi épidémiologique… Chacune a apporté quelque chose de différent, en fonction de qualités ou de préoccupations qui leur étaient propres illustrant ainsi toute la diversité du monde infirmier en même temps que les multiples aspects de ce métier. C’est le bref portrait de quelques-unes de ces femmes, infirmières d’exception que nous avons souhaité mettre à l’honneur à l’occasion de ce numéro spécial de la Revue Internationale des Services de Santé des Forces armées consacré au personnel infirmier. Toutes les personnes présentées ici ont affronté la première guerre mondiale ou d’autres après, toujours au plus près du feu des armes, fait montre d’un courage hors du commun, fait usage de tous les moyens dont elles disposaient matériels, physiques et psychiques, de qualités d’humanité et de force d’âme mais aussi d’adaptation et d'innovation, contribuant à faire de chacune d’entre elles une héroïne. Au-delà de la reconnaissance officielle dont la majorité d’entre elles a bénéficié, leur exemple mérite d’être connu de tous. Aucune n’est véritablement sortie indemne de la guerre, toutes ont dû puiser dans leurs ressources propres pour sortir de cette expérience terrible mais toutes sont restées fidèles jusqu’au bout à ce à quoi elles ont cru, à ce métier qu’elles ont honoré et pour la reconnaissance duquel elles ont fait don d’elles-mêmes. Je voudrais particulièrement remercier pour tout le travail biographique effectué par la Capitaine pharmacienne Lise PIERRE-VICTOR et l’Adjudant-Chef Catherine VAN DEN BERGHE. Il doit permettre à ces infirmières de rester des exemples pour celles et ceux qui poursuivent aujourd’hui une mission de soin et de soutien auprès des soldats et des victimes de la guerre. Médecin Général Inspecteur Prof. (2S) Humbert BOISSEAUX Président du Conseil Scientifique (par Interim) Rédacteur en chef de la publication

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EXCEPTIONAL NURSES

The disastrous state of care infrastructure during the Crimean War led Florence Nightingale to lay the foundations of what was required for treating the sick and the wounded. This provided the framework for an entire profession and the training required for its development. There is no doubt that no other nurse did more to raise the significance of nursing and draw attention to the fact that a proper nursing team was absolutely essential for any military medical service.

their work for the rest of their days. And, for the most part, these women disappeared into anonymity. Some of their stories emerged, more or less by chance, whether through the work of historians looking to do their accomplishments justice or through the women themselves finding the strength to speak about what they saw and experienced. Many nurses working in the field and faced with unimaginable danger endeavoured to make changes, to improve conditions for the war-wounded, enhance the quality of care in all its dimensions, both individually and collectively, in methods of care, hygiene, epidemiological monitoring… Each of these nurses made a different contribution, based on their own skills or concerns, illustrating the diversity of the nursing world as well as the many facets to this profession.

However, in terms of military medicine as a whole, it was the First World War that would go on to revolutionise nursing practices. The Great War, as it is often known, led to major breakthroughs and innovations and provided clear proof of the relevance of Nightingale’s approaches. At the outbreak of the First World War, military service was strictly reserved for male combatants; the battlefield was not accessible to women. However, this new form of armed conflict, its industrial impact and its duration transformed it into a “total war” that affected all facets of society in the countries involved. The patriotic spirit that sent soldiers towards the front spread throughout all of the countries, with people gearing up to batten down the hatches. The war effort encompassed each and every member of the population, male and female. Not only did women play an essential role in keeping the economies of the warring nations running, they were also required closer to the theatre of conflict. This was particularly the case for nursing staff, who appeared indispensable in the face of the human slaughter on the battlefield.

We wanted to highlight some of these remarkable nurses in this special issue of the International Review of the Armed Forces Medical Services, which is dedicated to nursing. All of the women presented in this issue fought in the First World War or subsequent conflicts, always as close to the field of battle as possible. They demonstrated extraordinary courage, using all of the material, physical and mental means at their disposal, but also displaying humanity, fortitude, versatility and innovation – making each and every one of them a true heroine. The majority of these nurses did receive official recognition at the time, however, their stories still deserve to be heard by all. None of them emerged from the war unscathed, and without exception they had to dig deep to walk away from the experience. Nevertheless, right until the very end, they all remained true to their belief in a profession they honoured and the recognition they achieved themselves.

Prior to the Great War, caring for wounded soldiers was largely the responsibility of the Red Cross national societies, which frequently didn’t offer its members any real professional status. It was a volunteer-based structure, with those committing to the cause needing to have sufficient means to support themselves financially. The First World War gave rise to the need for a large number of nurses. Despite these recruitment needs cutting short both training periods and training requirements, they still provided an opportunity for nurses to achieve a genuine professional status.

I would particularly like to thank Captain Pharmacist Lise PIERRE-VICTOR and Chief Warrant Officer Catherine VAN DEN BERGHE for all of their biographical research. These nurses should serve as role models to all of those currently devoting themselves to caring for soldiers and the victims of war.

Many nurses, often inspired by a duty to their country, embarked on this career path and demonstrated extraordinary feats of bravery and dedication. Some lost their lives, while most bore the psychological burden of

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Major General Prof. (ret.) Humbert BOISSEAUX, MD Chairman of the Scientific Council (Ad Interim) Editor-in-chief of the publication

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BEATRICE ALLSOP (Née en 1882)

Une infirmière comme tant d’autres… Beatrice Alice ALLSOP est emblématique des infirmières qui s’engagèrent pour soutenir le corps expéditionnaire britannique (British Expeditionary Force – BEF) envoyé en Belgique lors du déclenchement de la première guerre mondiale. Son parcours rend compte également du dispositif mis en place pour la prise en charge des blessés du front de l’ouest, durant la première guerre mondiale.

Au cours de la guerre, la chaîne d’évacuation évoluera et en juin 1916, Beatrice ALLSOP est cette fois affectée dans un « hôpital d’évacuation », l’HE n° 33 installé à Béthune. En effet, le nombre très élevé de blessés relevés au front et la gravité de leurs blessures mettent en évidence le besoin de positionner des infirmières qualifiées de plus en plus près du front, proximité inimaginable dans les plans établis avant la guerre. Un hôpital d’évacuation peut ainsi accueillir jusqu’à 1000 patients et réaliser des interventions chirurgicales précoces. Il rend donc nécessaire la présence d’infirmières spécialisées. Ce sont les compétences professionnelles de Beatrice ALLSOP qui la font affecter dans une structure d’évacuation dont l’activité est extrêmement importante.

Une conduite héroïque

Un parcours de formation classique

Le 7 août 1916, lors du bombardement de la ville de Béthune, l’hôpital d’évacuation n° 33 est victime d’un tir d’artillerie. Juste avant le déjeuner, des obus tombent près de l’hôpital. Il est décidé d’évacuer certains patients et de placer les autres dans les caves du bâtiment qui abrite l’hôpital. Vers 13h, un obus de gros calibre touche directement l’hôpital. Un début d’incendie doit être maîtrisé et plusieurs victimes, morts et blessés, sont à déplorer notamment au sein de l’équipe soignante. Face à ce bombardement qui se poursuit, l’ordre est donné de transférer tous les patients vers un autre hôpital d’évacuation.

Beatrice ALLSOP est née en 1882 dans un quartier de Londres. Elle est la fille d’un libraire qui possède une boutique sur High Street. Elle bénéficie d’une éducation au Stockwell College à Lambeth, établissement de la British and Foreign School Society destiné à former des institutrices. Ce ne sera cependant pas l’orientation qu’elle choisira et à 24 ans, en 1906, elle décide d’entrer à la Nightingale School of Nursing du St Thomas’ Hospital. C’est comme infirmière diplômée, qu’en août 1914, alors que la Grande-Bretagne prépare son entrée en guerre, que cette “sister” rejoint le Queen Alexandra’s Imperial Nursing Service Reserve (QAIMNSR).

Beatrice ALLSOP est blessée alors qu’elle est au bloc opératoire mais elle n’interrompt pas son activité. Comme elle, d’autres infirmières, pourtant touchées, participent activement à la mise en sécurité des patients et à leur évacuation. Durant les 3 heures que dure ce bombardement, plus de 200 blessés seront évacués et deux opérations chirurgicales urgentes menées à bien. Impressionné, le chirurgien général dira ensuite qu’aucune récompense ne peut être suffisante pour remercier ces femmes et ces hommes qui ont continué à travailler en gardant leur calme et sans qu’aucune confusion ne s’installe.

A ce moment-là, les infirmières ne bénéficient d’aucun enseignement spécifique préalable à leur déploiement. Pour nombre de ces jeunes femmes qui jusque-là ne faisaient pas partie de la réserve opérationnelle, l’environnement militaire leur est totalement inconnu. De plus et pour la première fois, ces infirmières militaires britanniques seront amenées à servir aux côtés de collègues d’autres pays, notamment françaises.

Une jeune infirmière britannique dans le dispositif de soins aux blessés de guerre

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La médaille militaire en signe de reconnaissance

En septembre 1914, Béatrice A LLSOP est mobilisée. Elle traverse la manche pour être affectée à l’hôpital général n° 7 installé dans un premier temps à Amiens puis à Saint-Omer. A ce moment-là, les « hôpitaux généraux » font part ie intégrante de la chaî ne d’évacuat ion des blessés qui, depuis la ligne de front, doit permettre de rapatrier les blessés les plus graves vers les hôpitaux militaires situés sur le territoire britannique.

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Le dossier militaire de Beatrice ALLSOP mentionne qu’après cela, c’est comme blessée qu’elle est arrivée à l’hôpital général n° 10 stationné à SaintOmer. Cependant, tout

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Chacune de ces affectations était accompagnée d’un rapport sur la manière de servir de ces infirmières du QAIMNSR. Dans l’un d’entre eux, il sera noté : « La sister BA Allsop a été parmi nous depuis le 12 septembre 1916. Durant cette période, elle a pratiquement toujours été responsable de la salle d’opération. Elle a géré le bloc d’une manière adaptée. Elle est excellente dans les fonctions d’aide opératoire ainsi que d’infirmière circulante. Rapide et très compétente, elle maintient toujours tout en bon ordre. Elle a encadré d’une manière admirable les garçons de salle ainsi que les autres personnels ».

comme ses autres collègues, elle a dès le lendemain repris sa place de soignante. Cinq de ces infirmières seront citées pour leur bravoure durant cette journée dont Beatrice Alice ALLSOP. Elles recevront ainsi la médaille militaire. En effet, le 21 juin 1916, un amendement a été introduit dans le Royal Warrant permettant, pour la première fois, que la médaille militaire soit décernée à une femme. Et c’est le roi Georges V en personne qui lui remettra cette distinction à Buckingham Palace, le 5 février 1917. Ainsi, à la fin de la grande guerre, 555 infirmières, appartenant notamment au QAIMNS ont pu être ainsi décorées de la médaille militaire pour ces actes de courage et de dévouement effectués sous le feu de l’ennemi.

En conclusion Après la guerre, Beatrice ALLSOP trouvera un poste de matrone assistante au Royal Sea-Bathing Hospital de Margate avant de devenir matrone du sanatorium antituberculeux du Northamptonshire County à Rushden.

La guerre qui se poursuit au rythme des affectations Beatrice ALLSOP sera ensuite affectée à l’hôpital d’évacuation n° 1 puis en septembre 1917, elle rejoindra l’hôpital général n° 24 installé à Etaples. Les changements d’affectation des infirmières sont alors fréquents, la matrone en chef du corps expéditionnaire britannique s’efforçant de répondre à l’évolution des besoins du front.

Cette infirmière comme tant d'autres n'a pas laissé de journal ou de lettres qui auraient permis de mieux saisir son vécu d'infirmière durant la guerre. C’est son dossier militaire qui rend compte de ce parcours emblématique. Ses blessures ainsi que la médaille militaire qu’elle a reçue témoignent d'une exposition aux dangers de la guerre. Aucun document ne permet cependant de connaître plus précisément l'existence d'éventuels traumatismes. Il est simplement fait état de qualités professionnelles mais aussi humaines et d’une adaptation remarquable qui ont mérité d‘être soulignées. Ce sont des historiens qui ont exhumé cette histoire militaire singulière mais comme la grande majorité des infirmières militaires anonymes, elle ne figure pas aujourd’hui dans Wikipédia !

Alors qu’elle est affectée à l’hôpital général n° 24, elle se pique le doigt avec une épingle. La plaie s’infecte et elle doit être rapatriée en Angleterre en juin 1918 afin de bénéficier d’une intervention chirurgicale à l’hôpital militaire de Millbank à Londres. Elle devra être amputée de la phalange distale de son pouce. Après sa convalescence, elle reprendra du service en France. Elle sera affectée à l’hôpital d’évacuation n° 4 installé à Solesmes puis à l’hôpital d’évacuation n° 58 installé à Tincourt et enfin à l’hôpital n° 14 situé à Boulogne avant de regagner le Royaume-Uni pour y être démobilisée.

BIBLIOGRAPHIE SPIRES K., BATES D., Beatrice Allsop, une infirmière sur le front occidental. SOINS - 786 - juin 2014 p 83-87.

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BEATRICE ALLSOP (Born on 1882)

A nurse like so many others… Heroic action

Beatrice Allsop is emblematic of the kind of nurses sent out to Belgium at the outbreak of the First World War to support the British Expeditionary Force (BEF). Her journey also provides an account of the systems in place to take care of those wounded at the western front during the First World War.

On 7 August 1916, the town of Béthune was hit by an artillery bombardment – casualty clearing station no. 33 did not escape the barrage. Shells began falling close to the hospital. A decision was made to evacuate certain patients and move the others down into the cellar of the hospital building. At around 1pm, a large-calibre shell struck the hospital directly. A fire had to be brought under control and a number of people, mostly within the medical team, were killed or injured. Faced by the subsequent bombardment, the order was given to transfer all of the patients to another casualty clearing station.

A traditional course of training Beatrice Allsop was born in 1882 in London as the daughter of a high-street bookseller. She was educated at Stockwell College in Lambeth, a teacher training college run by the British and Foreign School Society. However, at the age of 24 she decided to choose a different career path, enrolling at the St Thomas’ Hospital Nightingale School of Nursing in 1906. In August 1914, when Britain was preparing to enter the war, Allsop – by this time a registered nurse – j oined Queen Alexandra’s Imperial Nursing Service Reserve (QAIMNSR). At the time, nurses did not receive any special training to prepare them for their deployment. For many of the young women who had not been part of the reserve forces until that point, the military was a complete unknown. In addition, the British military nurses found themselves being sent to serve alongside nurses from other countries – notably France – for the first time.

Beatrice Allsop was injured while in the operating room, but that did not stop her working. Together with other injured nurses, Allsop continued to secure and stabilise casualties in the stations. Over 200 wounded soldiers were evacuated during the three-hour artillery bombardment, and two urgent operations were performed. Impressed by their dedication, the surgeon-general would go on to write that “no praise was great enough for anyone of them, that men and women worked alike in a calm manner, and there was no confusion”.

A young British nurse caring for the war-wounded Beatrice Allsop was mobilised in September 1914. She crossed the English Channel and was assigned to general hospital no. 7, based firstly in Amiens then in SaintOmer. At the time, these general hospitals were an integral part of the chain of evacuating casualties, which began at the front line and allowed the most seriously wounded soldiers to be repatriated to military hospitals on British soil.

The Military Medal as a gesture of recognition Beatrice Allsop’s military file notes that she arrived at general hospital no. 10 in Saint-Omer wounded herself. However, the next day she returned to her tasks as a nurse, as did her colleagues.

The chain of evacuation evolved as the war progressed. In June 1916, Beatrice Allsop was assigned to an evacuation hospital or casualty clearing station no. 33, in Béthune. The extremely high number of wounded soldiers being evacuated and the severity of their injuries demonstrated the need to position qualified nurses ever closer to the front, a situation that was inconceivable in the plans made before the war.

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Five nurses, including Beatrice Alice Allsop, were decorated with the Military Medal for their bravery that day. In fact, on 21 June 1916, the Royal Warrant was amended to allow women to receive the Military Medal for the first time. King George V presented the medals to the nurses in person at Buckingham Palace on 5 February 1917.

Each casualty clearing station was able to house up to 1,000 patients and perform early surgical interventions. It was vital that qualified nurses were present. It was in this extremely important casualty clearing infrastructure that Beatrice Allsop's professional skills came to shine.

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By the end of the Great War, 555 nurses, many of whom from the QAIMNS, were honoured for acts of bravery and dedication under enemy fire with the Military Medal.

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The war follows the pace of the assignments

assistant and as a general nurse. Quick and extremely competent, she kept everything in good order at all times. She supervised the orderlies and other staff members admirably. ”

Beatrice Allsop was assigned to casualty clearing station no. 1 in September 1917, before joining general hospital no. 24 in Etaples. Nurses’ assignments changed frequent ly as the matron-in-chief of the British Expeditionary Forces fought to meet the needs of the front line.

In conclusion After the war, Beatrice Allsop found a post as an assistant matron at Royal Sea Bathing Hospital in Margate before becoming matron of the Rushden Sanatorium for tuberculosis patients in Northamptonshire.

When assigned to general hospital no. 24, Beatrice Allsop accidentally pricked her thumb with a needle. The wound became infected and she was repatriated to England in June 1918. There, she underwent surgery to amputate the tip of the digit at the military hospital in Millbank, London.

Allsop was a nurse like no other, but she left behind no diary or letters allowing us a glimpse of her life as a nurse during the war. In fact, it’s her military file that tells of her outstanding career. Allsop’s injuries and the Military Medal she received are a testament to the dangers of war. However, there are no documents that can tell us exactly how she experienced the trauma. It is simply a record of Allsop’s professional skills but also her qualities as a human being, and of her remarkable versatility that deserves to be highlighted. Historians have unearthed this record of military history but, like many other nameless military nurses, you won’t find Beatrice Allsop in Wikipedia!

After recovering, Beatrice Allsop returned to service in France. She was assigned to casualty clearing station no. 4 in Solesmes, the n tra nsferred to casualty clearing station no. 58 in Tincourt and subsequently hospital no. 14 in Boulogne, before returning to Britain for demobilisation. Each of her assignments was accompanied by a report on the manner in which the QAIMNSR nurses went about their work. One such report reads as follows: “Sister B.A. Allsop has been with us since 12 September 19 16. She was almost always in charge of the operating theatre during this period. She managed the section in an appropriate manner. She excels in her role as operating

BIBLIOGRAPHY SPIRES K., BATES D., Beatrice Allsop, une infirmière sur le front occidental. SOINS - 786 - juin 2014 p. 83–87.

Interior of an English Hosp ital - Boulogne-sur-mer - Campaign 1914 - 1918

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YOLANDE BERTHELOT DE BAYE (1887-1970)

Une fortune consacrée à la cause des bléssés de la guerre L’enfance d’une jeune aristocrate

Général Pétain, commandant militaire du secteur, pour l’installation d’une équipe et de matériel au sein de l’hôpital militaire sit ué dans le château de Deuxnouds-devant-Beauzée. Il s'agit alors d'une autorisation exceptionnelle en raison du positionnement de cette formation dans la zone réservée aux armées. Là également, sous l'impulsion de l'aide apportée par Mademoiselle de Baye, cette structure sanitaire prend une dimension importante, remarquée de tous pour la qualité des soins qui y sont assurés. Mais c’est encore plus près du front que Yolande de Baye souhaite travailler.

Yolande de Baye est la fille cadette de l’union de deux personnalités originales : un père aristocrate, le baron Joseph Berthelot de Baye éminent archéologue passionné par l’empire russe et une mère, Marie-AnneBeatrix Oppenheim, une poétesse reconnue dans les milieux littéraires.

Celle-ci va profiter de la pré paration de l’offensive française d’août 1917 dans le secteur de Verdun pour obtenir la responsabilité de mise en œuvre d'hôpitaux d'évacuation au plus près des combats.

Yolande grandira avec sa sœur aînée dans ce milieu aisé et protégé de la Belle-époque. Lorsque la guerre éclate, son père n’est pas aux côtés de sa famille mais en Russie. Il ne regagnera la France qu’en 1920, une fois la guerre terminée.

La présence d’« un ange » face à la souffrance Directement exposée au feu de l'artillerie ennemie, l’infirmière assure soins et attentions aux blessés. Elle accompagne les mourants jusque dans leurs derniers instants, leur offrant écoute et réconfort. Elle assure également l’enregistrement des volontés du défunt afin que ceux-ci puissent être connus des familles. Cela lui vaut l’appellation « d’ange ».

Un engagement patriotique infirmier Dès la déclaration de guerre, la baronne de Baye et sa plus jeune fille Yolande décident, elles, d’un engagement total pour contribuer à l’effort de guerre. Patriotes courageuses, ces deux femmes renoncent à la vie que leur permet leur aisance matérielle pour venir en aide aux combattants. Elles décident ainsi de consacrer leur fortune à la mise en place d’ambulances destinées à soutenir les soldats qui défendent le pays.

Une attaque sur l’hôpital provoquera la mort de plusieurs de ses infirmières, la blessant elle-même grièvement. Elle s’en remettra, souhaitant ardemment poursuivre son action. Durant toute la fin de la guerre, la jeune infirmière et son ambulance appuieront l’action du service de santé, fournissant notamment une aide extrêmement précieuse lors de l’offensive franco-américaine effectuée fin 1918 dans la région de Verdun.

Elles se rapprochent donc des sociétés de la CroixRouge. Toutes deux s’engagent dans une formation d’infirmière, Yolande de Baye effectuant également des études de pharmacie.

Ce comportement exemplaire de courage et d’héroïsme lui vaudra d’être remerciée par le Président Poincaré en personne et de recevoir la Légion d’honneur des mains du Général Pétain.

En 1915, ces deux dames créent leur propre fondation, annexe d’une l’ambulance, la 4/22, positionnée à distance du champ de bataille. Elles financent la mise en place d’une équipe infirmière, l’achat de matériel médical, de salles d'opération et de radiologie, pour être en mesure de fournir une aide efficace aux unités militaires. Cette formation sera ainsi remarquée pour le rôle assuré lors de la bataille de Champagne, la fondation « de Baye » ayant permis aux équipes médicales soutenues de disposer d’équipements performants.

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Elle tiendra cependant toujours à souligner avec modestie n’avoir fait que son devoir !

L’Armistice La fin de la guerre ne marquera pas celle de l’engagement des dames de BAYE. A la suite de l’armistice, mère et fille continueront leur soutien patriotique notamment en fondant à Sarrebruck, au profit des troupes d’occupations en Allemagne, une cantine militaire associée à une salle de spectacle. Celles-ci ne fermeront leurs portes qu’en 1924.

Une volonté d’assister les blessés au plus près du front Dès 1916, forte de l’expérience acquise et à sa demande, Yolande de Baye obtient l’assentiment du

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Durant toute la grande guerre, Yolande de Baye a entretenu une relation épistolaire avec l’écrivain Edmond Rostand avec qui elle s’était fiancée. Elle n’eut cependant pas l’occasion de le retrouver car lui-même fut victime de la grippe espagnole juste après l’armistice, en décembre 1918. Elle retrouva donc après la guerre la pro priété familiale pour s’adonner notamment à une activité littéraire. Elle poursuivra cependant son aide aux veuves de guerre et son animation de cercles patriotiques.

progressivement et devant le besoin en nombre de personnels infirmiers, qu’un véritable statut sera progressivement donné aux infirmières, permettant à des femmes volontaires, issues de classes sociales moins aisées, d’intégrer les armées. BIOGRAPHIE CHARPY J-J., Berthelot de Baye Yolande (1887 - 1970) : brève biographie d'une Française légionnaire avec traitements à titre militaire . La Marne : Société d'agriculture, commerce, sciences et arts du département de la Marne, 2016.

Yolande de Baye est emblématique de ces femmes de milieux sociaux favorisés qui ont considéré que comme les hommes, elles avaient un devoir vis-à-vis de leur pays en guerre. Pour nombre d’entre elles, l’engagement comme soignantes s’est imposé, autorisé par une aisance financière qui le rendait possible. Ce n’est que

C/Yolande DE BAYE CHAVANCE, René, Vitry-le-François 1914-1918. Une ville de l’est pendant la guerre, 1922, p. 248 et suivantes. (CH 221). RENARD, Maryse, « Les dames de Baye », In Du pays sézannais, n° 9, septembre 2008, p. 15-23. (Delta 3256/ 1).

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YOLANDE BERTHELOT DE BAYE (1887-1970)

A fortune devoded to the war wounded The childhood of a young aristocrat

Here, de Baye was given responsibility for setting up an evacuation hospital close to the front line.

Yolande de Baye was the youngest daughter of two leading historical figures: Baron Joseph Berthelot de Baye, a distinguished archaeologist with a passion for the Russian Empire, and Marie-Anne-Beatrix Oppenheim, a renowned poet.

The presence of an angel in unimaginable suffering In Verdun, Yolande de Baye provided care and first aid to wounded soldiers within striking distance of enemy artillery. She accompanied the mortally wounded right up to their final moments, offering them comfort and a person to talk to. She also recorded soldiers’ last wishes, which could be passed on to the families. To wounded soldiers, Yolande de Baye took on the appearance of an angel.

Yolande grew up together with her sister surrounded by the prosperity and protection of the Belle Epoque era. When war broke out, Yolande’s father was in Russia away from the family and was only able to return to France in 1920 when the war was over.

An attack on the hospital killed several of her nurses and severely wounded many others, but Yolande de Baye remained steadfast and committed to her work.

A patriotic commitment to nursing When war was declared, Baroness de Baye and her youngest daughter Yolande decided to do everything they could in the name of the war effort. As committed patriots, these two women abandoned their lifestyles of material comfort to come to the aid of wounded soldiers. They chose to donate their fortune to the provision of ambulance units to help the soldiers who were defending their country.

As the war drew to a close, the young nurse and her medical facility supported the health service and provided vital assistance during the Franco-American offensive in the Verdun region at the end of 1918. Yolande de Baye’s bravery and heroism saw her personally thanked by President Poincaré and awarded with the Légion d’Honneur by General Pétain himself.

To do so, they approached the Red Cross societies. Both Baroness de Baye and Yolande completed nursing training, while Yolande also studied pharmacy.

She treated her work with the utmost modesty throughout, maintaining that she was simply doing her duty.

In 1915, the two women established their own foundation, at ambulance unit 4/22, located some distance away from the battlefield. They funded the provision of a nursing team as well as the purchase of medical supplies, operating rooms and radiology facilities in an effort to provide effective assistance to the armed forces. This facility would go on to play a key role in the Battle of Champagne, with the Fondation de Baye providing high-quality equipment to the medical teams there.

The armistice The end of the war did not mean the end of the de Baye family’s service. Following the armistice, mother and daughter continued to serve their country by setting up a military canteen connected to a theatre in Saarbrücken to assist occupying troops in Germany. The facility would remain open right up until 1924. Throughout the Great War, Yolande de Baye exchanged letters with the French author Edmond Rostand, with whom she became engaged. However, she was denied the chance to marry Rostand, who tragically fell victim to the Spanish flu in December 1918 shortly after the armistice was signed. Once the war was over, Yolande de Baye returned to the family home to devote herself to the world of literature. She also continued to support war widows and be engaged in patriotic activities.

A desire to help the wounded closer to the front From 1916, buoyed by her experiences and her ambitions, Yolande de Baye received the approval of General Pétain, the military commander in charge of the sector, to provide medical staff and equipment and set up a military hospital in a castle in Deuxnouds-devant-Beauzée. Given that the facility was located in an area normally reserved for the armed forces, the approval of the plan was out of the ordinary. Nevertheless, driven by Yolande de Baye’s desire to help, the medical unit took on a key role in the war and was valued by all for the high quality of care provided there. But even this wasn’t enough for Yolande de Baye – she wished to work even closer to the front. VOL. 93/3

Yolande de Baye is emblematic of the women who grew up in privileged surroundings but, like their male compatriots, believed they had a duty to their country. For many of them, serving as a nurse was a must; work that was enabled by their financial wealth. It was only gradually, and faced by such a great need for nursing staff, that the role of nurse went on to be accorded a

This desire came to fruition as preparations began for the French offensive in August 1917 in Verdun.

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genuine status that allowed women volunteers from less well-off backgrounds to join the armed forces too.

titre militaire . La Marne : Société d'agriculture, commerce, sciences et arts du département de la Marne, 2016.

BIBLIOGRAPHY

C/Yolande DE BAYE CHAVANCE, René, Vitry-le-François 1914-1918. Une ville de l’est pendant la guerre, 1922, p. 248 et suivantes. (CH 221).

CHARPY J-J ., Berthelot de Baye Yolande (1887 - 1970) : brève biographie d 'une Française légionnaire avec traitements à

RENARD, Maryse, « Les dames de Baye », In Du pays sézannais, n° 9, septembre 2008, p. 15-23. (Delta 3256/ 1).

Stained-glss window p ortrayting nurses in Douaumont (co-f unded by De Baye)

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V IOLETTE THURSTAN (1879-1978)

Une infirmière sur tous les fronts Une jeunesse itinérante

Finlande avant d’atteindre la Russie. Là également elle rencontre l’inorganisation d’hôpitaux débordés et soumis à des conditions d’hygiène inacceptables. Elle se met immédiatement à la tâche et effectuera pendant de longues semaines un travail d’organisation remarquable. Elle rejoint finalement une unité médicale mobile, qui l’amènera à apporter des soins aux blessés des bombardements de Łódź puis de Varsovie. Elle y sera elle-même blessée et contractera une pleurésie.

Anna Violette Thurstan, née en Angleterre en 1879, est la fille d’un médecin. Les nombreux déménagements de la famille l’ont amenée à fréquenter différents pensionnats en Europe avant de revenir en 1897 au Royaume-Uni pour y effectuer une formation d’infirmière au London Hospital Whitechapel .

C’est à l’occasion de sa convalescence qu’elle écrit son premier livre, Field Hospital and Flying Column, qui est à la fois témoignage de ce qu’elle a vu et vécu durant ces mois de guerre mais aussi une réflexion et des propositions qu’elle fait pour une amélioration des soins apportés aux blessés de guerre. Elle y fait valoir toute l’importance qu’il y a à ce que les infirmières soient correctement formées et diplômées, plaidant en faveur de l'enregistrement par l'État des infirmières qualifiées.

Pendant près de 10 ans elle exercera cette profession à la Bristol Royal Infirmary tout en développant son attrait pour les langues mais également l’histoire et la géographie.

Fin 1915, elle est de retour pour quelques mois en Russie en tant que représentante de la National Union of Training Nurses afin d’apporter un soutien aux réfugiés du front de l'Est.

Une entrée en guerre sur le front de l’Ouest Ayant rejoint une année plus tôt la Croix-Rouge britannique, elle se verra envoyée dès le début de la guerre, en août 1914, en tant que cheffe d'un groupe d'infirmières appelées pour aider la Croix-Rouge belge. Le premier contact qu’elle eut avec la guerre fut à Bruxelles celui de réfugiés démunis fuyant l’avancée ennemie. Mais c’est dans une ambulance proche de Charleroi qu’elle sera confrontée à toute l’horreur des combats dans un dispositif sanitaire totalement dépassé par l’afflux incessant des blessés. Elle constatera à ce moment toute l’insuffisance de formation d’infirmières certes dévouées mais sans encadrement.

Mais en 1916, c’est en Belgique que l’on retrouve Violetta Thurstan d’abord comme matrone d'un hôpital à La Panne, puis encore plus près du front avec la responsabilité d’un poste de secours à Koksijde. Ses efforts pour évacuer les soldats blessés sous le feu lui valent d’être décorée de la médaille militaire. Sa dernière affectation de la guerre sera à l'hôpital de campagne d'Ostrovo, près du front de Salonique. Le paludisme mettra finalement fin à son séjour macédonien.

L’occupation de la Belgique conduit à ce que toutes les infirmières britanniques quittent le pays, expulsées par l’occupant. C’est donc encadrée par l’armée allemande que Violetta Thurstan rejoint alors Copenhague.

Sortir de la guerre La fin du premier conflit mondial sera l’occasion de publication d’un autre ouvrage, un manuel sur les soins infirmiers durant la guerre mais surtout, son action remarquée durant la grande guerre lui vaudra la remise de nombreuses décorations comme entre autres la Croix russe de St George, la Médaille de la Reine Elisabeth de Belgique, l'étoile de l’Ordre serbe de St Sava.

Un long périple pour gagner le front de l’Est

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Décidant de ne pas regagner les î les britanniques, elle prend pa r conséquent la direction du nord dans un long périple qui la conduit à traverser la Suède puis la

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Après avoir été nommée pour un temps administratrice à la Royal Air Force féminine, son parcours changera de direction. La suite de sa vie sera en effet consacrée à une activité totalement différente, s’intéressant aux arts du textile et apprenant l’activité de tissage et de teinture en Suède, en Italie, en France et en Allemagne. Vers 1923, elle sera nommée directrice des industries bédouines dans les camps de réfugiés du désert libyen, supervisant les femmes bédouines fabricant des tapis.

une grande ouverture d’esprit et un goût des voyages mis au service d’engagements forts comme ce fut le cas durant le premier conflit mondial. La guerre lui a permis d’exercer sa profession d’infirmière dans des conditions aussi diverses que difficiles. Dans ce contexte, elle a constamment cherché à défendre ce métier en même temps que de le faire évoluer pour une meilleure qualité des soins. BIBLIOGRAPHIE THURSTAN V. Field Hospital and Flying Column; Being the journal of an English Nursing Sister in Belgium and Russia. Independently Published - 2019.

Elle aura ainsi de nombreuses occasions de voyager et sera membre de la Royal Geographical Society. Là également son goût pour l’écriture l'amènera à écrire sur le sujet sans quitter son activité de tissage et d’enseignement.

THURSTAN V. A Text Book of War Nursing - Scholar's Choice Edition - 2015. THURSTAN V. Hounds of War Unleashed. United Writers Publications Ltd - 1978.

Le parcours de vie de cette femme souligne à la fois

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V IOLETTE THURSTAN (1879-1978)

A nurse on all fronts A young traveller

At the end of 1915, she returned to Russia for a few months as a representative of the National Union of Training Nurses to help refugees on the eastern front.

Anna Violet Thurstan was born in England in 1879. Her father was a doctor and her family moved frequently, resulting in young Violetta Thurstan, as she liked to be known, visiting a number of different boarding schools around Europe. In 1897, she returned to Britain to train as a nurse at London Hospital Whitechapel.

Then, in 1916, Thurstan found herself returning to Belgium to become the matron of a hospital in De Panne, before taking responsibility for an aid station closer to the front in Koksijde. Her efforts to evacuate wounded soldiers under enemy fire would go on to earn her the Military Medal.

Thurstan worked as a nurse for almost a decade at Bristol Royal Infirmary while developing an interest in languages as well as history and geography.

Joining the western front Having joined the British Red Cross a year earlier, Thurstan was sent to lead a group of nurses called in to assist the Belgian Red Cross at the start of the war in August 1914. Her first contact with war came in Brussels, where she witnessed refugees fleeing the enemy advance. However, it would be at an ambulance unit near Charleroi where Thurstan would be confronted with the full horror of armed combat, in a medical establishment completely overwhelmed by the constant influx of the sick and wounded. This is when she began to see the inadequacy of the nurses’ training, who – although not lacking commitment – were completely unsupervised.

Her final assignment during the war would be at the Ostrovo field hospital near the Macedonian front, before malaria put an end to her stay in the Balkans.

The occupation of Belgium resulted in all British nurses leaving the country after being expelled by the occupying forces. Violetta Thurstan decided to travel to Copenhagen, under the close eye of the German army.

The war ends The end of the First World War gave Anne Thurstan the chance to publish another work, a manual for wartime nursing. Thurstan’s extraordinary service during the conflict also saw her rewarded with numerous decorations, including the Russian Cross of Saint George, the Belgian Queen Elisabeth Medal and the Serbian Order of St Sava.

A long diversion to reach the eastern front Opting not to return to the British Isles, Thurstan headed north on a long journey through Sweden and Finland before reaching Russia. Here too she came across hospitals that were in a state of disarray, overcrowded and with unacceptable hygiene conditions. Thurstan immediately got to work and embarked on some remarkable organisational work over a period of several weeks. Eventually she joined a medical field unit caring for people wounded in the bombings of Lodz and Warsaw. She was injured herself and contracted pleurisy.

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After a period of time serving as an administrator for the Women’s Royal Air Force, Anne Thurstan’s career then took a different path. She spent the rest of her life devoted to entirely different pursuits, particularly textile arts and learning how to weave and dye in Sweden, Italy, France and Germany. In 1923, she was appointed director of Bedouin industries in a refugee camp in the Libyan desert, overseeing Bedouin women employed in carpet making.

While recovering from illness, Thurstan took the opportunity to write her first novel: Field Hospital and Flying Column. It was a record of what she saw and experienced during those months of war but also a reflection on the care afforded to the war-wounded and how it could be improved. Thurstan highlighted the importance of giving nurses proper training and education and advocated for qualified nurses to be registered with the national authorities.

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She also travelled extensively and became a member of the Royal Geographical Society. Her desire to write on the subject remained strong, as did her involvement in weaving and teaching.

at the same time pursuing progress to enhance the quality of care. BIBLIOGRAPHY THURSTAN V. Field Hospital and Flying Column; Being the journal of an English Nursing Sister in Belgium and Russia. Independently Published - 2019.

Violetta Thurstan’s career typifies her wonderfully open mind and desire to travel the world while serving such an important role during the First World War. The war allowed her to practice as a nurse in conditions that were as wide-ranging as they were tough. She always sought to defend her chosen profession while

THURSTAN V. A Text Book of War Nursing - Scholar's Choice Edition - 2015. THURSTAN V. Hounds of War Unleashed. United Writers Publications Ltd - 1978.

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J ULIA STIMSON (1881-1948)

L’organisatrice du service infirmier de l’armée américaine durant la Première Guerre Mondiale Training School for Nurses. Elle trouve également le temps de mener à bien, à l’université, une maîtrise de sociologie qu’elle termine en 1917.

Au-delà de qualités personnelles exceptionnelles, Julia Stimson est emblématique de la place prise par une infirmière au solide bagage universitaire dans l’organisation de novo, d’un système de soins infirmier militaire performant au service des combattants.

Passionnée, travailleuse infatigable aux résultats exceptionnels, elle est l'une des rares jeunes femmes de son époque à disposer d’un tel bagage universitaire !

Un engagement au profit des armées Lorsque sous l'impulsion du président Woodrow Wilson les Etats unis s'apprêtent à entrer en guerre en 1917, Julia Stimson se porte volontaire.

Une jeunesse studieuse Julia Catherine Stimson est née à Worcester dans le Massachusetts, le 26 mai 1881 au sein d’une famille nombreuse. Son père est pasteur à la Pelgrim Congregational Church, une église chrétienne progressiste.

Sa détermination, son énergie et son charisme en font la personne adéquate pour organiser un service de santé infirmier à la hauteur de la tâche qui attend les forces américaines engagées dans le conflit. Elle devient donc infirmière chef de l'hôpital de base 21, une structure sanitaire importante organisée par la Croix-Rouge avec des personnels médicaux et infirmiers qui proviennent de l'université de Washington ainsi que de l'hôpital Barnes de Saint Louis. Fort de 26 médecins, 55 infirmières et 156 membres du personnel auxiliaire, c’était la première unité de ce type à être mobilisée pour le service à l'étranger.

C’est à l’âge de 5 ans qu’elle arrive pour la première fois à Saint-Louis avant que la famille ne déménage à New York où Julia a terminé ses études secondaires. Elle entre au Vassar College à l'âge de 16 ans, obtient son diplôme A.B. en 1901. Son souhait de devenir médecin ne rencontre pas l’assentiment familial. Elle étudie donc les illustrations médicales au Cornell University Medical College, la biologie à l'Université de Colombie, puis entre à la New York Hospital School of Nursing en 1904.

Cinq semaines après que les États-Unis aient déclaré la guerre à l'Allemagne, le 17 mai 1917, l'hôpital de base 21 est en route à destination de Rouen, en France. Sur place, les compétences organisationnelles de Julia Stimson éprouvées dans ses fonctions antérieures sont immédiatement à l’œuvre. Appréciée par ses supérieurs, elle est nommée dès avril 1918 infirmière en chef de la Croix-Rouge américaine en France.

C’est donc avec un solide bagage universitaire qu’après avoir obtenu son diplôme d’infirmière, en 1908, elle sera nommée surintendante des infirmières au Harlem Hospital nouvellement ouvert.

Une appétence pour le domaine médico-social

Sept mois plus tard, elle sera enfin appelée à diriger l'ensemble du service infirmier des forces expéd itio nnaires américaines. Les exigences extraordinaires de la Première Guerre mondiale ont mis à l'épreuve mais surtout confirmé le courage personnel, le sens politique et la capacité de leadership de Julia Stimson.

En août 1911, Julia Stimson accepte l’offre qui lui est faite de diriger le nouveau département des services sociaux de l’hôpital pour enfants de Saint-Louis. De retour dans cette ville, elle y devient l’une des premières travailleuses sociales professionnelles. Elle jouera là un rôle déterminant dans l'expansion des services de ce département, en sollicitant l'aide de bénévoles et en recueillant des fonds pour financer les salaires.

Le retour au Pays Grâce aux extraordinaires qualités montrées par Julia Stimson pendant la Première Guerre mondiale, celle-ci est devenue la surintendante du Corps des infirmières de l'armée avant de devenir la première doyenne de l'École des sciences infirmières de l'armée.

Tout en poursuivant son action dans le domaine médico-social, Julia Stimson assume à partir de 1914 le poste de directrice de la Washington University

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Après cette brillante carrière militaire, Julia Stimson quittera l'armée en 1937 pour présider l 'A m e r i c a n N u r s e s Association de 1938 à 1944.

en 1920 la première femme à atteindre le grade de major dans l'armée américaine. Elle sera enfin promue au grade de colonel à part entière six semaines avant sa mort à l'âge de 67 ans, en 1948. La fierté de son père pour les états de service de sa fille l’amènera à compiler les lettres adressées à sa famille durant la guerre au sein d’un ouvrage intitulé : Finding Themselves .

Si ses compétences seront de nouveau sollicitées durant la Seconde Guerre mondiale pour recruter des infirmières dans le Corps des infirmières de l'armée, elle prendra définitivement sa retraite dès la fin de la guerre.

BIBLIOGRAPHIE

Détentrice de nombreuses décorations, notamment de la Médaille du service distingué, décernée par le général Pershing et de la médaille Florence Nightingale, elle sera

STIMSON J., Finding Themselves. The Letters of an American Amy Chief Nurse in the British Hospital in France . Wentworth Press - 2019.

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J ULIA STIMSON (1881-1948)

Responsible for setting up a nursing service for the US army during the First World War expanding the department’s services, finding volunteers and raising money to finance salaries. In further pursuit of sociomedical prog ress, Stimson became director of the Washington University Training School for Nurses in 1914. She also found the time to complete a master’s degree in sociology at university, which she finished in 1917. Julia Stimson worked passionately and tirelessly to achieve exceptional results, and was one of just a handful of young women in that era to have such an outstanding university education.

Committing to the armed forces As the United States prepared to enter the First World War in 1917 under the leadership of President Woodrow Wilson, Julia Stimson volunteered. Her determination, energy and charisma made her the right person to organise a nursing service up to the task of assisting US forces engaged in conflict.

Beyond her outstanding personal qualities, Julia Stimson’s life is the story of a nurse with an excellent university education in a newly established organisation and a system of military nursing care benefiting wounded soldiers.

Julia Catherine Stimson was born into a large family in Worcester, Massachusetts, on 26 May 1881. Her father was a reverend at the progressive Pelgrim Congregational Church.

She became chief nurse at Base Hospital 21, a key medical facility run by the Red Cross and staffed by doctors and nurses from Washington University and Barnes Hospital in St. Louis. Equipped with 26 doctors, 55 nurses and 156 auxiliary members of staff, Base Hospital 21 was the first unit of its kind to be set up for a military campaign abroad.

At the age of five, Julia Stimson travelled to St. Louis for the first time, before the family moved to New York where she completed her secondary education.

Five weeks after the US declared war on Germany, on 17 May 1917, preparations were under way to set up the facility in Rouen, France.

A young student

She enrolled at Vassar College at the age of 16 and finished her bachelor studies in 1901. Her desire to pursue a career in medicine was not well received among her family. Nonetheless, Julia Stimson studied medical illustration at Cornell University Medical College and biology at Columbia University, before joining the New York Hospital School of Nursing in 1904.

Once established, the hospital soon benefited from the o rg a n is at io na l skills Julia Stimson had gained in her previous roles. Stimson was held in high esteem by her superiors and, in April 1918, was appointed chief nurse of the American Red Cross in France.

With an excellent university education and a degree in nursing to her name, Julia Stimson was appointed director of nursing at the newly opened Harlem Hospital in 1908.

An appetite for the sociomedical domain In August 1911, Julia Stimson accepted an offer to manage the new social services department at a children’s hospital in St. Louis. Upon her return to the city, she became one of the world’s first professional social workers. In St. Louis, Stimson play ed a key role in

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Seven months later, she was entrusted

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with the task of organising nursing care for the American Expeditionary Forces. The extraordinary strains of the First World War were a huge test for Julia Stimson, but also allowed her to demonstrate own personal bravery, her political intellect and her capacity for leadership.

Stimson returned to the army in the Second World War to recruit nurses to the Army Nurse Corps, before finally retiring for good at the end of the war. Julia St imson received mult iple awards for her work, including t he Dist inguished Serv ice Medal f rom Genera l Pers hing, and t he Florence Night ingale Medal. She was also t he f irst woman to achieve t he rank of major in t he US A rmy in 1920. St imson was promoted to t he rank of colonel six weeks before her deat h, at t he age of 67, in 1948.

The return to the US

Her father’s great pride at his daughter’s service led him to compile a set of letters she had written to her family during the war, entitled Finding Themselves .

Thanks to the outstanding qualities she had shown during the First World War, Julia Stimson was appointed superintendent of the Army Nurse Corps before becoming the first dean of the Army School of Nursing.

BIBLIOGRAPHY

Following her distinguished career in the military, Stimson left the army in 1937 to serve as president of the American Nurses Association from 1938 until 1944.

STIMSON J., Finding Themselves. The Letters of an American Amy Chief Nurse in the British Hospital in France. Wentworth Press - 2019.

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EDITH CAVELL (1865-1915)

Une infirmière engagée au service des malades et de son pays Une enfance sous le sceau de la religion Edith Cavell voit le jour en 1865 dans la localité de Swardestone en Angleterre. Fille d’un pasteur de l’église anglicane, elle est élevée dans un milieu modeste mais avec une haute exigence morale qui accorde une place importante à l’aide des personnes démunies.

saxon de l’école d’infirmières de Florence Nightingale et c’est donc à Miss Cavell qu’il confie la direction de son établissement. L’épouse du Docteur Depage, Marie, elle-même infirmière, aide Edith Cavell dans la gestion de l’établissement.

La diffusion d’un savoir infirmier Le niveau de formation est tel que la ville de Bruxelles ainsi que plusieurs hôpitaux belges sollicitent les services des infirmières enseignées par Edith Cavell et nombre de jeunes femmes de divers pays viennent se former là. Miss Cavell participe également activement au journal anglais « English Nursing Mirror » proposant des articles ou la diffusion de divers rapports d’activité et en 1912, elle crée même son propre journal qu’elle nommera simplement : « L’infirmière ».

Ce n’est qu’à partir de 25 ans qu’elle commence à voyager en Europe en débutant par Bruxelles où elle trouve une place de gouvernante. Elle y perfectionne ainsi son français et développe par la même occasion son goût pour la peinture.

Infirmière et patriote Lorsque la première guerre mondiale éclate, à la demande de la Reine Elisabeth de Belgique, le docteur Depage fonde un hôpital à l’arrière du front de l’Yser; « l’Océan ». Le 3 août 1914, date d’entrée en guerre de son pays et alors qu’elle est en vacances en famille à Swardestone, Edith Cavell rejoint rapidement la Belgique pour prendre la direction de l’institut du Dr Depage et l’école qui ne compte alors pas moins de 60 élèves infirmières. Cette clinique devient un Hôpital de la Croix-Rouge prêt à accueillir tous les blessés sans distinction.

La naissance d’une vocation Puis c’est en Autriche qu’elle poursuit son périple. C’est là qu’à la suite d’une visite dans un hôpital où l’accès aux soins était gratuit pour les malades que s’est éveillée sa vocation pour le métier d’infirmière. Mais Edith Cavell doit écourter son voyage pour revenir au chevet de son père malade. Celui-ci nécessitant son aide, la jeune femme rentre à Londres et durant de longs mois lui donnera les soins dont il a besoin. C’est à ce moment qu’elle décide de devenir infirmière. En 1896, à plus de 30 ans, Edith entame donc sa formation d’infirmière à l’Hôpital de Londres. Miss Cavell s’y montre aussi dévouée aux malades que désireuse d’apprendre. Le jour à l’hôpital et la nuit au domicile des patients elle travaille sans relâche. Pour sa résistance à la tâche mais aussi pour la rigueur professionnelle dont elle fait preuve elle sera gentiment surnommée « Clever Miss Cavell ».

La formation des infirmières belges En 1907, Edith Cavell revient à Bruxelles sur la sollicitation d’un professeur de chirurgie : Antoine Depage. Soucieux de développer le champ des compétences des infirmières de son pays, il fonde dans son institut chirurgical de Berkendael, la première école d’infirmières de Belgique « l’ École Belge d'Infirmières Diplômées ». L’enseignement novateur s’inspire du modèle anglo-

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Mais parallèlement à cette activité soignante et de formation, elle assure aussi les fonctions d’agent du Secret Intelligence Service britannique. Ainsi, dans son hôpital, Edith Cavell accueille certes tous les combattants blessés, mais avec l’aide d’un architecte bruxellois, Philippe Bancq, elle met en place une filière d’évasion et contribue aussi activement au retour des soldats notamment britanniques dans leur pays. L’infirmière a de cette façon permis, via l’institut Berkendael, le passage clandestin vers la Hollande, pays neutre, de plusieurs centaines soldats. Après dénonciation par un agent allemand infiltré, elle est arrêtée. Accusée de profiter de sa position pour mener une activité d’espionnage elle reconnaît les faits. Emprisonnée, jugée, elle est condamnée le 11 octobre 1915 à la peine de mort pour « trahison en bande organisée ». Elle a alors 49 ans. Au révérend qui sera autorisé à lui rendre visite dans sa cellule elle dira : « Je n’éprouve ni crainte ni appréhension; j’ai vu la mort si souvent qu’elle ne m’est pas étrangère ni effrayante. Étant en face de Dieu et

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Edith CAVELL accompagnée par le docteur Antoine DE PAGE

de l’éternité, je me rends compte qu’aimer sa patrie n’est pas suffisant. Je ne dois avoir de haine ni de rancune envers personne. » Le Général gouverneur militaire de Bruxelles ordonne son exécution immédiate et le 12 octobre 1915, Edith Cavell est fusillée malgré l’indignation de la communauté internationale.

Une infirmière reconnue pour son engagement Très vite l’infirmière sera élevée au rang de martyre. Les hommages se multiplient et la pro pagande anglaise utilisera son image de patriote pour animer les jeunes à s’engager militairement. L’effet escompté sera atteint avec des effectifs qui augmenteront notablement durant les semaines qui suivent la mort de l’héroïne. notamment de neutralité. Un certain nombre d’infirmières ont utilisé leur statut comme couverture pour des activités d’espionnage. Certaines ont été démasquées et fusillées. C’est cependant souvent l’admiration pour ces femmes héroïques, qui ont consacré leur profession à des fins patriotiques, qui a souvent prévalu ensuite.

A la suite de l’armistice, la dépouille de Miss Cavell sera ramenée en Angleterre. Nombreux sont ceux qui témoigneront de la reconnaissance envers cette infirmière exemplaire qui a tant fait en Belgique pour la profession d’infirmière en même temps qu’au péril de sa vie, elle n’a cessé de soigner.

BIBLIOGRAPHIE

A titre posthume, Edith Cavell se verra remettre diverses médailles témoin de son exceptionnel engagement. A Londres, une statue en marbre blanc à son effigie est dressée près de Trafalgar Square et dans de nombreux pays des rues ou édifices portent son nom, venant rappeler ce que la profession d’infirmière doit à cette héroïne.

ARTHUR T., The life and death of Edith Cavell, english emergency nurse known as “the other Nightingale”. J Emerg. Nurs. 2006 Feb; 32(1):30-5. BATTEN J., Silent in an Evil Time: The Brave War of Edith Cavell. Toronto: Tundra Book, 2007. BOUDIN H., Edith Louisa Cavell, Héroïne de guerre entre piété et laïcité, entre mythe et réalité. Seneffe : Memogrames; 2015.

Cependant, cette double position de soignante et d’espionne a aussi posé question. Depuis la première Convention de Genève de 1864, le droit international humanitaire stipulait que le personnel médical et sanitaire, militaire et civil, devait être respecté et protégé. Mais cela imposait aussi à ces personnels des devoirs

BUTCHER C., Edith Cavell : Faith Before the Firing Squad by Catherine Butcher. Oxford UK: Monarch Books, 2015. PROTHEROE E., A Noble Woman : The Life-Story of Edith Cavell. Glasgow: Good Press, 2019.

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EDITH CAVELL (1865-1915)

A nurse dedicated to serving the sick and her country A childhood under the banner of religion

Ms Cavell was also an active contributor to the journal English Nursing Mirror, submitting articles or reports on her activities. In 1912, she also created her own journal entitled simply L’infirmière, or the nurse.

Edith Cavell was born in 1865 in the village of Swardestone, England. Her father was an Anglican priest, and she was raised in modest surroundings but with strong moral convictions about assisting those less fortunate.

Nurse and patriot At the outbreak of the First World War, Dr Depage established the Ocean hospital at the rear of the Yser front at the request of Queen Elisabeth of Belgium. On 3 August 1914, Belgium entered the war and Edith Cavell, who was on holiday with her family in Swardestone at the time, returned to her adopted country as soon as possible to manage Dr Depage’s facility and the nursing school, which now had some 60 students. The clinic would later become a Red Cross hospital and take in all manner of wounded soldiers from both sides.

It was not until the age of 25 that Edith Cavell began to travel around Europe, starting in Brussels where she worked as a governess. Here she perfected her French and also discovered a penchant for painting.*

The birth of a vocation Edith Cavell’s journey continued in Austria, where, following a visit to a hospital where access to care was free of charge, she first became interested in the profession of nursing.

Alongside her work as a nurse and a teacher, Edith Cavell was also working as an agent for the British Secret Service. At her hospital, Edith Cavell welcomed wounded soldiers of all kinds but, with the help of Brussels-based architect Philippe Bancq, set up an escape route funnelling predominantly British soldiers out of Belgium and back to their homeland. Cavell also enabled several hundred soldiers to secretly cross the border to neutral Netherlands via the Berkendael Institute. She was then exposed by an undercover German agent and arrested. Cavell was accused of taking advantage of her position to conduct espionage, and she knew what that meant. Imprisoned and court-martialled, she was sentenced to death on 11 October 1915 for “organised treason”. She was just 49 years old. Before her death, she was visited in her cell by a reverend, to whom she said: “I have no fear nor shrinking. I have seen death so often that it is not strange or fearful to me. But this I would say, standing as I do in view of God and eternity, I realise that patriotism is not enough. I must have no hatred or bitterness towards anyone. “

However, she was forced to cut her trip short to return to her sick father’s bedside. Cavell returned to London and spent months giving her father the care and assistance he required. By this time her mind was made up: she wanted to become a nurse. In 1896, Edith Cavell – now in her early thirties – began nursing training at London Hospital. Ms Cavell’s devotion to the sick was only matched by her interest in learning. She went about her work relentlessly, spending the day at the hospital and nights at her patients’ homes. She was soon nicknamed Clever Miss Cavell for both her commitment to the task at hand and her precision.

Training Belgian nurses In 1907, Edith Cavell returned to Brussels at the request of a professor of surgery, Antoine Depage. Concerned with improving the skills of Belgium’s nurses, Depage had set up a surgical institute, the Berkendael Institute, and the first Belgian school of nursing, l’École Belge d'Infirmières Diplômées. The innovative teaching methods at the new school were inspired by the British model at Florence Nightingale’s nursing school, and Edith Cavell was offered the position of matron. Dr Depage’s wife, Marie, herself a nurse, assisted Edith Cavell in the management of the establishment.

The military governor of Brussels ordered her execution to take place immediately. On 12 October 1915, Edith Cavell was shot by firing squad to worldwide condemnation.

A nurse honoured for her dedication

Sharing nursing expertise

Very soon nurse Cavell was held up as a martyr. Tributes flooded in and her patriotic image was used as British propaganda to encourage young men to enlist in the army. The propaganda worked, too, with a notable rise in soldiers registering for service in the weeks after the heroine’s murder.

The level of training was so high that the city of Brussels and several other Belgian hospitals requested the services of the nurses taught by Edith Cavell and many young women from various different countries came to train there.

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* Edith Cavell painting of the chap el at Hugoumont Waterloo – 1892 or 1893

Edith Cavell was posthumously honoured with various medals for her courage and service. In London, a white marble statue of Cavell stands near Trafalgar Square and many streets and buildings around the world bear her name as a reminder to the debt the nursing profession owes her. However, Edith Cavell’s double role as nurse and spy also posed a number of questions. Since the signing of the first Geneva Convention in 1864, international humanitarian law stipulated that medical personne l, both military and civilian, must be respected and protected. But the convention also stated that such individuals had to remain neutral. A number of nurses used their protection by the convention to cover for espionage, some of whom were exposed and executed. However more often than not what remains is an admiration for these heroic women who used their profession for patriotic purposes. BIBLIOGRAPHY ARTHUR T., The life and death of Edith Cavell, english emergency nurse known as “the other Nightingale”. J Emerg. Nurs. 2006 Feb; 32(1):30-5. BATTEN J., Silent in an Evil Time: The Brave War of Edith Cavell. Toronto: Tundra Book, 2007. BOUDIN H., Edith Louisa Cavell, Héroïne de guerre entre piété et laïcité, entre mythe et réalité. Seneffe : Memogrames; 2015.

Ms Cavell’s remains were returned to England following the armistice. Many were grateful to this extraordinary nurse who had contributed so much to the nursing profession in Belgium and, despite risking her life, never stopped caring.

BUTCHER C., Edith Cavell : Faith Before the Firing Squad by Catherine Butcher. Oxford UK: Monarch Books, 2015. PROTHEROE E., A Noble Woman : The Life-Story of Edith Cavell. Glasgow: Good Press, 2019.

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ELLEN NEWBOLD LA MOTTE (1873-1961)

Une infirmière qui a pris le risque d’écrire contre la guerre Sortir de son environnement social

C’est à cette période qu’elle rencontre Mary Borden, autre infirmière américaine, elle-même membre du mouvement sufragette qui s’est mobilisée pour équiper en matériel et personnel un hôpital de campagne pour les soldats français près du front . Comme infirmière bénévole elle œuvre ainsi, à partir de 1915, dans des structures sanitaires mobiles au plus près des combats. Les blessés reçoivent là les premiers soins avant d’être renvoyés au front, s’ils récupèrent de façon satisfaisante, ou vers un établissement de l’arrière lorsqu’ils ont besoin de soins plus importants.

Ellen Newbold La Motte est née en 1873, à Louisville (Kentucky) dans une famille de riches industriels. C’est à Wilmington (Delaware) qu’e lle passe une adolescence au sein de la « fashionable set ». Mais elle aspire à s’extraire de ce milieu.

Un engagement qui perd son sens

Contre l’avis de sa famille elle s’engage, relativement tardivement, dans des études d’infirmière à la John Hopkins Training School for Nurses (Baltimore). Après avoir obtenu son diplôme en 1902, elle occupera des fonctions d’infirmière superviseur à l'hôpital Johns Hopkins puis de surintendante adjointe à l’hôpital St. Luke de Saint-Louis.

Cette expérience difficile va être l’occasion pour Ellen La Motte de commencer l’écriture d’un ouvrage décrivant son expérience de la guerre : The Backwash of War : The Human Wreckage of the Battlefield as Witnessed by an American Hospital Nurse . Le livre, publié en septembre 1916 fait aussitôt l'objet de censure en Angleterre et en France comme susceptible de porter atteinte à l’esprit de combat. Il est par contre immédiatement remarqué aux Etats-unis non seulement en raison des discussions que suscitent l’idée d’une entrée en guerre du pays mais aussi pour sa qualité littéraire. Il s’agit d’un témoignage qui sous forme de tableaux saisissants présente sans concession la réalité de la guerre. C’est moins le vécu des soldats, leur héroïsme au feu qui est dépeint dans ce livre qu’une description de toute la laideur de la guerre. C’est aussi une importante critique de l’hôpital décrit comme scène de la détresse et de la violence impitoyable infligée à des soldats en souffrance.

A partir de 1905, elle s'intéresse tout particulièrement à la tuberculose, commençant à écrire sur ce sujet et notamment dans le domaine de la santé publique, contestant souvent les positions établies sur la question. C’est ainsi qu’en 1910, elle est nommée surintendante de la division tuberculose du département de la santé de Baltimore, s’attachant à faire baisser la mortalité due à cette maladie dans les quartiers défavorisés de la ville. En même temps, Ellen La Motte montre une ardente volonté de réformisme social, s’inscrivant de façon militante dans le mouvement des suffragettes pour l’émancipation des femmes.

L’entrée en guerre des Etats-Unis conduira également à son interdiction et à ce qu’il sombre dans un véritable oubli littéraire. Il est cependant probable, au vu de la proximité que Ellen La Motte a pu entretenir avec Gertrude Stein et le milieu artistique parisien, que ce livre ait influencé l’écriture d’Ernest Hemingway !

Infirmière et écrivain au contact de la guerre En 1913, elle fait un voyage à Paris d’où elle publie son premier livre : L'infirmière tuberculeuse sa fonction et ses qualifications . C’est à l’occasion de ce séjour que Ellen La Motte va rencontrer la poétesse américaine Gertrude Stein.

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Sa confrontation avec une hiérarchie médicale jugée inerte et la déception de voir son expertise soignante traitée avec indifférence par le corps de santé a probablement contribué à son départ. Ellen La Motte ne poursuivra en effet pas longtemps son activité infirmière sur le front et après une année, elle quittera le service pour partir en Chine.

Lors du déclenchement de la guerre, en 1914, elle ne peut rester à l'écart et veut faire usage de son savoir professionnel pour soigner les victimes des combats. Elle revient donc à Paris pour proposer ses services à l'hôpital américain de Neuilly. Elle sert alors au sein du Service américain d’ambulance. Mais c’est au front qu’elle souhaite travailler.

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Après la guerre… L’écriture comme mode d’engagement Après cette expérience de guerre, Ellen La Motte s'est rendue en Asie, où elle s’est trouvée confrontée à d’autres

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horreurs et notamment celle de la dépendance à l'opium. Ces voyages l'amèneront à publier pas moins de six livres sur le sujet. La connaissance qu’elle a ainsi acquise concernant les problèmes liés au trafic d'opium l’a amenée à apporter son expertise en 1930 à la Société des Nations. Pour son travail, elle sera honorée par le gouvernement nationaliste chinois qui lui remettra la médaille commémorative Lin Tse hsü.

of Women Geographers ou encore du Women’s National Republican Club de New York. Ellen La Motte n’a certes pas été la seule à avoir écrit sur la guerre. Mary Borden avec The forbiden zone publié en 1929 a également écrit à partir de son expérience de travail acquise au sein du même hôpital de campagne sur le front occidental de la première guerre mondiale. Mais Ellen La Motte a innové dans cette voie en publiant son ouvrage alors même qu’elle se trouvait sur le front, prenant ainsi des risques. Son travail littéraire influencera de nombreux auteurs qui écriront ensuite sur ce sujet. BIBLIOGRAPHIE LA MOTTE E. N., The tuberculosis nurse, Her Function and Her Qualification . Palala Press; 2015. LA MOTTE E. N., The Backwash of War: The Human Wreckage of the Battlefield as Witnessed by an American Hospital Nurse. HardPress Publishing; 1916.

Elle reste l'auteur de nombreux livres et articles sur ses expériences en soins infirmiers et en temps de guerre et a poursuivi son activité au sein de diverses sociétés savantes comme la Johns Hopkins Nurses Alumnae Association, la Hugenot Society of America, l’Author’s League, la Society

WILLIAMS L., Ellen N. La Motte: Nurse, writer, activist. Manchester: Manchester University Press; 2019.

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ELLEN NEWBOLD LA MOTTE (1873-1961)

A nurse who took risk with her anti-war writing Escape from hig h society

who was rallying for support to help find equipment and staff for a hospital for French soldiers close to the front. As a volunteer nurse, La Motte began working in field hospitals near to the frontline from 1915. Here, wounded soldiers would receive care before being sent back to the front, provided they had suitably recovered, or being transferred to another facility if they required additional medical attention.

Ellen Newbold La Motte was born in 1873 in Louisville, Kentucky, into a wealthy industrial family. She grew up in Wilmington, Delaware, where she belonged to the “fashionable set”, but aspired to escape this lifestyle. Against the advice of her family, she took the relatively late decision to study nursing at the John Hopkins Training School for Nurses in Baltimore. She graduated in 1902 and became a nurse supervisor at the John Hopkins Hospital before taking on the role of assistant director at St. Luke’s Hospital in St. Louis.

A job loses all meaning This traumatic experience would be the starting point for Ellen La Motte’s work describing her experiences of war, entitled The Backwash of War: The Human Wreckage of the Batt lefield as Witnessed by an American Hospital Nurse. This book, published in September 1916, was immediately banned in the UK and in France as it was deemed to undermine the war spirit. In the United States, however, the book earned high praise, partly due to discussions surrounding the idea of the US entering the war, but also on account of its literary quality. It was an uncompromising piece of first-hand evidence documenting the reality of war. Ellen La Motte concentrated on the ugliness of combat rather than the experiences of soldiers and their heroism in the line of fire. Importantly, it was also an important critique of hospitals, which La Motte described as scenes of distress and ruthless violence inflicted on soldiers in great distress.

From 1905, Ellen La Motte’s focus switched to tuberculosis, which she began writing about in the context of public health – often contradicting established positions on the subject. This is how, in 1910, she became director of the tuberculosis division of the Baltimore healthcare department and was charged with lowering the disease’s mortality in the city’s less-affluent areas. It was at this time that Ellen La Motte became a fierce proponent of social reform, supporting the suffragettes’ efforts towards female emancipation in a militant fashion.

Nurse and writer travels to the front In 1913, Ellen La Motte travelled to Paris where she published her first written work: The Tuberculosis Nurse, Her Function and Her Qualifications. Paris was also where La Motte struck up a friendship with American poet Gertrude Stein.

The decision by the US to enter the war saw La Motte’s work banned there too, and the book seemed to be destined for literary oblivion. Given Ellen La Motte’s proximity to Gertrude Stein and the Paris literary scene of the time, it is likely that The Backwash of War actually influenced Ernest Hemingway’s writing.

When war broke out in 1914, La Motte immediately decided to make use of her professional skills to take care of the wounded. She returned to Paris to volunteer her services at the US hospital in Neuilly, which was also at the heart of American ambulance service. However, Ellen La Motte always wanted to work on the front. VOL. 93/3

Ellen La Motte’s confrontation with stagnant medical structures and the disillusion at seeing her nursing expertise being treated with such indifference by the medical establishment likely contributed to her leaving France. She did not continue her nursing work on the western front for much longer, leaving the forces for China after one year.

She also met Mary Borden, a fellow American nurse who was also a member of the suffragette movement,

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After the war… writing as a form of engagement

Association, the Hugenot Society of America, the Author’s League, the Society of Women Geographers and the Women’s National Republican Club in New York.

Leaving her experience of war behind, Ellen La Motte made her way to Asia. Here she was confronted by yet more horrors, this time linked to opium addiction. La Motte’s travels led her to publish no less than six books on the subject. The knowledge she acquired regarding the problems with the opium trade saw La Motte invited to the League of Nations to share her expertise in 1930. The Chinese government awarded her with the Lin Tse Hsu Memorial Medal in honour of her work.

Ellen La Motte is certainly not the only woman to have written about war. The Forbidden Zone by Mary Borden was published in 1929 and also described her experiences of working in a military hospital, on the eastern front, during the First World War. But La Motte was one of the first people to publish such a work while working on the front, at great personal risk. Her literary style was also a great influence on many writers who would go on to cover the same subject. BIBLIOGRAPHY

She went on to write numerous books and articles about her experiences in nursing and of wartime, and became a key figure in many scholarly societies such as the Johns Hopkins Nurses Alumnae

LA MOTTE E. N., The tuberculosis nurse, Her Function and Her Qualification . Palala Press; 2015. LA MOTTE E. N., The Backwash of War: The Human Wreckage of the Battlefield as Witnessed by an American Hospital Nurse. HardPress Publishing; 1916. WILLIAMS L., Ellen N. La Motte: Nurse, writer, activist. Manchester: Manchester University Press; 2019.

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MARY BORDEN (1886-1968)

Infirmière et écrivain, une femme qui a traversé activement le XXème siècle Une jeune femme de milieu aisé

temps qu'elle se montrera rapidement critique vis-à-vis des soins prodigués aux blessés et des matériels dont disposent les structures sanitaires. Elle a donc pris l’initiative de contacter le Général commandant en chef des Forces françaises pour lui proposer de financer et de mettre en œuvre un hôpital. Et en juillet 1915 c'est chose faite à Roesbrugge en Belg iq ue. L’hôpital Chirurgical Mobile N° 1 qui compte 160 lits est immédiatement surnommé « le petit paradis des blessés ». Mary Borden est en effet parvenue à rassembler en un temps record des matériels et du personnel infirmier dont elle assure de façon remarquable la direction.

Mary Borden est née sur les bords du lac Michigan, dans une famille très aisée de Chicago. Elle a grandi au milieu de 4 frères, partageant ses premières années de vie de façon agréable avant que sa mère ne sombre dans une religiosité austère. C’est sans doute par l’écriture qu’elle tentera de s'extraire d'une ambiance familiale devenue pesante.

C'est une expérience qui permettra, quelques années après la guerre en 1929, la rédaction du livre : The forbiden zone .

Adolescente attirée par les lettres et la philosophie, elle s'éloignera de sa famille pour suivre ses études dans une institution privée de New York puis au Vassar college, établissement pionnier d'un modèle éducatif prônant l’émancipation féminine. Cette période sera aussi marquée par la perte douloureuse de son père.

Désireuse de se rapprocher du front de la Somme où se préparait une offensive majeure, Mary Borden a proposé la création d'un second hôpital d'évacuation susceptible de compter jusqu'à 2000 lits. Là également, cet hôpital mobile de première ligne sera mis sur pied en quelques semaines avant qu'en mai 1917 Mary Borden ne souhaite retrouver son premier hôpital. Elle y subira un terrible bombardement qui conduira à ce que son courage et sa bravoure sous le feu ennemi soient honorés par les plus hautes autorités militaires.

La fin de ses études l'amène ainsi à entamer un tour du monde qui la conduira notamment en Inde où elle rencontrera son premier mari. Rapidement mariée puis mère, ce sera pour elle le moyen de desserrer l'étreinte maternelle. De retour en Europe, c'est le moment où elle écrit son premier roman d'inspiration largement autobiographique.

Une activité littéraire et politique Malgré les responsabilités prises durant la guerre, malgré sa présence permanente auprès des blessés, Mary Borden ne cessera d'écrire. Elle continua après la guerre et de manière prolifique, s'inscrivant dans le monde littéraire de l'entre-deux-guerres comme un auteur à succès et ceci malgré que sa nature rebelle et interrogatrice n'ait fréquemment suscité la controverse.

Contribuer à l’effort de guerre Lorsque la Grande Guerre éclate, Mary enceinte vit à Londres avec son époux et ses deux filles. Avant même d’avoir donné naissance à son troisième enfant, elle propose ses services au Comité de la Croix-Rouge française présent dans cette ville.

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Ainsi, beaucoup de femmes britanniques sans formation spécifique ni connaissances en soins infirmiers proposèrent bénévolement leur aide pour contribuer à l'effort de guerre.

Cette période l'a également amenée à accompagner activement dans son parcours politique son second mari, le capitaine britannique Edward Louis Spears qu'elle avait rencontré durant la guerre. Là aussi, elle n'a cessé de prendre parti sur les grandes causes qui lui tenaient à cœur et notamment celui des droits des femmes.

Et peu de temps après son accouchement, Mary Borden est donc partie en France où elle a été affectée comme infirmière dans un casino reconverti en hôpital de fortune.

Un désir d'action demeuré intact Lorsque la seconde guerre mondiale se déclenche, n'ayant rien perdu de son désir d'action, Mary Borden, devenue Lady Spears, se mobilise à nouveau pour créer avec son amie, Lady Hadfield une structure chirurgicale au profit des armées. L’ayant proposée au chef de la

Le souhait de faire évoluer les choses Infirmière novice, Mary apprendra très vite en même

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France libre, à Londres, l'ambulance « HadfieldSpears » accompagnera ainsi les Forces françaises libres durant toutes les années de guerre. En janvier 1940, Mary Borden est donc à la tête d'une formation composée d'infirmières et de conductrices anglaises qui débarque en Egypte. On la retrouvera au Liban, en Palestine et à Damas avant qu'elle ne revienne en Afrique du Nord dans le désert Libyen. Durant cette période, en plus de diriger son unité, elle aura également à remplir ses fonctions d'épouse du nouveau premier ministre du Levant, assurant sa fonction d'hôtesse de personnages qui furent marquants durant la guerre.

Durant toutes ces périodes de guerre, Mary Borden ne cessera d'écrire, avec au final une œuvre littéraire de plusieurs dizaines d'ouvrages. Elle ne suspendra cette activité que pour s’adonner, lors de ses dernières années de vie, à la peinture. Elle est décédée à l’âge de 82 ans au terme d’une vie que peu d’humains peuvent se vanter d’avoir vécue de façon si intense et impliquée.

Après la bataille d’El-Alamein, l’unité « HadfieldSpears » rejoindra la Tunisie avant de participer à la campagne d’Italie. Et le 18 juin 1945, elle défilera dans Paris libéré !

BIBLIOGRAPHIE

Après la guerre…

BORDEN M., The Forbidden Zone . London: Heinemann, 1929.

Mary Borden a été décorée pour son courage héroïque lors des deux guerres et a reçu du gouvernement français, la Croix de guerre, faisant d’elle la première femme américaine à recevoir un tel titre honorifique.

BORDEN M., Journey down a blind alley , New York, London, Harper & Brothers, 1946. CONWAY J., A woman of two wars, the life of Mary Borden . Munday Books; 2009.

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MARY BORDEN (1886-1968)

Nurse and novelist, a women who transcended the 20th century A young lady born into privilege Mary Borden was born on the banks of Lake Michigan into an extremely wealthy Chicago family. She grew up together with her four brothers in comfortable surroundings, before her mother fell into a world of religious austerity. Writing offered a way out of a family lifestyle that had become suffocating. As a young adult, Mary Borden held a great interest in humanities and philosophy and distanced herself from her family in order to pursue her education. She attended a private school in New York before enrolling at Vassar College, a pioneering educational institution when it came to advocating female emancipation. This period was also marked by the tragic death of her father. At the end of her studies, Mary Borden embarked on a world tour. She was particularly attracted to India, where she met her first husband. After her marriage she soon had children, allowing her to escape the clutches of her own mother. Upon her return to Europe, Mary Borden wrote her first novel largely inspired by her own experiences.

Contributing to the war effort Mary Borden was living in London with her husband and two daughters when the Great War broke out. Before giving birth to her third child, Borden offered her services to the London committee of the French Red Cross. Many other British women without any special training or other nursing expertise had also volunteered to contribute to the war effort. Sure enough, shortly after giving birth, Mary Borden left for France where she began working as a nurse in a makeshift hospital that had been set up in a casino.

A desire for progress

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Despite being a novice, Mary Borden quickly learned the skills of nursing and was soon critical of the kind of care being offered to the sick and wounded, as well as the equipment that was available. She took the initiative and contacted the chief commander of French forces herself to propose the idea of financing and setting up a hospital. In July 1915, her wishes came true with the construction of L'Hôpital Chirugical Mobile No. 1 in Roesbrugge, Belgium, which offered 160 beds and was immediately christened the “little paradise for

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the wounded”. Mary Borden succeeded in bringing together the necessary materials and nursing staff in record time and managed the unit with incredible expertise. This experience also inspired her to write a novel, The Forbidden Zone, some years after the end of the war in 1929. Driven by a desire to move closer to the western front at the Somme, where the armed forces were preparing for a major offensive, Mary Borden proposed setting up a second evacuation hospital capable of housing up to 2,000 beds. No sooner said than done, the new field hospital on the front was established just a few weeks. Mary Borden’s first field hospital was subject to intense bombardment in May 1917, and her courage and bravery under enemy fire would go on to be honoured by the highest military authorities.

A career in literature and politics Even though she no longer held the same responsibilities she did during the war and was no longer permanently surrounded by the wounded, Mary Borden did not stop writing. She continued after the war, becoming a prolific novelist and a huge success in the interwar period, despite frequently attracting controversy through her rebellious and interrogatory nature. This was also a period in which Mary Borden became active in the political career of her second husband, British captain Edward Louis Spears, whom she had met during the war. Despite these political distractions, she remained devoted to causes that were close to her heart, and particularly to women’s rights.

Appetite for action remains intact Mary Borden’s desire to take action had not diminished by the time the Second World War broke out. Lady Spears, as she was now known, mobilised once more together with her friend Lady Hadfield to set up a medical unit for the benefit of the armed forces. The idea was put to the head of Free France in London, and the Hadfield-Spears Ambulance Unit was soon accompanying Free French Forces throughout the war.

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After the war…

In January 1940, Mary Borden was the head of a unit comprising Brit ish nurses and superv isors t hat was stat ioned in Egy pt . She served in Lebanon, Palest ine and Damascus before ret urning to North Africa and the Libyan desert.

Mary Borden was greatly rewarded for her bravery and heroism across two world wars, receiving the Croix de Guerre from the French government – and in doing so becoming the first American women to receive such a military decoration. Throughout these periods of war, Mary Borden never stopped writing and published several-dozen works across her literary career. She only stopped writing to pursue another passion, painting, in her later years.

Besides organising her unit, Mary Borden also found herself hosting leading figures during the war as the wife of the new

Mary Borden died at the age of 82 after having lived life to the full in a way that few others can match. BIBLIOGRAPHY BORDEN M., The Forbidden Zone . London: Heinemann, 1929.

Minister to the Levant.

BORDEN M., Journey down a blind alley , New York, London, Harper & Brothers, 1946.

Following the Battle of El Alamein, the Hadfield-Spears Unit returned to Tunisia before joining the Italian campaign. Then, on 18 June 1945, it marched in liberated Paris !

CONWAY J., A woman of two wars, the life of Mary Borden . Munday Books; 2009.

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MARIE MARVINGT (1875-1963)

La passion de l’aviation au service des blessés Une jeunesse sportive

à détenir 4 brevets de pilote (avion, hydravion, ballon libre, hélicoptère). En 1909, elle s’illustre comme la première femme à traverser la Manche en ballon, au risque de sa vie.

C’est en France, à Aurillac dans le Cantal, qu’est née Marie Marvingt. Son enfance est marquée par la perte relativement précoce de sa mère puis de son frère. Elle se retrouve alors seule avec un père qui va n’avoir de cesse de faire partager à sa fille sa passion pour le sport.

Cette infirmière passionnée d’aviation a eu tôt la conviction de l’utilité de l’avion pour venir en aide aux blessés. Elle ne sera cependant pas suivie dans ce projet par les autorités notamment militaires du pays.

Un projet d’avion sanitaire Dès 1910, Mademoiselle Marvingt proposera au gouvernement français de développer un prototype d’avion sanitaire. Elle a l’ambition de faire don à la Croix-Rouge, d’un avion-ambulance qui aurait pour mission le rapatriement de blessés, le ravitaillement des postes de secours et le transport de l’équipe médicale avec son matériel dans un temps très court. Ce projet n’aboutira pas pour des raisons financières mais avant tout par manque de soutien des autorités.

Il va en effet initier Marie à toutes sortes de disciplines d’ordinaires réservées “aux garçons”. Ainsi, à 4 ans, elle est déjà capable de nager sur plusieurs kilomètres, presque aussi à l’aise dans l’eau que sur la terre ferme. Sa vie ne sera alors qu’une succession de défis et de records. Mais Marie Marvingt est aussi mue par une soif de connaissances qui l’amènera à suivre un parcours académique pour satisfaire notamment son souhait de maîtriser l’usage de plusieurs langues. Au terme de sa vie elle parlera parfaitement 4 langues vivantes en plus de l’Esperanto.

Participer à la guerre « comme les hommes » Avec le déclenchement de la première guerre mondiale, et forte de plus de 900 vols en avion, elle tentera de convaincre le gouvernement de l’engager au sein de l’armée de l’air. Mais les femmes ne sont pas les bienvenues sur le champ de bataille. Malgré cela, elle obtiendra néanmoins plus tard l’accord de participer à des opérations de bombardements sur une base militaire ennemie ce qui lui vaudra d’être récompensée par la Croix de guerre.

Savoir et vouloir Polyvalente dans les sports, Marie Marvingt l’est aussi au niveau de ses centres d’intérêts intellectuels. Une revue faisant son éloge, alors qu’elle n’a que 25 ans parle d’une jeune femme « hors normes », mettant en lumière son cursus de médecine et de droit à l’université de Nancy et son diplôme d’infirmière de la Croix-Rouge.

Insatisfaite de ne pouvoir participer directement aux hostilités, Marie Marvingt ne renonce pas et parvient tout de même à rejoindre le front, déguisée en homme, et à intégrer ainsi un bataillon de chasseurs à pied. La supercherie sera découverte conduisant alors à ce que le Maréchal Foch l’autorise à rejoindre le bataillon de chasseurs alpins sur le front italien des Dolomites.

Agée d’à peine plus de 30 ans, elle assure la rédaction d’un journal connu dans sa région. Elle pratique enfin le chant et la danse. La devise qu’elle s’est fixée « savoir vouloir » l’orientera sa vie durant.

Infirmière de la Croix-Rouge, skieuse et alpiniste émérite, Marie Marvingt pourra, au sein des troupes du 3ème Régiment d’Infanterie Alpine, prendre part au ravitaillement des unités, porter assistance et participer aux opérations d’évacuation des blessés.

La fiancée du danger Marie Marvingt enchaîne donc sans discontinuer les exploits sportifs, performant quels que soient les éléments. Sans cesse en quête de nouvelles disciplines, elle cherche en permanence à repousser ses limites, à affronter le risque au point de se voir dénommée comme « la fiancée du danger ». Elle collectionne donc les médailles dans des disciplines aussi diverses que le bobsleigh, le patinage artistique, le ski, le canoë, l’équitation, l’escrime ou le tir. VOL. 93/3

C’est sans doute dans les airs qu’elle se révèle la plus exceptionnelle, devenant la première femme au monde

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Des convictions inébranlables A la suite de la guerre, elle ne perd pas de vue son projet d’une aviation sanitaire au service des blessés. Cette passion qu’elle partage avec d’autres pionniers convaincus conduit en 1929 à l’organisation du premier Congrès international de l’Aviation sanitaire avec une assistance en provenance de plus de 41 pays, et à la fondation de l’association des « Amis de l’Aviation

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Sanitaire » dont elle est nommée vice-présidente. Elle sillonnera ensuite le monde pour des conférences visant à défendre, devant les plus hautes autorités civiles et militaires, ce projet assurément visionnaire. C’est en 1934 que l’armée française sollicitera Marie Marvingt pour la mise au point d’un programme aéromédical au Maroc, signant alors la véritable naissance de l’Aviation Sanitaire Civile .

Le souci de la formation des infirmières Attentive aux impératifs sanitaires des missions aéromédicales, Marie Marvingt mettra en œuvre un programme de formation pour les infirmières et les pilotes qui réalisent ces missions. Sera ainsi créé en 1932 le corps des infirmières de l’air dont la première promotion sera diplômée en 1935, forte des apports à la fois pratiques mais aussi théoriques apportés par Marie Marvingt notamment dans le domaine de la psychologie du vol.

désormais essentielle à la conduite de la guerre. Avec courage et dévouement, Marie Marvingt prendra des fonctions d’infirmière en service de chirurgie, inventant à cette occasion un nouveau type de suture particulièrement utile en situation d’évacuation sanitaire. En même temps qu’elle participera à la création d’un établissement de convalescence destinée aux aviateurs blessés au combat.

Fidèle jusqu'au bout à ses passions Après la guerre, Marie Marvingt sera honorée pour son action en étant nommée Officier de la légion d’honneur. Ses efforts et son « acharnement » à développer l’aviation médicale sont aujourd’hui unanimement reconnus et salués. Peu de temps avant de mourir, à plus de 80 ans et toujours adepte des déplacements à bicyclette, elle a également souhaité passer son brevet de pilotage… sur hélicoptère à réaction !

Le développement des évacuations sanitaires aériennes La seconde guerre mondiale verra le développement d’évacuations sanitaires devenues indispensables au soutien des forces militaires en opération. Au même titre que la pénicilline ou la transfusion sanguine, le Général Eisenhower évoquera cette avancée comme

BIBLIOGRAPHIE KAHN M., La fiancée du danger – mademoiselle Marie Marvingt, LePassage, 2020. MAGGIO R., Marie Marvingt, Fiancee of Danger : First Female Bomber Pilot, World-Class A thlete and Inventor of the Air Ambulance, North Carolina: McFarland, 2019.

Rep roduction d ’une aquarelle de 1911, rep résentant le 1er avion sanitaire de Marie MARVINGT

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MARIE MARVINGT (1875-1963)

Passion for aviation in the service of the wounded A sporty youth

This nurse with a passion for aviation would soon become a proponent of the benefits offered by aeroplanes in helping the wounded. However, it was not an area that the French authorities, and particularly the military, were willing to pursue.

Marie Marvingt was born in Aurillac, in the French département of Cantal. Her childhood was marked by the tragic loss of her mother, and then her brother, while she was still at a relatively young age. She grew up alone with her father, who shared his burning passion for sport with his daughter.

Medical aircraft project As early as 1910, Marie Marvingt submitted proposals to the French government for the development of a medical aircraft prototype. She wished to donate an air-ambulance to the Red Cross to help repatriate the wounded, supply aid stations and transport medical teams and their equipment within a very short space of time. The project never got going, partly for financial reasons, but above all due to the lack of support from the authorities.

Marie’s father would go on to introduce her to many different types of sport normally reserved “for boys”. At the age of four she was already able to swim several kilometres and felt just as much at home in the water as she did on land. Her life became a succession of challenges and records. Marie Marvingt was also driven by a thirst for knowledge that would lead her to study and meet her ambition to master multiple languages. As an adult, she would speak four languages fluently, as well as Esperanto.

Fighting in the war “like the men” With the outbreak of the First World War, and with more than 900 flights to her name, Marie Marvingt attempted to convince the government to enlist her in the French air force. However, women were not welcome on the batt lefield. Nevertheless, she would later receive approval to participate in one set of bombings on an enemy base, for which she was awarded the Croix de Guerre.

Knowing what to want from life Not only was Marie Marvingt a multi-talented athlete, she was also interested in a number of different intellectual pursuits. A magazine article about her written when Marie was 24 years old speaks of an “extraordinary” young woman and highlights her studies in medicine and law at the University of Nancy and her nursing diploma at the Red Cross. In her early 30s, Marie Marvingt was working as the editor of a well-known publication in her region. She was also a keen singer and dancer. Marie Marvingt certainly knew what she wanted from life, and it was a motto that would go on to live by.

The fiancée of danger

Despite her frustrations at not being allowed to join the hostilities directly, Marie Marvingt did not give up and managed to join the army disguised as a man, enlisting in a battalion of foot soldiers. Her real identity was discovered, but she was transferred to a battalion of Alpine troops at the Italian front in the Dolomites at the request of Marshal Foch himself.

Marie Marvingt continued to excel in her sporting achievements, performing well in any elements. Constantly in search of new disciplines, she sought to push her limits and take risks – to the point where she earned the nickname “the fiancée of danger”. She won numerous prizes in a diverse range of sports, from bobsleigh, figure skating and skiing to canoeing, horse riding, fencing and shooting.

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As a Red Cross nurse and experienced skier and mountaineer, Marie Marvingt helped to supply units, provide assistance and evacuate casualties as part of the 3rd Regiment of Alpine Troops.

Without a doubt, Marie Marvingt’s most outstanding achievements came in the air. She became the first woman in the world to hold pilot’s licences for four types of aviation (aeroplane, seaplane, balloon and helicopter). In 1909, she put her life on the line to become the first woman to cross the English Channel in a balloon.

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Unwavering convictions Marie Marvingt never lost sight of her vision of creating an air ambulance to help the wounded, even after the war. In 1929, this passion, which she shared with

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her fellow air-ambulance pioneers, led to the organisation of the inaugural International Congress of Medical Aviation. The congress was attended by people from over 41 different countries, and resulted in the founding of the Friends of Medical Aviation, of which Marvingt was the Vice-President. She travelled the world to attend conferences and speak to the highest civil and military authorities in support of what was without doubt a visionary project.

armed forces. Along with other breakthroughs such as penicillin or blood transfusions, General Eisenhower considered this development to be an essential element of warfare. Marie Marvingt continued to work with great courage and dedication as a surgical nurse, inventing a new type of stitch that proved particularly useful in medical evacuation situations. She also helped found an establishment to allow pilots who had been wounded in the war to recuperate.

In 1934, the French army commissioned Marie Marvingt to develop an air-ambulance programme in Morocco, marking the birth of civil medical aviation.

Faithful until the end

Concern for nurse training

After the war, Marie Marvingt was honoured for her service by being made an Officer of the Legion of Honour. Her efforts and relentless pursuit of development in medical aviation are widely recognised and valued today.

With her expert knowledge of the needs of air-ambulance missions, Marie Marvingt was able to implement a programme of training for the nurses and pilots. The airborne nurse corps was created in 1932, with the first cohort graduating in 1935 – thanks in part to the contributions made by Marie Marvingt in the practical and theoretical elements of the course, particularly in relation to the psychology of flight.

The development of airborne medical evacuation

Short ly before her death at the age of 88, Marie Marvingt was st ill a keen cyclist and wished to obtain a pilot’s licence again… this t ime for t ip j et helicopters !

In the Second World War, the development of medical evacuation systems became imperative to support the

BIBLIOGRAPHY KAHN M., La fiancée du danger – mademoiselle Marie Marvingt, LePassage, 2020. MAGGIO R., Marie Marvingt, Fiancee of Danger: First Female Bomber Pilot, World-Class A thlete and Inventor of the Air Ambulance, North Carolina: McFarland, 2019.

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GENEVIÈVE DE GALARD (Née le 13 avril 1925)

Une infirmière au cœur de la bataille Geneviève de Galard est une infirmière française qui s’est illustrée par l’attitude exemplaire dont elle a fait preuve durant la bataille de Diên Biên Phu en 1954.

assureront, notamment en Indochine, un travail de plus en plus dangereux au fur et à mesure que la guerre s’intensifie. À sa demande, elle est en effet affectée en extrême orient, au cœur de la guerre qui oppose les forces françaises à celles du Viêt Minh. C’est au début de l’année 1954 que se déclenche la bataille de Diên Biên Phu avec de nombreux blessés et des évacuations sanitaires qui deviennent de plus en plus périlleuses, les avions devant se poser au milieu d’intenses barrages d'artillerie.

Une adolescence marquée par la guerre Geneviève de Galard est issue d’une famille française traditionnelle plutôt aisée. Née à Paris en 1925, son enfance est marquée par la perte de son père alors qu’elle n’a que 9 ans. Sa mère se consacrera ensuite totalement à l’éducation de ses deux filles.

Le 28 mars 1954, alors qu’elle se porte volontaire pour une nouvelle mission d’évacuation, son avion est touché, lors de son atterrissage. Il ne peut donc repartir et l’équipage est pris au piège du camp retranché.

Une femme au milieu des combattants Geneviève de Galard se porte alors immédiatement volontaire pour assurer son travail d'infirmière dans l'hôpital de campagne du camp.

Un second moment marquant de sa jeune existence est le déclenchement de la seconde guerre mondiale. Elevée dans un esprit de patriotisme, la défaite est pour elle un choc. Les difficultés de la vie quotidienne sous l’occupation ennemie vont forger son esprit de résistance. Les alertes et les bombardements sont ses premiers contacts véritables avec la guerre.

Dans un contexte initial de relative hostilité masculine à son encontre, seule femme européenne au milieu des combattants, son attitude remarquable et son sang-froid vont contribuer à son acceptation et à créer sa légende.

Une vie inspirée par l’exemple des pionniers Ecolière studieuse, c’est aussi une jeune fille qui se passionne pour les récits héroïques des grands aventuriers, des pionniers notamment de l’aviation… En même temps, elle s’engage tôt vers des activités associatives, notamment auprès des malades et des handicapés et c’est ainsi qu’après des études universitaires de langues, elle décide de passer son diplôme d’état d'infirmière qu’elle obtient en 1950.

Au cœur de combats acharnés, pris dans un étau qui se resserre avec un ravitaillement de plus en plus épisodique, dans des conditions sanitaires effroyables, Geneviève de Galard va déployer toute son imagination et son humanité pour consoler les mourants et tenter d'entretenir le moral face aux pertes humaines toujours plus importantes.

Mais désireuse de vastes horizons en même temps que d’engagements forts, elle passe deux années plus tard le concours de convoyeuse au sein de l’armée de l’air française.

Convoyeuse volontaire

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Pour cela, elle sera décorée au cœur de la bataille de la légion d’honneur par le commandant du camp.

L’histoire est marquée, au sortir de la seconde guerre mondiale, par des soulèvements militaires qui vont conduire à la fin de l’empire colonial français. En même temps, ces combats voient le développement de l’aviation sanitaire avec des infirmiers qui assurent l’évacuation et le convoyage des blessés.

La reddition Les troupes françaises de Diên Biên Phu cessent le combat Le 7 mai 1954. Malgré la volonté contraire des vainqueurs, Genevieve de Galard se bat pour rester avec les blessés pour continuer

Geneviève de Galard fera partie de ces pionnières qui

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à leur prodiguer les soins qui leur sont nécessaires. Cela aura pour eux un important effet de rassurance. En même temps, l’infirmière refusera toute coopération avec l’ennemi, n’hésitant pas, à ses risques et périls à cacher certains médicaments nécessaires à ses blessés lorsque l’ennemi veut les réserver à son propre usage !

Elle sera en effet, chose exceptionnelle, invitée aux États-Unis par le Congrès, descendra les rues de Broadway en fête et recevra du président Eisenhower en personne la médaille de la liberté (Medal of Freedom) à la Maison-Blanche. C'est aux États-Unis qu'elle sera pour la première fois surnommée « l'ange de Diên Biên Phu ». A côté de l’hommage populaire dont le courage est tourné en emblème de résistance contre le communisme, elle est considérée comme exemplaire pour contribuer à créer des vocations. Censée incarner la valeur du service et le sens du devoir, la presse américaine la comparera à Florence Nightingale marchant entre blessés et morts de la guerre de Crimée.

Ce n’est que le 24 mai 1954, avec les derniers blessés évacués que Geneviève de Galard acceptera de mauvaise grâce de quitter ses frères d’armes, prisonniers maltraités !

Une vie au service des blessés Si Geneviève de Galard a repris ensuite son travail de convoyeuse et fini son contrat militaire, elle a ensuite fait le choix de sa famille. Elle n’a cependant cessé de porter attention aux blessés militaires notamment à l’hôpital du Val-de-Grâce ou à l’institution nationale des invalides.

Les obligations d’une héroïne Son retour en France sera très attendu et la presse fera d’elle « l’héroïne de Diên Biên Phu » ! L’évolution d’une bataille emblématique avait attiré les médias du monde entier et amené de grands organes de presse à lui proposer l’exclusivité du récit d’une jeune femme au milieu des combattants. Si elle a su se montrer extrêmement discrète devant la presse, elle n’en devra pas moins satisfaire à des impératifs plus politiques !

BIBLIOGRAPHIE

DE GALARD G., Une femme à Diên Biên Phu. Paris : Les Arènes; 2007.

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GENEVIÈVE DE GALARD (Born April 13, 1925)

A nurse at the heart of the battle Geneviève de Galard was a French nurse who distinguished herself by her exemplary service at the Battle of Bien Dien Phu in 1954.

Growing up against a backdrop of war Geneviève de Galard was born into a relatively well-off, traditional French family. Born in Paris in 1925, her childhood was marked by the loss of her father at the age of only nine. Her mother devoted herself entirely to educating her two young daughters. Another key moment in Geneviève de Galard’s childhood was the outbreak of the Second World War. Raised among patriotic surroundings, France’s defeat in the war came as a huge shock. But the problems of daily life in occupied France would go on to foster a spirit of resistance in her. Sirens and bombing would be her first real contact point with the war.

A life inspired by the great pioneers As a studious schoolgirl, Geneviève de Galard was fascinated by the heroic tales of the great adventurers, and in particular the pioneers of aviation… At the same time, she soon became involved in extracurricular activities – including caring for the sick and the disabled. After finishing her university studies in languages, Geneviève de Galard decided to complete her nursing diploma, which she obtained in 1950. With dreams of broadening her horizons while maintaining her own personal commitments, de Galard spent two years as an in-flight nurse in the French air force.

land and take off under intense artillery bombardment. On 28 March 1954, Geneviève de Galard had volunteered for another evacuation mission, but her aircraft was hit by enemy fire as it attempted to land. The aircraft was unable to take off again and the evacuation team became trapped in the entrenched camp.

A camp under the spotlight Straight away, Geneviève de Galard volunteered to work as a nurse in the camp hospital. Initially faced by relative hostility from her male colleagues as the only European woman in the camp, her remarkable attitude and composure would help her to be accepted and mark the start of a legend. In the midst of fierce fighting, facing less and less frequent supplies in appalling sanitary conditions, Geneviève de Galard would use all of her imagination and human qualities to console the dying and attempt to maintain moral in the face of rising casualties. She would go on to be awarded the Legion of Honour by the camp commander for her service.

Surrender The French forces at Dien Bien Phu ceased their fire on 7 May 1954. Against the will of the victorious side, Geneviève de Galard fought to stay with the wounded in order to continue giving them the care they required – to the soldiers’ great relief. At the same time, she refused to cooperate with the enemy at any time, even concealing medical supplies required by the French troops when

Volunteering as an in-flight nurse At the end of the Second World War, military uprisings brought the French colonial empire to its knees. At the same time, this combat led to developments in medical aviation, with nurses responsible for securing the evacuation and transfer of the wounded. Geneviève de Galard was a pioneer in this area, and would go on to perform increasing dangerous work, particularly in South-East Asia, as the war intensified. She was assigned to Asia at her own request, in the midst of a war waged by the Viet Minh in opposition of the French forces. VOL. 93/3

The Battle of Dien Bien Phu took place at the start of 1954 at the cost of countless lives. Medical evacuations became increasingly perilous as aircraft attempted to

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the Viet Minh tried to use them themselves, at enormous personal risk. It wasn’t until 24 May 1954, when the last casualties were evacuated, that Geneviève de Galard reluctantly accepted to leave her brothers-in-arms behind as prisoners of war.

The duties of a heroine Geneviève de Galard’s return to France was eagerly awaited, with the press christening her “the heroine of Dien Bien Phu”. The progression of this key battle had attracted the attention of the world’s media, with some of the largest publications in the world attempting to secure the exclusive story of a young woman in the trenches with the soldiers. Despite maintaining great discretion away from the press, Geneviève de Galard had more political duties to fulfil. She would be invited to the United States by Congress, participate in a celebratory parade on Broadway and receive the Medal of Freedom at the White House from

none other than President Eisenhower himself. It was in the United States that Geneviève de Galard would be dubbed “the Angel of Dien Bien Phu”. Besides her tale of extraordinary courage that became a symbol of resistance against Communism, Geneviève de Galard was vital in helping to promote worthy vocations. De Galard was said to embody the value of service and sense of duty, and the American press would compare her to Florence Nightingale walking among the dead and wounded in the Crimean War.

A life devoted to serving the wounded Geneviève de Galard returned to her previous career as an in-flight nurse and ended her military contract, opting to spend more time with her family. Nevertheless, she continued to treat soldiers wounded in battle, notably at the hospital in Val-de-Grâce and at the Institution Nationale des Invalides. BIBLIOGRAPHY

DE GALARD G., Une femme à Diên Biên Phu. Paris : Les Arènes; 2007.

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L’HISTOIRE DE L’ENGAGEMENT INFIRMIER MILITAIRE; QUELQUES RÉFÉRENCES BIBLIOGRAPHIQUES THE HISTORY OF MILITARY NURSING ENGAGEMENT; SOME BIBLIOGRAPHICAL REFERENCES ABEL-SMITH B., A history of the nursing profession. London: Heinemann; 1960.

DEPAGE A. DUSTIN AP, DEBAISIEUX G., Ambulance de l’Océan. Paris : Masson; 1917.

ANTIER C., Résister, espionner : nouvelle fonction pour la femme en 1914-1918. Guerres mondiales et conflits contemporains, 2008/4; 232 : 143-54.

DIEBOLT E., FOUCHÉ N., Devenir infirmière en France, une histoire atlantique ? (1854-1938). Paris : Publibook; 2011.

APPLETON E., A Nurse at the Front: The First World War Diaries of Sister Edith Appleton. Great Britain: Simon & Schuster UK Ltd; 2012. BOWDEN J., BARCLAY T., Nurses at War: The True Story of Army Nursing Sisters' Courage in World War II. London: Wyndham Books; 2015. BRAYLEY M., World War II Allied Nursing Services. Oxford: Osprey Publishing; 2012. BRIDGES DC., A History of the International Council of Nurses 1899-1964. Pitman Medical Publishing Company Ltd; 1967. BUNDY ER., Surgical nursing in war. Philadelphie: Blakiston’s Son & Co; 1917. Conventions de Genève du 22 août 1864 pour l'amélioration du sort des militaires blessés dans les armées en campagnes. Genève, 22 août 1864. CREWDSON D., Dorothea's War: The Diaries of a First World War Nurse. UK: George Weidenfeld & Nicholson; 2013. CROFTON E., The women of Royaumont: A Scottish Women’s Hospital on the Western Front. East Lothian: Tuckwell Press; 1997. D’ANTONIO P., Nurses in War. The Lancet. 2002; 360: 17-8. DARFEUIL G., HUMANN S. Infirmière pendant la Première Guerre mondiale. Journal de Geneviève Darfeuil, Houlgate-Paris, juillet 1914 - novembre 1918. Paris : Gallimard Jeunesse; 2012. DELAHAYE C, RICARD S., La grande guerre et le combat féministe. Paris : l’Harmatan; 2009. VOL. 93/3

DE LAUNOY J., Infirmières de guerre en service commandé, Front de 1914 à 1918. Seneffe : Memogrames; 2015.

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ENGLUND P., Vingt destins dans la Grande Guerre : La beauté et la douleur des combats. Paris : Points; 2014. FARMBOROUGH F., With the armies of the tsar: a nurse at the Russian front, 1914-18. New York: Stein and Day; 1975. FARRELL M., Pure Grit: How American World War II Nurses Survived Battle and Prison Camp in the Pacific. New York: Harry N. Abrams; 2014. FESSLER D., No Time for Fear: Voices of American Military Nurses in World War II. Michigan: Michigan State University Press; 1997. GARCIA J, LEFORT H, LAMACHE C, TABBAGH X, OLIER F., Les infirmiers français dans la guerre 1914-1918. Soins 2014; 786 : 49-54. GASS C., MANN S., The War Diary of Clare Gass, 19141918. Montreal: McGill-Queen's University Press; 2000. GUILLEMAND J., Histoire des infirmières : de la naissance de la Croix-Rouge à l’institution de la profession. Paris : France-sélection; 1991. HALLETT CL., Containing Trauma: Nursing Work in the First World War. Manchester: Manchester University Press; 2009. HARRIS K., More than Bombs and Bandages: Australian Army Nurses at Work in World War I. Newport: Big Sky Publishing; 2011. KNIBIEHLER Y., Cornettes et blouses blanches : les infirmières dans la société française (1880-1980). Paris : Hachette; 1984. KUHN B., Angels of Mercy: The Army Nurses of World War II. New York: Aladdin; 1999. LESLIE JH., An historical roll with Portraits of those women of the British Empire to whom the Military Medal has been awarded during the Great War 19141918, for the Bravery and Devotion under Fire. Sheffield: WC Leng; 1920.

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LINEBERRY C., The Secret Rescue: An Untold Story of American Nurses and Medics Behind Nazi Lines. New York: Back Bay Books; 2014.

POTTECHER J., Lettres d'un fils - 1914-1918 : Un infirmier de chasseurs à pied à Verdun et dans l'Aisne. Louviers : Ysec Editions; 2007.

LOODTS P., La grande guerre des soignants : médecins, infirmières et brancardiers en 1914-1918. Bruxelles : Memogrames; 2008.

POWELL A., Women in the warzone. Stroud: Sutton; 2008.

MACDONALD L., The Roses of No Man's Land. London: Penguin Books; 2013. MANN S., MORIN-PELLETIER M., Briser les ailes de l’ange. Les infirmières militaires canadiennes (10141918). Montréal : Athéna éditions; 2006. MONAHAN E., NEIDEL-GREELEE R., And If I Perish: Frontline U.S. Army Nurses in World War II. The United States: Anchor Books; 2004. MORILLON M, FALABRÈGUES JF., Le service de santé, 1914-1918. Paris : Bernard Giovanangeli Editeur; 2014. MORIN-PELLETIER M., Des oiseaux bleus chez les poilus. Les infirmières des hôpitaux militaires canadiens-français postés en France, 1915-1919. Bulletin d’histoire politique 2009; 17 (2) : 57-74. MORIN-ROTUREAU E., 1914-1918, combats de femmes. Les femmes pilier de l’effort de guerre. Paris : Autrement; 2004. NESSMANN P., La fée de Verdun. Paris : Flammarion jeunesse; 2016. NUTTING MA, LLOYD DOCK L., A history of nursing. Charleston: Bibliobazaar; 2010.

RAMIO, A., TORRES C., Enfermeras de guerra. Esplugues de Llobregat : Ediciones San Juan de Dios – Campus Docent; 2015. REES P., The Other Anzacs: Nurses at War 1914-1918. Australia: Allen & Unwin; 2008. SCHULTHEISS K., Bodies and Souls: Politics and the Professionalization of Nursing in France, 1880-1922. Harvard University Press; 2001. SMITH N., The Australian nurses in France during the Great War. Soins. 2014; 786: 92-95. TAYLOR E., Wartime Nurse: One hundred years from the Crimea to Korea 1854-1954. London: Robert Hale; 2001. TICHADOU L., Infirmière en 1914 Journal d’une Volontaire. Marseille : Gaussen; 2014. TOMAN C., Sister Soldiers of the Great War: The Nurses of the Canadian Army Medical Corps, Vancouver: UBC Press; 2016. TYRER N., Sisters in Arms: British Army Nurses Tell Their Story. London: Weidenfeld & Nicolson; 2008. VANE AP, MARBLE S., Contribution of the US Army Nurse Corps to the First World War. Soins. 2014; 786: 99-105.

OLIER F., Paramédicaux dans les armées. Trois siècles pour parvenir au statut des militaires infirmiers techniciens des hôpitaux des armées (1708-2008). Médecine et armées 2008; 36 : 497-505.

WIGLE SL., Pride of America, we’re with you: the letters of Grace Anderson, US Army Nurse Corps, World War I. Rockville: MD: Seaboard Press; 2007.

PINEAU F., Les infirmières dans la Grande Guerre. Le personnel féminin de la Croix-Rouge pendant la Première Guerre mondiale. Nonant : Orep; 2020.

World War I Nurse, A war nurse's diary: sketches from a Belgian field hospital. New York: The Macmillan Company, 1918.

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References Ref-1: Huang C et al: Lancet 2020; 395: 497–506 Ref-2: Guan W. et al., NEJM 28 Feb 2020, https://www.nejm.org/doi/full/10.1056/NEJMoa2002032 Ref-3: Zhou et al., Lancet , March 9, 2020 , https://doi.org/10.1016/S0140-6736(20)30566-3 Ref-4: Chen N. et al., Lancet 2020; 395: 507–13 Ref-5: Xiao-Wei, X. et al., BMJ (Online); London 2020, 368 (Feb 19, 2020).DOI:10.1136/bmj .m606 Ref-6: Huang Y et al., medRxiv preprint 2020, doi: https://doi.org/10.1101/2020.02.27.20029009 Ref-7: Schuetz P. et al., Exp. Rev Anti-infect. Ther., 2018, 16:7, 555-564, DOI: 10.1080/14787210.2018.1496331

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A RT ICLES

Le « petit ange noir » devenue héroïne de guerre. Augusta CHIWY, l’infirmière oubliée.*

SUMMARY The “Little Black Angel” Becomes a War Hero. Augusta CHIWY, the Forgotten Nurse.* Augusta Chiwy is a young Belgian-Congolese nurse who, like many of her fellow nurses, j oined the war to take care of wounded soldiers. Despite her heroism during the Second World War, Augusta Chiwy and her story were long forgotten – like many of her nurse colleagues. The “little black angel”, as she was nicknamed at the time of her nursing studies, had some particularly traumatic experiences from a young age. Snatched away from her Congolese mother at the age of 9, it was in Belgium where Augusta grew up. The Second World War was raging and at j ust 23 years of age Augusta Chiwy was suddenly plunged into the horrors of the Battle of the Bulge. On 16 December 1944, in the area almost by chance, the young nurse accepted a request for assistance from a military doctor who was struggling to cope with the influx of wounded men. Augusta Chiwy bravely accompanied Captain John “Jack” Prior, chief medical officer of the 20th Armoured Infantry division, in his duties. She risked her life to follow him out onto the battlefield, exposed to enemy fire. Deeply traumatised by what she experienced, Augusta would bear the psy chological scars for the rest of her life. Her extraordinary story led historian Martin King to quite rightly give her the recognition she deserves *.

MOTS-CLÉS : Infirmière, Service médical, Médecine de guerre, Bataille des Ardennes, Seconde guerre mondiale. KEYWORDS: Nurse, Medical service, Wartime medicine, Battle of the Bulge, Second World War.

L’histoire de l’humanité est faite de guerres dont la cruauté n’a d’égale que le courage, le dévouement, la force d’âme qu’elle révèle chez des femmes et des hommes que rien ne prédestinait à cela. Il en est ainsi de personnes qui viennent au secours des victimes de la guerre et notamment des infirmières. Si les hommes ont longtemps souhaité tenir les femmes à l’écart des champs de bataille, elles s'y sont progressivement imposées, témoignant alors de qualités exceptionnelles. Nombre d’entre elles resteront à tout jamais inconnues. D’autres apparaissent un beau jour à la lumière, plus ou moins fortuitement. C’est le cas d’Augusta Chiwy que rien ne prédestinait à se trouver plongée au cœur d’une des plus grandes batailles de la seconde guerre mondiale.

UNE PETITE FILLE NÉE AU CONGO

Augusta Chiwy

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Augusta naît au Congo belge, le 6 juin 1921, d’une mère congolaise et d’un père belge. A l’âge de 9 ans elle est arrachée par son père, Henry Chiwy, des bras de sa maman. Celui-ci, vétérinaire de formation, regagne son pays natal, la Belgique, où Augusta débarque donc

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en 1930. C'est un homme qui présente une addiction à l’alcool et se montre peu aimant voir malveillant et parfois violent. Il mourra d’une cirrhose alcoolique peu après la seconde guerre mondiale.

bombardements. Les généraux américains n’ayant pas pris la mesure des informations qui leur avaient pourtant été transmises, leurs forces sont insuffisantes pour faire face à l’offensive allemande qui se dirige sur Bastogne. Des ordres de déplacement des troupes américaines vers les Ardennes belges sont alors opérés. Le 20ème bataillon d’infanterie blindée, dans lequel le médecin Capitaine John « Jack » Prior a été nouvellement affecté en tant que médecin en chef, prend donc la route en direction de Bastogne, à l’instar de deux autres divisions, la 10ème division blindée (Team O’Hara) et la 101ème division aéroportée (Team Cherry ).

La jeunesse d’Augusta a donc été marquée par l’absence d’une mère dans un pays qui lui est étranger et où elle rencontre toutes les dimensions d’une discrimination raciale alors omniprésente. Son oncle, le frère de son père, est médecin. Il occupera auprès d’elle une place importante. Au début des années 1940, et grâce à son aide bienveillante, Augusta part pour Louvain afin d’y effectuer des études d’infirmière. L’école des infirmières est adjointe à l’hôpital Sainte-Elisabeth qui sera le futur lieu de travail d’Augusta. La jeune femme et ses condisciples sont alors sous la tutelle de religieuses bénédictines et doivent se plier aux règles très strictes des sœurs. Mais à la différence d’autres de ses camarades, Augusta s’en accommode parfaitement. Elle développera même de forts sentiments pour l’une des sœurs qui a fait d’elle son « petit ange noir ».

Le 18 décembre, des unités de la Team Cherry entrent dans Bastogne et au fur et à mesure que les bombardements s’intensifient, la situation est de plus en plus difficile pour les soldats alliés qui ne parviennent pas à prendre l’ascendant sur l’ennemi. Le 20 décembre, la bataille fait rage contraignant les forces américaines à opérer de nouveaux mouvements de troupes autour de Bastogne.

DES DISPOSITIFS SANITAIRES SOUS TENSION Les dispositifs sanitaires en soutien des combattants sont fortement sollicités et leurs tâches rendues complexes par la grande mobilité des unités. Celle du Dr Prior était alors particulièrement difficile en raison de l'absence de médecins rompus à la médecine de guerre mais également à un manque cruel de matériel médical. Les conditions d’hygiène dans lesquelles il devait travailler étaient de surcroît tout à fait déplorables. Il était donc en demande d’aide humaine et de moyens matériels pour assurer le soutien des combattants. Le docteur Jack PRIOR

LA BATAILLE DES ARDENNES Au mois de mai 1940, la Belgique est envahie par l’ennemie. C'est donc dans un pays sous régime d'occupation que Augusta Chiwy poursuit ses études et débute une carrière d'infirmière dans cette institution religieuse qui lui est chère. Le 6 juin 1944 est marqué par le débarquement des forces alliées en France et devant l’avancée des troupes américaines, commence le repli des forces allemandes. En septembre 1944, la Belgique a été partiellement libérée par les alliés : les forces armées américaines sont positionnées au sud du pays tandis que les forces britanniques, canadiennes et polonaises progressent plus au Nord. Mais ce mois de décembre 1944, semblable à la neige et aux températures glaciales, les Allemands s’invitent le long de la ligne américaine de 140 kilomètres où les militaires en sous-effectif sont çà et là. Le matin du 16 décembre, trois armées allemandes passent à l’offensive, les rockets « Screaming Meemies » se font entendre, sonnant le début de ce que l’on appellera la bataille des Ardennes. VOL. 93/3

Certains bastognards (habitants de Bastogne) commencent à quitter la ville alors que ceux qui restent se réfugient dans les caves pour se mettre à l’abri des

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Le docteur Jack PRIOR lors de la Bataille des Ardennes

LES CONDITIONS DE TRAVAIL AU POSTE DE SECOURS Les températures en cette période de l’année n’étaient pas clémentes et pouvaient atteindre -28 °C dans la région. Les militaires américains, à l’inverse de leurs ennemis n’étaient pas préparés à un hiver aussi rigoureux, et en souffraient particulièrement. La vie dans ce poste de secours situé rue de Neufchâteau était extrêmement difficile. Augusta et Renée ont fait preuve de beaucoup de professionnalisme et d’une grande bravoure. Toutes deux avaient des fonctions bien spécifiques liées à leurs compétences et à leur niveau de tolérance de la situation : Renée Lemaire supportait difficilement en effet de s’occuper des soldats dont la gravité des blessures l’effrayait. Elle a assuré essentiellement des soins courants et la délivrance des quelques médicaments disponibles tandis que Augusta accompagnait et assistait le docteur Prior dans les actes médicaux les plus complexes. Jack a pu ainsi compter sur le soutien technique remarquable d’Augusta pour la réalisation d’une amputation. L’infirmière a accompagné également à plusieurs reprises le Dr Prior jusque sur le lieu des combats, assurant ainsi la relève de blessés graves exposée à l’artillerie ennemie. Elle a ainsi essuyé des tirs, sauvée selon ses dires par son petit gabarit. Son dévouement mais aussi sa résistance à la tâche ont fait l’admiration de tous.

Le Général McAuliffe commandant les forces américaines a par conséquent fait le choix de s'adresser à la population locale afin d’obtenir de l’aide en personnels de santé et en matériel. C'est ainsi qu'une première infirmière présente à Bastogne, Renée Lemaire, a accepté d’apporter son aide à l’équipe du Dr Prior.

L'ENTRÉE « EN GUERRE » D'AUGUSTA CHIWY Il se trouve qu’au matin du 16 décembre, suite à l’invitation de son père à le rejoindre pour les fêtes de Noël, Augusta Chiwy avait décidé de prendre le train en direction de Bastogne, lieu de résidence de sa famille. Ce voyage, qui devait être bref et festif, allait profondément changer le cours de la vie de la jeune femme. Ayant appris la présence de cette infirmière et alors que la ville était soumise à d'intenses bombardements, « Jack » Prior se rend en personne au domicile de la famille Chiwy, afin de la convaincre de venir lui apporter son aide. C’est ainsi que le 21 décembre, en pleine bataille, A ugusta et Jack font connaissance. La jeune infirmière appréhendait énormément de rejoindre une équipe médicale militaire, craignant notamment que la couleur de sa peau ne la mette en difficulté ! Mais son sens du devoir la conduit à accepter d'intégrer ce poste de secours. Elle y rejoint Renée Lemaire, présente ici depuis peu. Immédiatement à la tâche, les deux infirmières n'ont pas eu le loisir d’échanger que quelques mots. Au cours de ces journées harassantes, leur temps était totalement consacré à soigner les victimes des combats.

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LES TRAUMATISMES DE GUERRE Le 21 décembre, L’état-major américain a reçu l’ordre de défendre Bastogne coûte que coûte et d’empêcher l’ennemi d’envahir la ville. En face, Hitler faisait de Bastogne un objectif à atteindre, demandant à ses forces d’obtenir la reddition des défenseurs de la ville. Le 22 décembre, une demande pour cela a été donc transmise au QG du général Anthony McAuliffe. Le commandant américain a répondu par la négative avec un célèbre « Nuts ! » devenu depuis légendaire. Et donc dès le 23 décembre, une nouvelle offensive débutait, menée par la 26ème Volksgrenadier Division. C’est dans ce contexte que l’équipe médicale du docteur Prior a été une nouvelle fois sollicitée pour rapatrier de nombreux blessés vers le poste de secours. Lors de cette mission, le médecin accompagné de son infirmière se sont retrouvés sous la menace de soldats de la 26ème division ennemie. Évoquant les conventions de Genève, ils ont pu tout de même sortir vivant de cette situation périlleuse. Augusta gardera d’importantes traces de ce moment traumatique au cours duquel elle s'était trouvée face à la réalité de sa possible mort. Sans répit, un autre événement tout aussi traumatique est survenu le lendemain même, veille de Noël. C’est cette fois une explosion qui a anéanti le poste de secours du Dr Prior. Lors de cette journée terrible, sa camarade Renée Lemaire, dont le dévouement conduira les blessés à parler d’elle comme de « l’Ange de Bastogne », a été tuée. La perte de cet alter ego l’a touchée profondément.

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Bastogne n’a pas d'accalmie le jour de Noël. Ce 25 décembre 1944 a été pour Augusta sans doute l'une des pires journées de sa vie, la ville ayant vécu un véritable déluge de feu et d'acier. Épuisés physiquement autant qu’émotionnellement, ce n’est pas la trêve que le médecin et l'infirmière avaient pu espérer !

LA FIN DE LA BATAILLE Après cette destruction de leur poste de secours Augusta suivit le Dr Prior et les rescapés de l’équipe médicale pour une réinstallation dans la caserne Heintz, célèbre à Bastogne. Là ils ont poursuivi sans faillir la mission qu’ils s’étaient donnés : assurer des soins mais aussi donner de l’espoir aux soldats blessés. Le docteur Prior a dû cependant mettre en garde Augusta sur le fait que malgré le travail formidable qu’elle effectuait au risque de sa vie, les soldats de la 101ème n’accepteraient pas d’être soignés par une infirmière noire. Par conséquent, A ug usta Chiwy a eu pour tâche de s’occuper exclusivement de blessés noirs du 969ème régiment d’artillerie de campagne. Elle a accepté une fois de plus le devoir qui lui était confié avec le même dévouement et le même professionnalisme dont elle avait fait preuve jusqu’à présent ! Le 26 décembre, le général McAuliffe a annoncé la nouvelle tant attendue : la 4ème division blindée de la troisième armée du Général Patton venait d’arriver à Bastogne. En fin d’après-midi, elle perçait l’offensive ouest de la 5ème division Panzer. Le 27 décembre, les Américains continuaient leur avancée pour reprendre Bastogne non sans une forte opposition des Allemands qui étaient cependant déstabilisés par la rapidité et l’agressivité de l’adversaire.

UNE MARQUE INDÉLÉBILE Avec l’arrivée des renforts, le docteur Prior et Augusta ont pu compter sur une nouvelle équipe médicale et chirurgicale. Les bombardements ennemis ont cessé le 2 janvier et le 17 la team Desobry et le docteur Prior ont quitté Bastogne. Même si Augusta Chiwy a survécu à la guerre, elle en est restée fortement marquée par les épreuves inhumaines vécues, comme infirmière bénévole âgée d’à peine 23 ans. En effet, depuis la bataille des Ardennes, Augusta Chiwy n’a cessé de présenter des troubles anxieux qui ne l’ont plus quittée jusqu’à sa mort en 2015.

RESUME A l’instar de nombreuses soignantes, Augusta Chiwy est une jeune infirmière belgo-congolaise qui s’est engagée dans la guerre pour porter assistance aux combattants blessés. Comme la majorité de ces femmes, elle est restée dans l’anonymat de très longues années malgré tout l'héroïsme dont elle a fait preuve durant cette période. VOL. 93/3

Le « petit ange noir », comme elle a été surnommée lors de ses études d’infirmière, avait connu dès son plus jeune âge, des moments particulièrement douloureux.

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Arrachée des bras de sa mère congolaise à l'âge de 9 ans, c’est en Belgique qu’elle a poursuivi son parcours de vie. Alors que la seconde guerre mondiale faisait rage et qu’elle n’avait à ce moment que 23 ans, elle s’est trouvée plongée dans la bataille des Ardennes. Le 16 décembre 1944, présente sur les lieux de façon presque fortuite, l’infirmière a accepté de répondre à la sollicitation d’un médecin militaire submergé par l’accueil des blessés. Elle a alors accompagné courageusement le Capitaine John « Jack » Prior, médecin en chef du 20ème bataillon d’infanterie blindée dans son activité de médecine de guerre. Au risque de sa vie, elle l’a suivi jusque sur le champ de bataille, sous les bombes. Profondément traumatisée par ce qu’elle a vécu là, Augusta en a porté le poids psychologique durant le reste de sa vie.

Son exemplarité a fort justement amené l’historien Martin King à lui offrir la reconnaissance qu’elle mérite*. BIBLIOGRAPHIE 1. Bastogne Barracks, Introduction, Site http://www.bastognebarracks.be/introduction/ 2. BEEVOR A., Ardennes 1944: Hitler 's Last Gamble . Penguin Books Ltd; 2016. 3. KING M., L’infirmière oubliée. L’histoire inconnue d’Augusta Chiwy, héroïne de la bataille des Ardennes . Bruxelles : Racine ; 2012. 4. PIKETTY G., La Bataille des Ardennes: 16 décembre 1944 3 1 j anvier 1945 . Paris : Tallandier ; 2014. 5. WHITING C., The Last Assault: 1944 - The Battle of the Bulge Reassessed . Barnsley: Pen & Sword Books Ltd; 2004.

Augusta Chiwy en p résence de l ’historien Martin King

* L’infirmière oubliée. L’histoire inconnue d’Augusta Chiwy, héroïne de la bataille des Ardennes. de Martin King. En 2007, l’historien britannique, Martin King, s’est rendu dans les Ardennes belges, là où des hommes s’étaient battus autrefois lors d’une des plus grandes batailles de l’histoire militaire américaine; la bataille des Ardennes. A Bastogne, ville mémoire, il a visité « Bastogne barracks » le centre d’Interprétation de la Seconde Guerre Mondiale où il a poussé la porte de cette cave dans laquelle le général Anthony McAuliffe a répondu, un 22 décembre 1944, « Nuts ! » à la demande de reddition du commandant allemand. Dans cet endroit, un lieu de commémoration modeste était érigé pour « l’Ange de Bastogne », Mademoiselle Renée Lemaire, cette infirmière tuée dans le bombardement du poste de secours dans lequel elle apportait soins et réconfort aux blessés. Il a aussi appris là l’existence d’une seconde infirmière, belgo-congolaise, qui avait également fait preuve de dévouement et de courage en décembre 1944.

Le désir de rendre j ustice à cette infirmière oubliée a conduit l’historien à entreprendre des recherches sur cette autre héroïne de la bataille des Ardennes. Il la rencontra et de cette rencontre est né un ouvrage… et l’exemplarité de l’action de cette femme a inspiré une production cinématographique. Le livre de Martin King permet d’honorer la mémoire d’une grande infirmière. * King, M., Searching for Augusta: The Forgotten Angel of Bastogne. Guilford: Lyons Press, 2020. In 2007, British historian Martin King visited the Ardennes where men fought in one of the greatest battles in US military history, the Battle of the Bulge. In Bastogne, the town of remembrance, he visited Bastogne Barracks, a Second World War visitor centre, where he opened the door to the very cellar room where General Anthony McAuliffe issued his famous riposte “Nuts!” on 22 December 1944 to German demands for surrender. Here there was a small memorial to the “angel of Bastogne”, Renée Lemaire, the nurse killed in the bombing of the aid station where she was caring for and comforting wounded soldiers. King also learned of the existence of a second nurse, half-Belgian half-Congolese, who had also demonstrated enormous dedication and courage in December 1944. The desire to do the story of this forgotten young nurse j ustice drove the historian to begin researching this other heroin of the Battle of the Bulge. He tracked her down, and from this meeting a book was born... and the life of this extraordinary young woman even inspired a film production. Martin King’s work is all about honouring the memory of a wonderful nurse.

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