Florence Nightingale centenary: Nursing by numbers

Statisticians recognise Florence Nightingale as an early pioneer of their discipline. The first woman to be elected a Fellow of the Royal Statistical Society, she was an excellent mathematician, inventing the ‘coxcomb’ (a type of graph) among other statistical methods.

She used an evidence-based approach to negotiate, influence and achieve change in policy and practice, not just in the healthcare of soldiers, but also in the broader public health arena both at home and abroad.

This year, a range of events around the UK will mark the centenary of her death (see box, right), including the opening of the refurbished Florence Nightingale Museum in London.

Caroline Worthington, museum director, says: “This is a special year for Florence, and the new museum is a very fitting tribute to someone who has contributed so much to modern-day nursing.

“Florence has inspired so many men and women to join a profession on which we all rely, and it is fascinating to see that the issues she tackled such as hospital hygiene, caring for soldiers and the training of nurses are still hugely relevant today. We are excited about welcoming a wide range of audiences to discover more about this iconic Briton.”

Nightingale was determined to become a nurse despite parental objections, and during her twenties spent weeks working at the Lutheran Kaiserwerth Institute in Germany. This experience enabled her to secure a post running an ‘Establishment for Gentlewomen during Illness’ in central London. Then, in 1854, war minister Sidney Herbert asked her to go the Crimea. He was responding to the public outcry at reports of horrific conditions and inadequate care for wounded and dying soldiers. Nightingale gathered together a group of women to travel with her to Scutari in Turkey, and thus began her famous nursing career.

Facts and figures

During the Crimean War, Nightingale carefully collected mortality data and when she returned to England after the war, used this to draft figures commonly known as ‘coxcombs’. The figures illustrate deaths from war wounds and from other causes, notably insanitary living conditions.

One statistical website (www.understandinguncertainty.org) includes an interactive animation feature entitled ‘Nightingale’s Roses’. Click on this and see Nightingale’s ‘coxcombs’ alongside bar charts (using the same data) for comparison. The findings were published in the form of pamphlets and distributed to influential politicians. As a result, reforms were implemented in military hospitals. According to the Royal Statistical Society: “There is no doubt that the innovative diagrams designed by Florence Nightingale produced the necessary change in the minds of those who held political power to alter the course of history.”

One of her early studies showed that even in peacetime, soldiers were more likely to die than civilians due to their living conditions. As Nightingale’s biographer Mark Bostridge says: “Florence’s groundwork for the investigation into the health of the Army demonstrates what were to become some of the hallmarks of her working style in years to come: the careful marshalling of the most accurate raw data and, if this was unavailable or inadequate, the dispatch of questionnaires to obtain it, together with the enlistment of the finest expertise to help understand it and formulate solutions.”

Adolphe Quetelet, the academic and sociologist who pioneered the idea of applying statistics to social phenomena in the 19th century, was a major influence on Nightingale. The century saw the emergence of the discipline of statistics, and she became fascinated with the idea of collecting and analysing data, and writing reports that she could use to lobby for change.

Firm beliefs

Having identified trends and systematically discovered what was happening in any particular area, problems could be targeted and data used to convince those in authority to act. Bostridge describes how “Quetelet’s theories offered Florence a firm methodological framework, corroborating her overriding belief in discernible laws, and confirming statistics as a sacred science which would permit man to read the mind of God”.

Nightingale felt she had been called by God and her faith was a strong motivating factor in her work. Ever independent, however, she followed her own religious path, not strongly identifying with any particular branch of Anglicanism. She was driven to improve conditions for others in a range of settings during a time of change and rapid urbanisation during the Industrial Revolution. Above all, she felt strongly for ordinary soldiers, and believed they deserved better treatment and more respect. She had friends in high places and used them to improve this situation.

Nightingale also studied conditions in workhouses and hospitals, maternal mortality rates and public health in India. Her sharp intellectual powers and negotiating and influencing skills enabled her to effect change – an extraordinary achievement for a Victorian woman. Nightingale spent years studying the health of the British army in India and Indian public health in general and setting reform in progress.

This work was conducted from a distance – mostly from her sick bed in London (she spent decades virtually housebound with a mystery illness now thought to have been chronic brucellosis contracted while working in the Crimea). She received only selected visitors, which gave her the benefit of many undisturbed hours to analyse data, write reports and devise lobbying strategies. Nightingale worked well past retirement age and was widely published. Her famous book, Notes on Nursing (1860), is still in print.

The Crimean War work made Nightingale a celebrity in Victorian Britain. She used this to great effect for decades. People continued to listen to her views on public health and hospital design. The Nightingale Fund, set up by Sidney Herbert, raised thousands of pounds and enabled her to establish The Nightingale School of Nursing at St Thomas’ Hospital in London.

Inspirational figure

So is Nightingale an inspiration to OH nurses deployed to Iraq today? Jeremy Smith, president of the Association of Occupational Health Nurse Practitioners and acting area manager for Atos Healthcare, went there in 2003 as a Territorial Army volunteer.

“I’ve never really thought about Florence Nightingale. I only know what I learnt in school history lessons about her work in the Crimea,” says Smith. “I did hear a talk a couple of years ago at the Imperial War Museum about Mary Seacole’s Crimean work, and I am particularly inspired by the First World War nurses as they were literally working on the front line. In Iraq, I was working in a field unit mostly using my trauma nursing skills. Later my OH skills came to the fore as I was the only nurse in my unit qualified in OH. OH skills were very useful when soldiers were returning to work after their treatment.”

Lt Col Caroline Whittaker, RRC, senior lecturer in public health (OH) at the University of Glamorgan, is more directly inspired by Nightingale. Whittaker was in charge of nursing in a 200-bed field hospital in Iraq.

“It was about resolve, getting on and doing the job and trying to make the best of things,” she says. “Above all, making sure that patients were well cared for to a good standard. We didn’t consciously think about Florence Nightingale or the history of military nursing – it was just your job and you wanted to do it to the very best of your ability.”

Nevertheless, the nurses did all celebrate Nurses Day on 12 May (Nightingale’s birthday). “I got all the nurses to make posters illustrating their work and we attended a service and just took a step back to reflect on our work. It was special – there were all the nurses I was serving with and it made me feel so proud of what they had done. And then we just got back to work.”

Whittaker says Nightingale’s legacy is important to the military. “The military does have a close relationship with Florence Nightingale and I’ll be going to Westminster Abbey in May for the service,” she says. “She was a remarkable woman. She set off from a comfortable, upper middle class home and achieved all those wonderful things in an era where there were few opportunities for women.”

The Florence Nightingale Foundation grants nurses research and travel scholarships and leadership scholarships providing them with ‘the opportunity to broaden their professional development through travel to other countries, to observe trends and work in their own particular area of practice’.

Nightingale had her critics, both during and after her lifetime, but was fondly remembered by Crimean soldiers as the “lady with the lamp”. She was also a founder of the modern nursing profession, a pioneer statistician, an advocate for the health of soldiers, for infection control and for public health. Why not go and have a look at the new Florence Nightingale museum, or join in some of the centenary celebrations and find out more.

References

1 www.florence-nightingale.co.uk

2 www.understandinguncertainty.org

3 Royal Statistical Society website www.rss.org

4 Bostridge Mark (2008) Florence Nightingale the woman and her legend Viking Penguin, London p315

5 As above p172

6 Nightingale Florence (1860) Notes on Nursing: what it is and what it is no 1969 edition Dover Publications Inc, New York

7 www.florence-nightingale-foundation.org.uk

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